Is It Time to Consider the ‘Whole Person’ as Part of Sepsis Protocols?
By Joseph Shega, MD, Chief Medical Officer, VITAS Healthcare
Recent research should convince physicians and administrators to consider how sepsis infections in persons near the end of life impact healthcare value—particularly metrics for patient and family satisfaction, in-hospital mortality, hospital readmissions and Medicare per-beneficiary spend.
The research demonstrates that sepsis is far more common, costly and consequential as a cause of hospital death and readmission than many healthcare professionals previously thought. It also finds that 40% of patients who entered the hospital with sepsis and died were eligible for hospice care before admission.
That second finding alone should serve as an indication to primary care physicians, specialists, hospitals and health systems that many of their seriously ill patients can benefit from hospice care earlier in their disease trajectory.
Timely Hospice Care Supports Patients, Reduces Costs
An early referral to hospice care holds promise of improving the quality of patients’ lives by sparing them the severity of a sepsis-related hospitalization, while also addressing a medical crisis estimated to cost $3.5 billion a year for hospital readmissions alone, according to “Epidemiology and Predictors of 30-Day Readmission in Patients with Sepsis” in the March 2019 issue of CHEST®.
Overall, sepsis was present in 52% of patients at hospital discharge and was the leading immediate cause of death (34.9%), based on a JAMA Network study of 568 hospital deaths or hospital discharges to hospice, titled “Prevalence, Underlying Causes, and Preventability of Sepsis-Associated Mortality in US Acute Care Hospitals.”
The next most common underlying causes of death in patients with sepsis were cancer (21%), chronic heart disease (15.3%), hematologic cancer (10.3%), dementia (9.7%) and chronic lung disease (9%); all five are also major diagnoses for hospice referrals in the US.
All physicians should consider their seriously and chronically ill patients to be at high risk for sepsis.
Another revealing sepsis-related fact from the JAMA study was the reduced likelihood of sepsis patients enrolling into hospice prior to death, compared to non-sepsis patients. In fact, of the 568 study patients who died in the hospital or were discharged to hospice care, sepsis patients were 56% less likely to die with the benefit of hospice services, compared to non-sepsis patients, despite the fact that 88% of the sepsis deaths were unpreventable.
As such, a significant number of sepsis patients who are dying do not benefit from hospice, a standard in end-of-life care.
Hospital protocols appropriately emphasize early sepsis identification with the integration of treatment protocols to improve sepsis-related mortality. However, the same protocols generally do not consider the conditions that put patients at risk for sepsis, particularly the identification of progressive non-curable conditions that include end-stage cancer, heart disease, dementia and lung disease.
Management protocols that fail to consider the context surrounding the development of sepsis, particularly among patients near end of life, can lead to medical care that is inconsistent with patient goals and values and that contributes to suffering and harm.
Taken together, clinicians are called to better identify patients at the end of life with sepsis in order to conduct goals-of-care conversations within the context of the patient’s condition—with a clear recommendation to hospice services when appropriate.
Asking ‘Whole-Person’ Questions of Patients
In my estimation, ED physicians, hospital physicians, and specialists should approach septic patients or their healthcare decision-makers with deeper, broader, “whole-person” questions. And those questions should be asked with the same fervor as vital signs and determination of organ function:
- Who is this person with sepsis?
- How long has this patient been sick?
- What other underlying diseases or comorbidities are present?
- Where is this patient in the trajectory of his or her disease?
- Where was the patient receiving care before admission to the hospital?
- Would we be surprised if this patient died within 12 months?
- Would hospice care be a better alternative for this seriously ill patient?
Asking whole-person questions in a timely and honest manner might alter the reality—for the better—that many seriously ill patients who are already nearing the end of life are nonetheless dying of sepsis in the hospital—and they’re dying without the benefits, end-of-life preferences and qualify-of-life focus of compassionate hospice care. Studies show that sepsis-related readmissions could be reduced by up to 90% if end-of-life patients who are most at risk for sepsis could be identified and referred earlier in their disease trajectory to hospice care.
Hospice Can Help Reduce Sepsis-related Deaths
It seems apparent from these two studies that seriously ill patients with underlying, chronic diagnoses or comorbid conditions are not being referred early enough in their disease trajectory to hospice care if at all, either because physicians are not asking the right questions or because current sepsis protocols do not take into consideration the “whole-person,” long-term impact of chronic diseases and comorbidities that put patients at higher risk of sepsis.
The JAMA authors say their findings “underscore that most fatalities occur in medically complex patients with severe comorbid conditions,” a finding that calls for “further innovation in the prevention and care of underlying conditions” to reduce sepsis-associated deaths.
Preventing and managing underlying conditions in seriously ill patients is exactly what hospice care does.
All physicians should consider their seriously and chronically ill patients to be at high risk for sepsis, especially if they receive care in hospitals or long-term care facilities. Those same patients also should be considered possible candidates for hospice care at a time during their disease trajectory when they can most benefit from hospice’s services, resources, emphasis on quality of life and support for patients’ preferences for compassionate end-of-life care.
