The heavier someone is, the less likely they are to have what many people might call a "good death", with hospice care and a chance to die at home, a new study finds. And that difference comes with a financial, as well as a personal, cost, the research shows.
A new study done at the University of Michigan Institute for Healthcare Policy and Innovation and published in the Annals of Internal Medicine draws this conclusion from an in-depth analysis of records from more than 5,600 senior citizens taking part in a long-term health study.
The researchers looked at how the seniors' body mass index or BMI - a measure of obesity -- 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 someone's BMI, the less likely they were to enter hospice at all, the researchers found. And for those seniors who did use hospice services at the end of their lives, people with obesity spent fewer days in hospice than those with lower BMIs.
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. But that percentage dropped as BMI rose.
The one thing that was higher among people with higher BMIs was the cost to the Medicare system for the care they received in their last six months of life.
"Obesity is a complex disease, and this study has shown another side of its effect on patients and the healthcare system. Patients with obesity are less likely to receive high quality end-of-life care," says John Harris, M.D., M.Sc., who led the study during a fellowship at U-M and is now an assistant professor at the University of Pittsburgh School of Medicine.
Although the study didn't look at the reasons why people with obesity received less hospice care, senior author Jennifer Griggs, M.D., M.P.H., a professor at the U-M Medical School, suspects that several factors may be 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."
Griggs, who treats patients with cancer at the U-M Comprehensive Cancer Center, notes 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 - but physicians may not notice the gradual changes that occur over time 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," she notes.
Harris and Griggs also note that previous studies have shown a general bias against people with obesity among healthcare professionals, especially physicians. They suspect, but cannot show with the new data, that this may also play a role in the end-of-life care decisions. Griggs also notes that obesity, and the role of obesity as a barrier to optimal care, isn't even mentioned in Dying in America, a landmark 2014 Institute of Medicine report.
The new results, Harris says, suggest that more policy attention should be focused on people with more severe levels of obesity. "These patients' voices, and those of their caregivers, need to be heard," he says. "They may need extra help. They deserve the best healthcare and better health outcomes."