hospice

“You should understand that hospice is a philosophy and a movement, but it may actually be the cutting edge of medical progress at the present time. And that's always a strange thing because we always think that science is the cutting edge, but in fact the idea that you can successfully care for people -- including themselves and their family, their spiritual needs as well as their physical needs -- is shown every day in hospice, and it makes the hospital a rather barren place. The idea that it is not curative is a hangover from the past. In fact, it's a -- becomes a blend. It's not curative, but it addresses specific physical problems that patients have since they're going to die, and their diseases are not curable. It's called "not curable medicine." But in fact, it addresses that sickness at every level of the human condition – the physical, the emotional, the social, and so forth. And that's what makes it, both so wonderful, and also a breeding ground for understanding where medicine should go in general.”

Eric Cassell, M.D.
Clinical Professor of Public Health:
Cornell University Medical College
Quote taken from transcript of a roundtable discussion on www.npr.org/programs/death

The word hospice is derived from the Latin word “hospitium” meaning guesthouse. It was originally used to describe a place of shelter for weary travellers. The first hospice was established in the 1960’s in London. This hospice was called St. Christopher’s and it was the first program to use modern pain management techniques to compassionately care for the dying. The first US hospice was established in 1974 in New Haven, Connecticut.

Hospice is not necessarily a place, but a concept of care designed to improve the quality of a patient’s last days by offering comfort and dignity. Hospice provides support to patient’s and their families when a life-limiting illness does not respond to cure-oriented treatments, or when the patient decides he/she no longer want to continue life-prolonging procedures. In hospice, the unit of care is the patient and their loved ones. Each hospice patient is provided care by an interdisciplinary team of medical professionals and volunteers. This team usually consists of a physician, a nurse, a social worker, a chaplain, a volunteer and a home health aide. Typically, the nurse visits the patient on regularly scheduled days and provides pain management and symptom control. He or she will keep the physician informed about the patients changing needs and condition. The physician can then adjust pain medication dosages accordingly. Nurses are available twenty-four hours a day, seven days a week. A home health aide provides assistance to the patient's daily personal needs, like bathing and cleaning. The social worker helps with practical and financial issues, as well as counseling and emotional support for the patient and their family. They also evalutate the need to volunteers in the home and facilitate communication within the family and community. Chaplains provide spiritual support to patients and families. They often serve as a liason between the patient, their family and their religious community. Chaplains can also assist with funeral arrangements and memorial services.

In 1998 alone Hospice programs in the United States cared for more than 540,000 people. Today, there are more 3,100 hospice programs in the US, including Puerto Rico and Guam. Eighty percent of hospice care is provided by skilled caregivers and the family of the patient in the patient’s home. Hospice units for inpatient care are sometimes available when a family cannot participate in the care of the patient, or when a patient requires more care than can be given in the home.

One of the main objectives of Hospice is to make sure a patient is not in pain while they are dying. This type of medicine is called Palliative Care, and it is a fast growing specialty in medicine today. The focus of palliative care is not finding a cure, but finding the most effective course of treatment through medication and individualized personal care to assure that the patient will be comfortable.   Surveys have shown that the greatest fear of people who are dying is that they will be in great pain, and that fear is not that far from reality. A study published in 1995 in The Journal of the American Medical Association found that among 9,000 terminally ill patients being treated in teaching hospitals, half were in moderate to severe pain during their dying days. Some experts have said that this is partly because many doctors today do not have adequate training in palliative medicine, and do not know how to properly prescribe the unusually high doses of medication that dying people often need. It is believed that if students in medical schools around the country were taught palliative medicine during their residencies, a drastic change for the better could occur in the United States' health care system.

    One pressing aspect of how to incorporate palliative care into mainstream medicine is how to finance it. Many of the palliative care programs that have already been instituted are paid for with donations. More than seventy percent of the Americans who die each year are elderly individuals who are covered by Medicare. Medicare has reimbursement catagories for thousands of diseases, but not one for someone who is simply dying. That, in effect, means that Medicare will not pay for the patient's treatment unless they are eligible for Medicare Hospital Insurance (Part A). If the patient is eligible for Medicare Hospital Insurance (Part A), there are certain requirements that must be met. A physician must certify that the patient has less than six months to live, assuming their disease follows it's expected course. The patient must sign a statement choosing hospice care over standard Medicare treatments and benefits. The patient must also only receive care from a Medicare-approved Hospice program. If the patient meets these qualifications Medicare will cover a variety of services including physcians' services, nursing care, the cost of medical supplies and appliances related to the terminal illness, outpatient drugs for symptom management and pain relief, short term acute inpatient care, home health aide and homemaker services, physical and occupational therapy, medical social services, and counseling, including dietary and spiritual counseling. There are also special benefit periods that apply to hospice care. A person who receives Medicare may receive hospice care for two 90-day periods, followed by an unlimited number of sixty day periods. These benefit periods may be used consecutively or at intervals, but regardless of the order the patient must be certified as terminally ill at the start of the period. The patient can change hospice programs one time each benefit period. The patient also has the right to cancel hospice care and return to standard Medicare benefits at any time. Once a patient has returned to standard Medicare benefits, they can switch back to hospice benefits at the start of the next benefit period.