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Hospice & Other Palliative Care Institutions
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Hospice is an approach to end-of-life care where the most urgent objective is to address the physical and emotional needs of the dying Hospice care focuses on the patient and family rather than the disease and on providing comfort and pain relief rather than on treating illness or prolonging life Hospices provide intensive caring with the goal of helping people live well until they die Hospice embodies the palliative care philosophy that emphasizes individualized attention, human contact, and an interdisciplinary team approach Hospice care can include arranging for respite for family caregivers and providing legal, financial, and other services While some hospice care is provided in hospitals and institutional residences, about 80% of patients receiving hospice care remain at home where they can be cared for by the family and visiting hospice staff Primary care clinicians are strongly encouraged to continue caring for their patients during the time they are receiving hospice care Hospice care is highly rated by families and has been shown to increase patient satisfaction, to reduce costs (depending on when patients are referred to hospice care), and even to decrease family caregiver mortality More than 25% of all patients who die in the United States receive hospice care, and about 50% of these people have endstage cancer Hospice care tends to be used late in the course of the end of life The median length of stay in hospices in the United States is just 26 days, with 34% of patients dying within 7 days after beginning hospice care Most hospice organizations require clinicians to estimate the patient s probability of survival to be less than 6 months, since this is a criterion for eligibility to receive Medicare or other insurance coverage Regrettably, the hospice benefit can be difficult to provide to people who are homeless or isolated or who have terminal prognoses that are difficult to quantify
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As part of advance care planning, clinicians can encourage patients to express their preferences about the use of CPR Most patients and many clinicians are uninformed or misinformed about the nature and success of CPR Only about 15% of all patients who undergo CPR in the hospital survive to hospital discharge Moreover, among certain populations especially those with serious systemic noncardiac disease, metastatic cancer, and sepsis the likelihood of survival to hospital discharge following CPR is virtually nil Patients may ask their clinician to write an order that CPR not be attempted on them Although this order initially was referred to as a DNR (do not resuscitate) order, many clinicians prefer the term DNAR (do not attempt resuscitation) to emphasize the low likelihood of success Patients deciding about CPR preferences should also be informed about the sequelae of surviving CPR These may include fractured ribs, lacerated internal organs, and neu-
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Winzelberg GS et al Beyond autonomy: diversifying end-of-life decision-making approaches to serve patients and families J Am Geriatr Soc 2005 Jun;53(6):1046 50 [PMID: 15935032]
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While the initiation of hospice care is often described as a transition from aggressive care to comfort care, hospice care also provides aggressive care, though not directed at achieving a cure or prolonging life It is more appropriate to consider hospice care as one among many health care resources available to patients at the end of life Helping patients decide when to avail themselves of the resources of hospice or inpatient palliative care is an important function even for clinicians providing the most aggressive and intensive curative medical interventions One advantage of providing palliative care simultaneously with other medical treatment early on is that it avoids any decision about when to start palliative care and what it means to the patient While most people prefer to die at home, inpatient palliative care may be more appropriate for patients with complex, severe symptoms that are difficult to manage at home
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