How Does the Timing of Hospice Referral Influence Hospice Care in the Last Days of Life?


Address correspondence to Susan C. Miller, PhD, Center for Gerontology and Health Care Research, Brown University School of Medicine, 2 Stimson Street, Room 207, Providence, RI 02912. E-mail:


OBJECTIVES: To determine factors associated with the type of hospice care received in the last days of life and, in particular, how the timing of referral influences the use of continuous hospice home care and inpatient hospice care.

DESIGN: Retrospective cohort study.

SETTING: Twenty-one hospice programs across seven states under the ownership of one hospice parent provider.

PARTICIPANTS: Hospice patients who were cared for and died between October 1, 1998, and September 30, 1999 (N = 28,747).

MEASUREMENTS: Patient sociodemographic and clinical data were merged with use data from the provider's centralized information system to examine the factors associated with the differing levels of hospice care in the last week of life. In the last days of life, patients were classified as having received routine hospice home care only, having received continuous hospice home care, or having died in an inpatient hospice bed.

RESULTS: Twenty-three percent of the patients received continuous hospice home care during the last week of life, and 34% died in an inpatient hospice bed. Patients with hospice stays of less than 7 days had a lower likelihood of receiving continuous hospice home care than those who had stays of more than 30 days (adjusted odds ratio (AOR) = 0.81, 95% confidence interval (CI) = 0.75–0.87). Patients with hospice stays of 14 days or less had a greater likelihood of dying in an inpatient hospice bed. Furthermore, patients with stays of less than 7 days who were referred from hospitals were six times likelier to die in an inpatient hospice bed than those who were referred from another source (AOR = 6.40, 95% CI = 5.74–7.14). Patients in nursing homes had a 93% lower likelihood of dying in an inpatient hospice bed than patients in the community without a live-in caregiver (AOR = 0.07, 95% CI = 0.03–0.19). Strong independent associations were observed between several other covariates and the study outcomes, particularly the covariates of which state hospice care was provided in and level of pain intensity.

CONCLUSION: Findings suggest that continuous hospice home care in the last week of life is less likely to occur when patients have short hospice stays. Also, the probability of dying in an inpatient hospice bed is substantially greater for patients referred from hospitals and referred closer to time of death. Further work to determine the appropriateness of use of the different levels of hospice care is needed.