Hospice - Making the Unknowns of Hospice Care Known

This week’s New England Journal of Medicine contained an exceer” by Gail Gazelle, MD. She is a member of the Division of General Medicine and Primary Care at Brigham and Women’s Hospital’s and president of MD Can Help.

In her piece, Dr. Gazelle says use of hospice care is increasing.

•Medicare beneficiaries in Hospice Care increased from 534,000 in 2000 to 797,000 in 2004, a 49% jump

•Medicare payments for Hospital rose from 2.9 billion to 6.7 billion over the same period, a 130% increase.

But she adds “Despite its increased use, many aspects of Hospice Care are still misunderstood by both physicians and patients.”

Among these misunderstandings are:

1)Hospice patients need not to have cancer. Less than half of Hospice patients have terminal cancer. Nearly 40% of hospice admissions are for end-stage cardiac disease, end-stage dementia, debility, pulmonary disease, and stroke.

2)Hospice care at home is free. In about 80% of cases, Medicare is the primary payer – for care most often provided in the home. Most expenses are paid in full, medication, equipment, and visits by hospice nurses and aides.

3)Hospital addresses concerns surrounding end-of- life care – dying with dignity, dying at home without unnecessary pain, and reducing the burden placed on family caregivers.
4)More than 98% of families touched by home care report they are satisfied with hospice care and would recommend it to others.

Dr. Gazelle feels many patients are referred to hospice too late to experience its true benefits. She says late referrals are largely due to physician attitudes.

•Preoccupation with cure even though cure in no options in many late stage disease.

•The belief that the death of a patient is a professional failure.

•The fear that hospice referral will destroy a patient’s hopes for cure.

•The view that hospice care is only for the imminently dying rather than a service designed help people live as long as they can as well as they can.

To determine eligibility, the attending physician and hospice medical director must certify that the patient to the best of their judgment is likely to die within 6 months. Hospice develops a plan in accordance with the wishes of the patient and family. The goal is ensure that pain and symptoms of insomnia, dyspnea, depression. agiation, nausea, and emotional and spiritual distress are attended. Most care is provided by a hospital nurse, and most patients are not seen by a physician.

I have personal experience with hospice. My twin sister, who was dying from mad-cow disease, was treated at home for the last month of her life by hospital nurses, and in her comatose condition was allowed to die with withdrawal of IVs. My son, a hospice chaplain and soon to be an Episcopal priest, wants to spend his life overseeing hospice care. And my wife, a nurse, and I plan to take a course preparing to be hospital volunteers