Hospice Care: Something to Think About

End of life care in the United States today is tied more and more to hospice organizations. Therefore, improvement of end of life care must logically focus on the hospices' growth and development. Some issues have been identified that either need clarification, or may be areas for quality improvement studies.

For example, in order for a hospice organization to be approved by Medicare, the hospice must provide for inpatient care. Inpatient care for hospice patients often takes place in a skilled nursing facility (SNF); the hospice contracts with the SNF to provide this care. For many patient situations, this may be adequate, however resources in personnel and equipment differ greatly between hospitals and SNFs. The dying patient may sometimes benefit from options available only at an acute care hospital.

Another problem associated with the Medicare hospice program, is that it provides for care based on prognosis, rather than on symptoms or need. Unfortunately, making prognoses about when a patient is going to die is notoriously inaccurate, until the patient enters the active dying phase. This active phase is when the patient is no longer taking food or fluids, and prognoses are accurate at this point. One person (and family) that has "6 months or less to live" may have very different needs to another person (and family) with "6 months or less to live." Individualized care planning, based on current symptoms and needs, is an important priority.

The financial guidelines of the Medicare hospice reimbursement plan has been confusing for both patients and providers. Most hospice/ home health agencies charge more than $107 for a daily nursing visit, and if other services are added, the cost goes even higher. Therefore, in order for a hospice to be able to afford the routine home care, some patients must need minimal care (once a week or less) to compensate for those who need more. The general inpatient care is only intended for brief periods of time to stabilize a patient and then the patient is supposed to be returned home. Also, respite care is provided only once in each certification period. If a patient is actively dying and the family wants the patient moved to the hospice, unless this move can be timed to coincide with respite or construed as acute or chronic symptom management, the family may have to pay the cost.

Additionally, while Medicare allows recertification after 6 months, the government is investigating some hospices for fraud, that have provided services beyond 6 months. Therefore, hospices are often reluctant to admit patients who may live beyond 6 months, effectively cutting service time.

In conclusion, hospices can and often do provide wonderful care for patients and their families. Hopefully, as hospice care grows and matures as a care service option, the path that needs to be taken, when caring for the patient at the end of his or her life, will become smoother.