Two recent studies highlight how sepsis’ impact often extends well beyond the acute event that led to a patient’s hospitalization. The studies emphasize two particular points that should inform physicians and clinicians as they consider referring these patients to specialized care:
- Medicare patient data gathered between 2012-2017 shows that sepsis patients face considerably poorer health outcomes following hospital discharge when compared to non-sepsis patients, including elevated risk for death and increased use of advanced healthcare services.
- Sepsis survivors exhibit strong indicators of persistent inflammation and immunosuppression for up to a year after hospital discharge, increasing their risk of readmission or death.
Both studies indicate a significantly elevated risk of death among sepsis patients after they have been discharged and ostensibly “cured.” Of course, sepsis patients–particularly those of the Medicare cohort, who are largely of advanced age–rarely leave the hospital in better condition than they entered.
The Yende study, in particular, shows that neuroendocrine and inflammatory responses to sepsis can continue long after the patient survives a septic episode. For patients with advanced or chronic diseases—as was the case with nearly 78% of participants in the study—these biomarkers are associated with decline.
Post-sepsis Discharge: A Critical Juncture
In many cases, these individuals’ life expectancies upon discharge will be less than six months. This is a critical juncture: While comfort-focused hospice care could provide an ideal source of support for the eligible patient, their family, and their caregiver(s), most sepsis patients are simply sent home without even a discussion about palliative end-of-life care and its benefits.
Frankly, such an oversight is a disservice to everyone involved. The sepsis patient is left with physical and/or cognitive dysfunction, often without significant options for symptom management. Their partner or family will either need to assume caregiving duties or turn to costly private services. And the physician and hospital staff will likely see the patient again following another acute event, a readmission that impacts performance scores, strains resources, and unnecessarily fills beds.
By no means do I intend to lay the blame for these unfortunate circumstances on physicians. Timely hospice referrals require ongoing education about end-of-life care, and open, ongoing communication between hospice providers and referral sources.
Those of us in hospice are working hard to bridge the gap, but even as our healthcare system transitions to a value-based model, the mentality of fee-for-service still permeates our nation’s acute-care facilities, and many hospitalists see a discharge home as a success.
Hospice: A New Way Of Judging Success
In hospice, we judge our successes on the patient’s quality of life and the fulfillment of their goals and wishes near life’s end. Usually, that means going home with 24/7 support from an interdisciplinary hospice team. Whether home is a traditional residence, an assisted living facility, or nursing home, the hospice team will assist caregivers (and/or facility staff) with direct clinical care and education, integrative services, bereavement support, and delivery of medication, equipment, and supplies.
In other cases, improving quality of life means remaining in a general inpatient setting with hospice support, taking the burden off hospital staff until the patient is able to transition home or until the patient dies. Hospice offers complex modalities in any setting, so patients who would otherwise be confined to an ICU can usually return home to be among loved ones.
With support from hospice, a sepsis patient and their family are more likely to report higher satisfaction of care and greater quality of life. The patient’s emotional and spiritual needs can be met alongside their physical needs, thanks to care from chaplains, social workers, music and massage therapists, and other integrative specialists. Finally, the patient is more likely to die at home, surrounded by loved ones, rather than in the hospital.
Because sepsis is most common in patients with advanced or chronic diseases that indicate hospice eligibility, acute incidences of sepsis should always trigger a hospice eligibility assessment. We owe it to our patients, their loved ones, and our colleagues in healthcare, all of whom can benefit from the support that timely end-of-life care offers.