Palliative Care as a bridge to hospice

31May13

Traditionally when people think of palliative care they assume it means that the person is going to die. In reality palliative care is care aimed at alleviating symptoms. For example someone taking an over the counter acetaminophen for a headache is receiving palliative care. In palliative care the focus changes from trying to identify an underlying cause and focusing on relieving the suffering from the symptom regardless of what is causing it.

It comes as a surprise to many people that often times the underlying cause is not known and may not be known without subjecting a person to more pain and suffering. In these instances targeting the symptoms of discomfort becomes the more humane method of treatment. Some conditions like Alzheimer’s Dementia cannot be diagnosed until death by autopsy. While there are objective tests that raise index of suspicion or point in the direction of a diagnosis they are not confirmatory. So a patient with Alzheimer’s Dementia can be treated to help mitigate the impact of an illness that is expected to decline with the development of multiple other medical problems.

The primary aim of palliative care is to restore or maintain quality of life. Similar to primary care the philosophical aim is to help a patient live the best possible life they can given their circumstances.

Palliative care is sometimes the first step in progressing towards hospice. Hospice is a formalized program that brings together an integration of services including a physician, registered nurse, social worker, chaplain and home health aide for respite care.  Hospice is a medicare covered benefit and various rules do apply. Sometimes people are discharged from hospice if they plateau. The criteria for hospice has changed over the years. Previously a physician would be asked to answer the question is this person going to die in 6 months? If the answer was yes, then the person would be enrolled in hospice and many times the patient would outlive hospice. In the effort to balance resources physicians would often wait to long to make the referral and most people would die within 24 hours of being place on hospice.

Now the question that is asked is would you be surprised if the patient died in 6 months? This has led to far more referrals to hospice. So many infact that hospice has become big business. Medicare pays a fixed dollar amount regardless of the amount of care that is actually rendered. Families then have to supplement the care with private funds as they see fit. As a result in NYC there is an average of a 5-7 day wait to get onto a hospice program which once in place takes at least 2 days to become fully implemented. Many times the person dies in this waiting period, but the family is left unsupported and the patient may have needlessly suffered. Many times this is the person that is taken to the Emergency Room and heroic measures are implemented only for the person to end up dying in an intensive care unit.

There is a nurse practitioner medical house call practice that provides palliative care as a bridge to hospice with in 24-48 hours. In the traditional hospice model the Nurse Practitioner is not able to certify the patient as terminal and make the referral to hospice, but once a condition has been deemed terminal the nurse practitioner can take over the care management. This restriction does not apply to private paid hospice only to government funded hospices. 

In the above scenario the private practice nurse practitioner would come to the home and evaluate the patient, reach out to the patient’s previous physician to gather data and diagnostic results that have led to the terminal diagnosis i.e. dementia, cancer, CHF, COPD, complicated geriatric syndromes etc. The nurse practitioner would then order medications for comfort (also known as the comfort pack) and help place home health aides. The nurse practitioner would provide the family education and psychosocial support and help instruct the aides on how to care for the specific needs of the patient. At the same time the referral would be made to a traditional hospice program should the family desire. If the patient should die before the hospice opening becomes available then the pronouncement of death and certificate can be made by the Nurse Practitioner or the previous physician as they will have been informed and consulted in the process. The patient is able to remain in the home and pain free while getting the care they need when they need it.

I also advise that if the patient cannot get out to the physicians office due to excessive burden that the medical house call be investigated. Medical house call practices are not all gone and some are up and coming. This may be the best way to insure timely care is delivered and pain and suffering are diminished.

I invite your comments on the topic of palliative care, end-of-life care, hospice, medical house calls. If you find this article helpful please share it with others. 



One Response to “Palliative Care as a bridge to hospice”

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