After the recent furor in the press about the "costs" of hospice and the rise of for-profit hospices, it seems important to correct the public record. Although the Medicare hospice benefit, like all government programs, has been the victim of fraud and abuse, hospice care remains the gold standard for care of the dying. More importantly, it is increasingly apparent that the multidisciplinary approach to chronic illness that began with the hospice movement has become the "best practice" for care of all patients in the future.
Hospice care is a philosophy and approach to supporting patients at the end of life that emerged in the 1960s and became a Medicare program in 1986. The growth of hospice began as a response to health care that had become increasingly technological, creating a medical establishment that viewed dying as a failure of modern medicine. As life expectancy increased, and chronic disease and cancer supplanted trauma and infections as the prevailing causes of death, dying became increasingly removed from our homes and our lives. Early hospice pioneers recognized that rather than being a medical event, dying is a process that happens within families and communities. They understood that inside this broader context, pain and distress usually have multiple sources. The hospice founders devised a team approach to address each one of these: nurses to alleviate physical suffering; a social worker to help with family, financial and other stressors; a chaplain to deal with existential distress and spiritual alienation; and others as needed to provide control of "total pain." Hospice was one of the first programs to use this multidisciplinary approach to put the patient and family - rather than disease - at the center of medical care.
With the spread of the hospice movement and advances in medicine, it became apparent that this holistic approach to patient care was needed much earlier in the course of advanced disease. Enrollment in hospice requires that patients have a six month life expectancy, but many persons with serious illness live for years with untreated distress. The specialty of palliative medicine grew out of the failure of hospice programs to serve a burgeoning population of patients living with chronic illness. It brings multidisciplinary, patient-centered and goal-directed care to these patients much earlier in their disease trajectory.
Why is the palliative care model a "best practice" for managing patients with chronic illness? Let's look at the facts.
First, early palliative care and hospice enrollment result in better outcomes. Multiple studies have demonstrated that less aggressive care at the end of life and longer hospice stays result in enhanced quality of life, and better physical and mental health for surviving caregivers. Other studies have demonstrated improved survival for hospice patients with certain terminal illnesses. Recently, a landmark study revealed that patients with advanced lung cancer who received early palliative care along with standard cancer care lived six weeks longer than patients who got standard cancer care alone.
Second, hospice and palliative care result in significant cost savings. Patients who receive palliative care have fewer hospital admissions and readmissions, fewer emergency room visits, shorter intensive care unit stays and receive fewer burdensome and futile interventions. This translates into savings overall for the Medicare system. A 2013 study showed that financial benefits for Medicare grow the longer the patient receives palliative care services. The authors concluded that rather than working to reduce Medicare hospice spending, the Centers for Medicare and Medicaid Services should focus on ensuring that patients' preferences are elicited earlier in the course of disease and barriers to hospice enrollment are removed.
Third, multidisciplinary palliative care is based on shared decision-making between medical providers and patients. Palliative care and hospice teams work with patients to formulate realistic care plans that take into account a myriad of needs and, most importantly, are congruent with patient and family values.
Improving the U.S. health care system requires simultaneous pursuit of three aims: ensuring positive health outcomes and patient satisfaction while reducing costs. This triple aim has become a widely adopted framework for health care reform. Multidisciplinary palliative care satisfies all components of the triple aim, and provides a model for "best" management of patients with advanced chronic illness. Pioneered by the hospice movement, this individual and family-centered, goal-directed and cost-effective health care is the "medicine" most of us will eventually need, and all of us deserve.
ABOUT THE AUTHOR
Dr. Margaret Jacobson is medical director at Whatcom Hospice and is in practice at Family Care Network's Squalicum Family Medicine.