The practice became popular in England, Asia, Australia and Africa. It was only in the early 70s that the hospice concept was introduced and accepted in the United States through the efforts of physicians Cicely Saunders and Elisabeth Kobler-Ross. These practices included effective pain management, comprehensive home care services, counseling for the patient, and acceptance of death as the natural end of the care delivery by health care professionals, bereavement counseling after the patients death, and continued research and education (Wexler & Frey). Quality care at the end of life soon combined with grief counseling and bereavement care. The government stepped in to contain health-care costs when reimbursement for inpatient hospitalization was significantly reduced. Home-based hospice care also became popular as a more inexpensive alternative to hospitalization or care in a nursing facility (Wexler & Frey).
The hospice concept was not immediately accepted by conservative health professionals. The concept emphasizes caring more than curing. It also allows interaction with complementary and alternative medicine practitioners. A hospices primary function or service is to enable the patient and his family to accept death as a natural part of the life cycle (Wexler & Frey, 2004). In addition, it provides pain management and psycho-spiritual support and complementary and alternative therapies. Approximately 80% of hospice patients are in the terminal or end-stage of cancer. Traditional medical facilities provide pain medications when requested, a hospice administers these medications regularly and before they are needed. The intention is to prevent pain from recurring. Furthermore, the problem of addiction and other long-term consequences is not a concern in the case of terminal illness. The concern is to provide effective relief to the greatest degree possible (Wexler & Frey).
A second major service of a hospice is to relieve physical, psychological, emotional and spiritual discomfort to the patients family and others close associates (Wexler & Frey, 2004). It relies on members of the clergy, pastoral counselors, social workers, psychiatrists, massage therapists and other trained volunteers to alleviate the discomfort. A hospice also provides grief and bereavement counseling and support groups to assist family members in expressing or resolving emotional tensions. And it allows the use of complementary and alternative therapies, in addition to conventional medicine, in the control of symptoms and in improving the patients well-being. A 2002 study conducted on the inclusion of such therapies showed that patients who received them expressed more satisfaction with hospice care than those who did not receive them.
These therapies include acupuncture, music therapy, pet therapy, bodywork, massage therapy, aromatherapy, Reiki or energy healing, Native American rites, herbal treatment and similar methods intended to soothe the patient and his family and friends (Wexler & Frey). A survey was conducted in 2000 on more than 9,000 patients discharged from more than 2,000 hospices on the services they received (Carlson, 2007). It revealed that 22% of them received five major palliative care services, which varied among the hospices. These palliative care services were nursing care, physician care, medication management, psychological care, and caregiver support. Approximately 14% of the hospices provided all five services and 33% provided only one or two services. Only 59% of these patients received medication management services. These included administering medication, dispensing correct dosages, and setting and following dosage schedule.
The National Hospice and Palliative Care Organization reported that, as of 2003, there were 3,139 hospice programs in operation in the United States, Guam and Puerto Rico (Wexler & Frey, 2004). The Centers for Disease Control and Prevention National Center for Health Statistics said that, in 2000, there were 11,400 combined home health and hospice care agencies, which served 1.5 million patients. It also reported that, at present, more than 90% of hospice care is delivered at home, although based in medical facilities. Hospital-based programs often provide hospice care in a wing or a floor in the building. There are also independent and for-profit hospices exclusively for the care of the terminally ill. Most programs offer both inpatient and home care and allow patients to use one or both types of service (Wexler & Frey). In 2005, the National Hospice and Palliative Care Organization reported that more than 4,100 hospice programs were operating nationwide (Marshall, 2007).
A third of these were for-profit companies. The rise in figures led financial analysts to view the hospice industry as among the strongest growing areas in healthcare. Hospice is cost-effective and more people are getting aware of the concept. Records showed that hospice spending had grown at 26% annually since 1989 as compared with 7% increase in overall health expenses in the same period. Despite this statistical increase, the hospice market has yet to be substantially tapped. Of the approximately 2 million apparent deaths in 2003, only 710,000 were in hospice. But new government regulations in the 80s boosted the growth of hospices.
These regulations allowed hospice providers into assisted living centers and nursing facilities. Since their exposure to the patients, the industry became a more attractive enterprise. The hospice concept has grown from a voluntary effort to a highly profitable industry worth $9 billion today. It is predicted to continue growing as baby boomers opt for the good death. Of the 47 hospices in Colorado, 53% are non-profit and 36% are for-profit. Nationwide, for-profit hospices multiplied four times between 1994 and 2004 at six times the growth of non-profit hospices (Marshall).
