Ethical Analysis of For-Profit Market Competition and Its Impact on Live Discharge From Hospice

Abstract: 

Background: Live discharge from hospice occurs when a patient is discharged from hospice prior to their death. A surge in for-profit market competition has increased the number of for-profit hospices in the U.S., along with worse outcomes related to live discharge. For-profit hospice organizations are seen to have a narrower range of services, fewer nursing visits, and higher rates of live discharge, hospitalizations and emergency room visits. De-certification, an act of declaring someone no longer terminally ill, revokes the ability for patients with ambiguous end of life timelines to stay in hospice. This form of live discharge, while seeking to foster a just utilization of resources, may unfairly deprive beneficiaries of the model of care that best aligns with their goals. This paper explores how for-profit market competition may drive hospice enrollment and discharge criteria, promoting injustice to vulnerable populations.

Discussion: It is proposed that for-profit market competition in hospice promotes injustice through de-certification because it unfairly impacts marginalized groups and denies patients’ right to quality care. These two premises are presented, along with alternate perspectives synthesized in relation to current literature.

Conclusion: This analysis of live discharge from hospice reveals a complex ethical dilemma involving principles of justice, beneficence, patient rights, and autonomy. While de-certification may attempt to allocate resources effectively, it disproportionately affects those with ambiguous timelines, such as patients with dementia. Overall, we need to critically examine profit-driven motives within end-of-life care, emphasizing an importance in reforming hospice practices to ensure equitable access to quality care.

Kevin Costello, MD, MPH – Internal Medicine, Geriatric Medicine – Albany Medical College