The heavier someone is, the less likely they are to have what many people might call a “good death” with hospice care or the chance to die at home, according to a new study from researchers at the University of Michigan’s Institute for Healthcare Policy and Innovation. And that difference comes at a financial, as well as a personal, cost.
[Photo: Dr. Jennifer Griggs]
The study, published online in the Annals of Internal Medicine, draws this conclusion from an in-depth analysis of records from more than 5,600 seniors taking part in a long-term health study.
The researchers looked at how the seniors’ body mass index, a measure of obesity also known as BMI, related to end-of-life measures such as their use of hospice services, which provide supportive care to people in their final months of life.
The higher a person’s BMI, the less likely he or she was to enter hospice. Someone who had a BMI of 40 had less than a 23 percent chance of having hospice services at the end of life, while those in the “normal” weight range, with a BMI of 20, had a 38 percent chance, the researchers found.
For those seniors who did enter hospice, people with obesity spent fewer days there than their leaner counterparts.
About 60 percent of the seniors in the study died at home—an experience that most Americans say they would choose for their own deaths. That percentage dropped as BMI rose.
Elevated among people with high BMIs: the cost to the Medicare system for the care they received in their last six months of life.
Although the study didn’t examine the reasons people with obesity received less hospice care, Dr. Jennifer Griggs, a professor at the University of Michigan School of Public Health and Medical School, suspects several factors are involved.
“For hospice teams, as for hospital and home-health teams, it can require more staff to take care of people who are obese, but Medicare hospice reimbursement is capped no matter what a person’s BMI,” she says. “Also, obesity may mask the signposts and changes that physicians might use to determine when it is time for a person to enter hospice.”
Dr. Griggs, who treats patients with cancer at the University of Michigan’s Comprehensive Cancer Center, says that even in overweight and obese people, it’s possible to see the signs of cachexia, or the natural “wasting away” that occurs toward the end of life. This can include more pronounced cheekbones, collarbones and pelvic bones.
Still, physicians may not notice the gradual changes in a heavier person. A major change in body weight is also more noticeable on a leaner person.
“To refer a patient for hospice, you have to believe that they are in the dying process,” Dr. Griggs says.
Dr. Griggs also says previous studies have shown a bias against people with obesity by health care professionals, especially physicians. The researchers suspect, but cannot show with the new data, that this may also play a role in decisions about end-of-life care. Dr. Griggs notes that obesity, and its role as a barrier to optimal care, isn’t even mentioned in Dying in America, a landmark 2014 Institute of Medicine report.