For Whom the Death Tolls

The Connection Between Hospice Fraud and Euthanasia

Hospice can be a fulfilling option for those seeking more control over their end-of-life decisions, but a recent report has brought attention to widespread hospice abuse throughout the United States. This abuse is concerning not only because it shows a disregard for the worth and dignity of all people at every stage of life, but also because of its likelihood to push the elderly toward assisted death. Despair and coercion are already pushing people toward assisted death, and suspicion that hospice may be tainted with abuse is likely to expand the market for medically mediated self-termination.

Benefits of Hospice

How does hospice benefit those in its care? As Dr. Atul Gawande states in the book Being Mortal (2014), the priority of hospice care is to help those with a terminal illness to have the best possible lives right now, without continued risky surgeries that may sacrifice their quality of life in the present for a mere chance of extending life in the future, as certain medical procedures may end up shortening or worsening their remaining time. Hospice’s goal, when carried out as intended, is to relieve the patient’s pain and discomfort, maintain their mental awareness, assist with housekeeping, or allow for visits with family and friends - whatever helps the patient to live their best possible life given the circumstances. Hospice and palliative caregivers discuss with patients their priorities and end-of-life goals and adapt medications and accessibility amenities in the home accordingly.

In addition to allowing patients to have more control over their lives, these end-of-life care options have even shown to extend life. A 2010 Massachusetts General Hospital study assigned 151 patients with stage-four lung cancer to two groups - one group received strictly oncological care, and the other received oncological care and palliative care visits. Those who saw palliative care specialists stopped chemotherapy sooner, entered hospice sooner, and had less suffering at the end of their lives. What’s more interesting is that those in the palliative care group lived 25 percent longer than the strictly oncological group. A study from 2007 showed similar results regarding hospice care on the extension of life. It was found that out of a group of 4,493 patients with terminal cancer or end-stage heart failure, hospice care extended survival rates in those with pancreatic cancer, lung cancer, and heart failure by an average gain of three weeks, six weeks, and three months, respectively.

Dr. Gawande gives several accounts of patients in hospice care continuing to shape their stories and control their lives as best they can, from meeting with old friends and relatives to one who hosted a final piano recital as a way of saying goodbye to students. It is important to us as humans to fulfill the “dying role,” he states, adding that this is one of the most important roles in life for both the dying and those left behind. The dying role can include sharing memories, establishing legacies, passing on keepsakes, settling relationships, making peace with God, and whatever else allows people to end their lives according to their priorities. Denying patients this dying role, he argues, is cause for everlasting shame. The financial manipulation, mistreatment, and lack of oversight in the hospice industry only further stifles this dying role process.

Manipulation

An investigative journalism piece by newsroom ProPublica revealed rampant abuse in the hospice industry. Former hospice employees admitted that they had been pushed by upper management to contribute to Medicare fraud and to mistreat patients in order to increase profits for what is now a multi-million-dollar industry. Marsha Farmer, an AseraCare employee, was promised bonuses and perks in return for “selling” hospice services to people who weren’t even dying in order to meet her company’s quota requirement. She would tell prospective patients about a government service offering free medications, housekeeping, etc., and once they agreed, she would manipulate their chronic symptoms on paper to show proof of “terminal illness.” Farmer would also attempt to calculate how many people in her area were expected to die soon, and when she didn’t think the numbers would meet quota, her supervisor threatened to fire her. AseraCare medical directors would even pre-sign blank admissions forms to secure more patients, obviously enabling misleading patient records.

Mistreatment

In Massachusetts, Patricia Marbles was enrolled in Amedisys’s hospice services due to end-stage chronic obstructive pulmonary disease. Amedisys also gave out bonuses as rewards for enrollment numbers, causing medical directors to consistently discharge and recertify patients who weren’t dying. Marbles had pain that was under control, but upon starting hospice, she was prescribed copious amounts of narcotics, and eventually suffered, and survived, a Percocet overdose. It was found that she was taking the equivalent of dozens of Percocet pills a day. For her “treatment,” Amedisys had billed Medicare half a million dollars.

In California, Carl Evans, enrolled in Vitas hospice for “tentative” end-stage thymus cancer, was placed on a barbiturate for agitation and an anti-seizure medication, despite having no history of seizures. He was prescribed this medication simply to prevent him from sneaking out to his girlfriend’s house, as he had previously done, since he was still mobile, sociable, and cognitively aware. The drugs made him wobbly and lethargic, and he died less than two weeks later. Evans’s daughter, a hospice nurse, later reviewed his charts and found that they were billing Medicare for “uncontrolled pain and/or severe and demanding symptoms.” Evans did not have these symptoms, but the coding allowed Vitas to bill Medicare four times more per day.

If the average length of a hospice stay goes past six months, Medicare requires repayment. To avoid this repayment, other than manipulating the enrollment numbers with new patients, some hospices will “discharge” patients from services. Others will engage in even more heinous acts. A hospice owner in Texas, for example, told his nurse to overdose a patient who was on hospice services “too long.” “He better not make it tomorrow. Or I will blame u,” he texted the nurse.

Lack of Oversight

ProPublica reporter Ava Kofman stated, “ProPublica’s investigation pointed out that practically anyone can open a hospice. I came across hospices owned by vacation-rental superhosts, a man convicted of drug distribution, and a criminal-defense attorney (who once represented a hospice employee convicted of fraud and was later investigated for hospice fraud himself).” Since “practically anyone” can open a hospice, some owners will open up hospices until they get audited or reach the Medicare-reimbursement limit, then shut down, keep the money, and open up a new hospice and start the process all over again.

There is also scarce oversight of hospices. While widespread complaints about the quality of hospice care abound, inspections are required only once every three years. It was found that from 2012 to 2016 the majority of hospices had significant lack of care, such as poorly trained staff, failure to properly manage pain, and inadequate treatment of bedsores. Despite these insufficiencies, only 19 of more than 4,000 hospices in the United States were denied further Medicare funding.

While there are resources to help families avoid hospice abuse and fraud, unless these abuses are rectified, some people will continue to view assisted suicide as their best end-of-life option. Often, those seeking to end their lives do so because they fear unreasonably burdening their caregivers, whether private or institutional, or because their physical and psychological conditions have led them to depression, loneliness, or a loss of control over their lives. If they do not have options for good end-of-life care, bad actors in our society will continue to view the elderly as disposable burdens and shrug them off as quickly as possible through assisted death options.