Issues and Approaches
Hospices operate on thin investment margins of only 8 to 12% on the average and receive Medicare payments of only $125 per day per patient for routine home care (Marshall, 2007). They are lucky to have thousands of volunteers to support operation. But making a profit can be difficult. Medicare regulations state that hospice can be used only up to six months. Yet many patients die just weeks from arrival. If death comes within two weeks of admission, the costs go quite high. Another problem that for-profit hospices confront is maintaining a level of quality care (Marshall). Most hospices require physicians to estimate that the patient is unlikely to survive to six months (Wexler & Frey, 2004). This intention is to maintain Medicare eligibility. This disqualifies terminal patients with uncertain prognoses, the homeless and isolated patients. Moreover, health care costs constrain patients to limit their stay in hospices.
The shortened stay reduces the chance and time for pastoral and psychological counselors to help the patient and the family to deal with the situation effectively (Wexler & Frey). Short stay also incurs more and more costly care (Solnik, 2002). Medicare and private insurers pay per diem, which means that reimbursements remain the same and hospices must cover the rest of the expenses. Furthermore, the patient may not need much care at times and that increases the delivery cost per day. But hospices realize they have to live with this reality (Solnik). Other problems arise when staying too long in a hospice (Solnik, 2002). Prior to admission, two physicians must agree that the patient probably has six months or less to live. The patient must also agree to replace the use of life-saving equipment and treatments with palliative ones.
The purpose is to keep him comfortable. If he survives the six-month limit, Medicare payments drain and the hospice must eventually reimburse some of the payments (Solnik). The cost of more effective pain medication has added to the cost of hospice care (Solnik, 2002). Hospices admit they are losing money because of the treatment modes applied to end-of-life care. Regulations must cover all the expenses incurred in all the stages of terminal illness. Medical procedures, like chemotherapy and radiation, are frequently used to alleviate pain and symptoms and for cure. Intravenous medications tackle pain but are also costlier than other forms. The appearance of new and costlier drugs blurs the fine line between life-saving and mere comfort-giving. Chemotherapy can shrink a tumor to allow swallowing and radiation can ease or reduce pain. If the hospice is not well financed, one or two patients who demand these procedures can bring cost problems to the hospice.
Shareholders who fear that the return on their investment is jeopardized may decide to cut down on staff. They may also shed off community grief centers, extensive bereavement care, alternative therapies, and inpatient care centers. The multicultural view of death is another issue in hospices in the United States and Western Europe (Wexler & Frey, 2004). Migrants with Easter cultures have an entirely different perspective from those with Western cultures. The Chineses concept of death is a sharp example. The views of death and end-of-life values of other cultures should be incorporated into the policies of hospice care programs (Wexler & Frey). The low rate and significant increase of physician services are additional troubles for hospices (Carlson & Morrison, 2007).
In most cases, hospice physicians participate only in care planning meetings, not in direct or actual patient care. The 6% increase in the number of patients receiving physician services was not considered significant. Still less than a third of these patients received hands-on physician services. This could be the offshoot of the original and non-medical concept of hospice care (Carlson & Morrison). The range of hospice services provided in different regions has also been found to vary by region (Solnik, 2002; Wexler & Frey, 2004). Patients in the Northeast received a significantly narrower set of services than those in other regions. Alternative forms of palliative care for end-of-life patients are quite common in the Northeast. These forms have recently expanded as hospital-based palliative care programs more than in other regions. This trend could have influenced the role and scope of hospice care offered in that region (Solnik, Wexler & Frey).
One more issue or problem is regulation of hospices itself (Solnik, 2002). In order to pay for hospice care, Medicare or a private insurer requires two physicians to sign a document that the patient has only six months or less to live. It then pays only for palliative treatment or management of symptoms and pain, not for the cure of the disease. This compels the patient to choose comfort or care over cure. The hospice industry has been by lobbying for a change in the regulation to allow or include curative treatment in hospice care. In collaboration with this initiative, the National Hospice and Palliative Care Association has also been lobbying for increased insurance reimbursements to include payments for costly procedures, like chemotherapy and radiation therapy (Solnik). Some approaches to these issues have been noted. Increased disease complexity, the diversity of diagnoses and symptom burden are likely to increase direct physician care (Carlson & Morrison, 2007).
