It was found that medical expenses for one month before death were 2.5 times the monthly average of medical expenses for the year before the death. Half (50%) of medical expenses before death of all cancer patients were spent in three months before death. As medical technology advances, various treatments and more care services are provided to patients when death approaches. However, due to the lack of facilities to properly take care of end-stage patients in peace, the general ward is used to provide continuous medical services to patients [10].
Excessive medical expenses before death may increase further in Republic of Korea, which is entering a super-aged society. Health insurance finance recorded a deficit of W177.8 billion in 2018. Its cumulative reserve is decreasing to W20,596 billion. It is expected to be exhausted by 2025. If policies to strengthen security are continuously promoted, such health insurance deficit will further increase year by year and the cumulative reserve fund will decrease accordingly, thus further increasing financial depletion [11].
According to results of this study, the cost of drugs used during 7 days before death in the general ward was 6.67 times higher than that in the hospice ward. In the case of cancer patients, the use of hospice services had steadily increased from 7.3% in 2008 to 20.9% in 2018. However, many cancer patients are still dying in general wards rather than in hospice wards [12]. Financial resources of the hospice ward consist of national health insurance and national support funds. It is not easy to reduce the cost of drugs used in general wards. Reducing the proportion of patients with terminal cancer care in general wards and increasing the utilization rate of hospice services can be an alternative solution for the problem of health insurance deficit and depletion.
Opioids accounted for 23% of drug costs in the hospice ward, higher than 2% in the general ward. It was also found that 94.8% of all hospice patients used narcotics while only 81.7% of those in general wards used them. The reason for using a lot of opioids was to ensure that the patient was comfortable and pain-free in the hospice ward. In hospice wards, opioids were used to control and treat pain. If necessary, drugs were sufficiently used. For hospice patients in 2017, the mean pain measured by NRS was reduced from 3.2 to 2.2, indicating a significant (p < 0.001) pain relief [13]. Symptom control was well regulated in the hospice ward as shown in results measured by NRS.
In the general ward, various drugs were used to control pain. However, in the hospice ward, effective injections were mainly used to control pain. Although the number of drug types used in the hospice ward was smaller, higher doses might have resulted in more costs. In the hospice ward, even if the patient was unconscious at the end of life, the pain control was actively implemented so that the patient could spend a comfortable end of life. In the hospice ward, drugs were not simply reduced or restricted for end-of-life patients. Because the hospice ward was concerned about side effects such as blood pressure, decreased breathing, and decreased consciousness. Recognizing these side effects, appropriate medications were selected and used for patients, allowing them to maintain comfort without feeling pain.
Different from findings for the general ward, the number of drugs and cost decreased significantly in the hospice ward from the 7th day before death to the last day before death. This was because unnecessary drugs were not used as death approached. Ducan et al. have studied Medicare Limited Data Set 2015–2016 and found that the average hospitalization cost is US$ 638 for 4–7 days before death and US$5,983 for 1–3 days before the death, an increase of about 10 times. However, the hospice ward was covered by a comprehensive compensation system. Its cost was US$ 230.74 per day, resulting in lower hospitalization costs for patients receiving end-of-life care in a hospice ward than in general ward. [14].
Reasons for lower costs in hospice ward than in general ward are as follows. First of all, the hospice ward has different predictions of death from the general ward. Looking at drug use in general wards, PO, fluids, antibiotics, and so on are being used continuously until the end of life. In the hospice ward, end-of-life patients are frequently contacted. If the patient is predicted to die within a few days, Dying Care Pathway [15] is applied. If Dying Care Pathway is applied, the hospice ward will regulate fluid supply to a minimum volume. The reason is that supplying excessive fluids to end-of-life patients does not extend their survival period[16–17]. In addition, side effects due to fluid imbalance or increased bronchial secretion due to fluid supply are increased[18]. Instead, drugs that mainly control accompanying symptoms are provided. If the drug used for the patient does not help or can harm the patient's symptoms, the usage of such drug is discontinued. However, in general wards, it is difficult to frequently contact end-of-life patients. Thus, evaluation is not properly performed. Since the patient is not judged to be in a terminal stage, the drug will be used continuously without reducing the dose. It can be the main cause of high cost by continuing to use drugs such as excessive fluids, injections, antibiotics, oral drugs, and so on, even right before death .
Secondly, in the hospice ward, Physician Order for Life Sustaining Treatment (POLST) and Advance Directives (AD) are prepared and a high proportion of patients are hospitalized with agreement for POLST and AD. When a patient enters the terminal stage of life, it is easy to proceed according to the POLST. Guardians also understand and prepare for the end of life so that consent for drug reduction can be easily obtained. In general wards, the proportion of patients who do not reveal their intention to discontinue life-prolonging treatment is high. Because there are parents who wish to continue life-prolonging treatment, it is impossible to easily reduce the dose of the drug. As more drugs are used and the number of drugs is increased, costs are also increased.
There were 36.2 deaths per 100,000 people due to lung cancer, 20.6 deaths per 100,000 people due to liver cancer, and 17.5 deaths per 100,000 people due to colon cancer in Republic of Korea [1], accounting for 46.9% of all cancer deaths. If these lung cancer, colon cancer, and liver cancer patients in their terminal stages use hospice wards instead of general wards, money could be saved. Republic of Korea's dying quality (palliative care) ranking had increased from the 32nd out of 40 countries in 2010 to the 18th out of 80 countries in 2015 [19]. In the 2017 satisfaction survey of bereavement families, the satisfaction rate for hospice was 97%, which was higher than the satisfaction rate of 69% for cancer treatment institutions used before enrolling in hospice [20]. This suggests that hospice is giving patients a comfortable and dignified death and giving guardians satisfaction.
The number of hospitalized hospice institutions had increased from 81 in 2017 to 84 in 2018, 88 in 2019, and 86 in 2020 and 2021 [5]. To increase hospice utilization rate by terminal cancer patients, it is necessary to increase the number of hospice institutions. However, not all institutions are expanding due to low remuneration based on a daily flat rate system. Considering the difference in drug costs between the hospice ward and the general ward based on results of this study, expanding support in a way that preserves more daily flat rate in the hospice ward will result in an increase in the number of inpatient hospice institutions. It may be a good idea to develop and implement incentive policy that allows patients with terminal cancer, which seriously differs in cost, to be cared for in a hospice ward with a higher priority [21].
Since this study analyzed patients who died in the hospice ward and general ward of one metropolitan university hospital, results of this study could not be generalized for all hospitals. In addition, names of some drugs might have changed depending on the year. Some drug prices might also differ depending on the year. In this study, the comparison of cost was calculated only by the type and cost of the drug. In the case of general wards that do not provide life-sustaining treatment other than drugs, additional calculation of the cost of CPR and ventilator treatment might show more differences. Since this study only compared drug costs, it was impossible to accurately compare actual expenses. More research will be needed in the future.
In this study, the current status of differences in drug types and costs in hospice and general ward was determined. The government plans to increase hospice utilization rate of terminal cancer patients to 30% by 2022 [19]. Patients at the end of their lives absolutely need care to end their lives by respecting their right of self-determination while having less physical peace and less psychological pain. A hospice ward plays a very important part in national and social costs. It can lead to lower cost but higher quality alternatives for dying patients. Thus, it is necessary to create a healthy policy and environment to promote the use of hospice through more research in the future.