Patients With Poor Health Literacy Less Likely to Elect Hospice

Patients who have low levels of health literacy are more likely to seek intensive curative treatment at the end-of-life, as opposed to choosing hospice care. In addition to disparities in hospice utilization associated with race or ethnicity, a patient’s understanding of their condition and the available treatments may also be a contributing factor, according to a recent study in the American Journal of Hospice & Palliative Medicine. 

Health literacy is the degree to which individuals can obtain, process and understand basic health information and services needed to make appropriate health decisions, according to the Institute of Medicine. A health illiterate patient may have a strong overall ability to read or have an advanced education but have a limited understanding of information specific to health care.

“Medicare beneficiaries who resided in low health literacy areas were likely to receive aggressive end-of-life care,” the study indicated. “Tailored efforts to improve health literacy and facilitate patient-provider communications in low health literacy areas could reduce end-of-life care intensity.”


Patients who lack an understanding of health care information or terminology, do not understand their own illnesses, or who misconstrue the nature of hospice or palliative care may lack the necessary tools to make an informed decision about their end-of-life wishes

For the study, researchers conducted a retrospective analysis of nearly 650,000 Medicare fee-for-service decedents who died between July and Dec. 2011. They used a Health Literacy Data Map to calculate health literacy scores by ZIP code. For the purposes of this study, a score of 225 or lower was defined as low health literacy. Aggressive end-of-life care measures included repeated hospitalizations within the last 30 days of life, no hospice enrollment within the last six months of life, and/or in-hospital death.

Close to 83% of decedents in low health literacy areas pursued aggressive end-of-life care, compared to about 73% in high health literacy ZIP codes. Patients in low health literacy areas were also much less likely to utilize hospice.


Low health literacy is very common in the United States, often impacting older adults. As many as one-third of Medicare enrollees have a low-level of health literacy, and research indicates that this increases across-the-board health care costs by as much as 5% annually.

“Elderly managed care enrollees may not have the literacy skills necessary to function adequately in the health care environment,” a Journal of the American Medical Association study found. “Low health literacy may impair elderly patients’ understanding of health messages and limit their ability to care for their medical problems.”