A second barrier is the inability of physicians to predict the time of death. Medicare and most insurance plans offer hospice benefits only to patients with a life expectancy of six months or less, but the median survival for patients with dementia is several years and varies enormously. Patient assessment becomes even more difficult as the dementia advances and the patient can no longer describe his or her symptoms or notify caregivers of discomfort.
A third barrier is the poor fit between dementia and health care financial incentives, which reward providers for transferring rapidly declining patients into hospitals where the process of dying is prolonged. "The only parties who may not be better off from the transfer," note the authors, "are the patient and family."
The solutions involve education, better prognostic tools, and changes in the health care system. Geriatrics, dementia, and palliative and end-of-life care are all under-represented in medical school curricula and deserve more attention as the numbers of elderly continue to increase. Physicians also need to educate the public, to create a baseline of awareness before families have to face these issues directly and make difficult decisions about a loved one.
Perhaps most urgent, however, is a nationwide effort to "align the financial incentives in the system with the provision of palliative care." The authors suggest relaxing the criteria for hospice to accommodate earlier referral of patients with dementia. Nursing homes should be financially rewarded for providing good end-of-life care rather than for transferring dying patients to a hospital.