When Hospice Referrals Are Placed to Improve Hospital Mortality Metrics

Key Message: Hospitals are implementing initiatives to increase hospitalized patient transitions to hospice care in order to reduce inpatient mortality quality measures created by healthcare performance companies. This session will discuss the ethics of these initiatives, which have potential to benefit or harm patients and families at the end-of-life.

Abstract: Hospitals increasingly aim to improve their performance in specific quality metrics defined by healthcare performance companies. Over two-thirds of US acute care hospitals and 97% of academic medical centers assess the quality metric of inpatient mortality (1).

One way hospitals can reduce inpatient mortality, thereby improving this quality metric, is to convert patients from observation or inpatient admission status to inpatient hospice status (2-3). Patients transitioned to inpatient hospice status may remain physically within the same room of the acute care hospital they were initially admitted to, but will no longer count as an acute care hospital death per the definition of this quality rating.

Across the nation, some hospitals have created initiatives to increase patient transitions to hospice, to improve this quality metric. For example, some hospitals have required patients transitioned to comfort measures only status to have a referral to hospice order placed. Other hospitals have provided financial incentives to clinicians based on the number of dying patients they transition to hospice.

For many hospitalized patients, increasing access to hospice care may help them receive high-quality, comprehensive end-of-life care. However if the intent in providing this care is primarily driven by improving inpatient mortality metrics rather than providing high-quality end-of-life care for patients, the pursuit of initiatives to increase hospice enrollment for hospitalized patients is ethically questionable.

This oral presentation panel by a multidisciplinary, geographically diverse group of palliative medicine and hospice experts will discuss ethical complexities of promoting inpatient hospice transitions with the intent of reducing inpatient acute care hospital mortality metrics. We will discuss initiatives pursued at US hospitals which aim to increase hospice transitions, potential benefits and harms of these approaches, health disparities associated with these initiatives, and the importance of hospice and palliative medicine clinician involvement in decisions about these initiatives.

References: (1) Vizient, Inc. The value of Vizient. Accessed June 24, 2025. Website: https://www.vizientinc.com/about-us
(2) Marks S. The questionable practice of hospice flipping to improve inpatient mortality. J Pain Symptom Manage. 2015 Mar;49(3):e1-2
(3) Kozar RA, Holcomb JB, Xiong W, Nathens AB. Are all deaths recorded equally? The impact of hospice care on risk-adjusted mortality. J Trauma Acute Care Surg. 2014;76(3):634-641