The patients primary care physician may continue to monitor the patients condition but he is also unlikely to possess appropriate training, knowledge and skills on palliative care (Carlson ^ Morrison). Consolidation efforts in the industry has helped hospice care providers gain greater access to fund sources (Solnik, 2002). This is illustrated by the merging of hospice services among the Charles Hospital and Rehabilitation Center, Mercy Medical Center and Good Samaritan. They created Good Shepherd. They, however, found that reducing the costs of products and services would not sustain them without extensive financing or fund-raising (Solnik). Some studies focused on the availability of hospice care to the elderly in the rural areas (Solnik, 2002). Findings showed that the range of hospice services in the areas were comparable with those in the urban areas. The probability of fewer services in the rural areas can be dealt with by increasing reimbursement to cover travel expenses and attract skilled health professionals (Solnik).
A New York legislation would expand Medicaid payment for freestanding hospices in response to the six-month limit requirement (Solnik, 2003). The initiative encouraged the construction of freestanding hospices, such as The Visiting Nurse Service & Hospice of Suffolk, Inc. on Long Island and the Hospice Care Network in Manhasset. Freestanding hospices would create and provide facilities for the exclusive use of hospice care. Hospice beds in hospitals and nursing homes are currently only a small part of the overall facility. This would provide family support to take care of patients who do not have it and need it in their condition. Hospice care providers consider freestanding hospices a potentially important part of their industry (Solnik).
The City of South Bend in Indiana is the seat of St. Joseph County in a region known as Michiana (Answers.com, 2008). The region covers counties in Indiana and Michigan. South Bend is famous for the University of Notre Dame and the winning football team, The Fighting Irish. It has a 107,789 population as of 2000. The Citys has nine medical centers, prominently the Hospice of St. Joseph County (McMahon, 2008). Employment in the health care and social services is 13.4% of the total.(McMahon). The Indiana Hospice & Palliative Care Organization supervises hospice care in the City. Among the issues it confronts are treating the homeless at the end-of-life, the costs of end-of-life care to elderly patients, pain management, care-giving at the end-of-life, and futile care (2007). Treating the homeless at the end-of-life is a major concern for the City. They can seldom access hospice service for lack of resources for inpatient hospice, a home or social support (Indiana Hospice & Palliative Care Organization, 2007). In addition, these homeless are already beset with substance abuse problems and mental illness.
Their need for hospital care is 3-4 times greater than expected and 36% longer than poor patients who have homes and encounter similar health problems. Some organizations offer them medical respite, short-term shelter with basic services for those too sick to function on the street. These organizations cannot, however, care for those who are nearing death. (Indiana Hospice & Palliative Care Organization). Keeping to a medication regimen is a critical problem among homeless patients. They lack the money to buy them, lose their belongings or suffer from symptoms of mental illness or substance abuse (Indiana Hospice & Palliative Care Organization, 2007). Other problems they confront are the control of pain, the inability to discuss death and dying at home. Because of drug abuse, they may be opioid-tolerant and, thus, may need higher doses.
If they stop taking drugs, they need specific treatment to handle withdrawal reactions. The homeless also less willing to discuss death on account of what they have been denied in life. A study found that the homeless expect to die suddenly and violently. This expectation affects their willingness to discuss death. The homeless are also unlikely to have a surrogate or confidant who can make decisions for them in the event of incapacitation. Ethics committees or court-appointed guardians take their place for the function. And dying at home is not an option because they have no home. They are also unlikely to observe house rules in hospices. Experts recommend that homeless patients at the end-of-life be encouraged to form trusting relationships to insure or enhance curative and palliative care at that period (Indiana Hospice & Palliative Care Organization).
City laws are slated for revision to respond to these issues ((Indiana Hospice & Palliative Care Organization, 2007). One will direct the Health Department to name a commission, which will enact rules for physicians to order for life-sustaining treatment. The other revision will further strengthen healthcare powers of attorney. Living wills merely provide instructions concerning life-sustaining treatment. Powers of attorney concerning the end-of-life wishes of a patient belong to the spouse as first priority, followed by adult children and then close friends ((Indiana Hospice & Palliative Care Organization).#
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