The Medical Minute: Hospice care -- compassion in dying

January 09, 2007

By John Messmer
Penn State Family and Community Medicine
Penn State Milton S. Hershey Medical Center
Penn State College of Medicine

The only sure things in life, they say, are death and taxes. While nothing can assuage the sting of death, taxes -- although inevitable -- need not be depressing and uncomfortable. Technologic advances have revolutionized medical care in the last 50 years. Treatments abound that present alternatives to facing the possibility of death and give people hope that their demise may be postponed. Physicians' training often does not address dealing with death, and they become part of the reason that people fail to plan what they want when the time comes. The latest edition of The Medical Minute, a service of Penn State Milton S. Hershey Medical Center, examines hospice care's ability to fill the final stage of life with peace and dignity.

Views on dying have changed in the last half-century. In the past, most people died quickly from infectious diseases or at birth with little time to prepare. Life expectancy has improved through advances in public health and technology such as antibiotics, life-support systems, advanced surgical techniques and effective medical treatments for cardiovascular disease and cancer. Death is still inevitable, and it can sometimes be a lonely, lengthy and unpleasant process.

When most people think of discomfort in dying, they typically think of cancer. The reality is that death results from many other conditions that tax patients and their families during the dying process. Though much heart disease is preventable and treatable, still a heart can fail slowly with no hope of improvement. Neurologic deterioration as in Alzheimer's dementia can take a very long time, particularly with highly effective treatments for pneumonia and other illnesses that a generation ago ended a person's life more quickly. Even old age itself has the potential to be a burden.

In 1969, Elizabeth Kübler-Ross published "On Death and Dying," a book which raised Americans' awareness of the emotional needs of dying patients and their families. She turned the spotlight to the work of Dame Cicely Saunders, United Kingdom, and Florence Wald, dean of the Yale University School of Nursing in the 1960s. Their work led to the 1974 establishment of the United States' first hospice, located in Connecticut. Apparently, the hospice concept filled a void, as evidenced by the establishment of roughly several thousand hospices in the decades since then.

Hospice care provides supportive social, emotional and spiritual treatment of terminally ill people. Hospice medical treatments focus on palliative care to reduce or control pain, anxiety and other troubling symptoms. Hospice caregivers view the final stage of life as a time that should be lived to the fullest and shared by a circle of family and friends.

Hospice care professionals and volunteers work to keep families together and provide care and support in the home if possible, but short-term care in a skilled nursing facility or hospital also is available if needed. Many services are offered, including nursing and physician services, emotional and pastoral care and home-health aides. Hospice organizations can include volunteers who help with daily tasks such as shopping, driving and companionship.

Hospice is not "giving up"; medical treatment continues in hospice. The difference is that care is directed to treatment of pain, difficulty breathing, anxiety, depression and other symptoms, so that the final months or weeks of life are more comfortable. Treatment is not aimed at cure but at palliation. Once a person has reached the point where improvement or cure is not possible, the goal changes from living longer to dying well. This positive approach to death helps to remove the anger, depression and guilt that can accompany the dying process. The dying person and his or her survivors can find serenity in a peaceful death.

Sometimes doctors will suggest hospice care when there is no further treatment for a condition, but formal referral by a physician is not necessary -- anyone can initiate a request. For a patient to receive hospice care, however, a doctor must certify that the patient is not likely to live for more than six months. The hospice care team and doctor will work out a plan of care aimed at providing only those treatments that relieve symptoms. There is no time limit for hospice services. If the person's condition improves, hospice can be discontinued and begun again later if needed or extended as long as the person is considered to be terminally ill -- that is, not likely to improve or be cured.

Hospice care is paid for by Medicare and Medicaid and most managed-care organizations. It is available to people of all ages, not just the elderly. Medicare and Medicaid pay for all aspects of hospice care with a $5 co-pay for medications.

Hospice is available almost everywhere. Many hospitals have hospice organizations, and private hospice services are listed in the Yellow Pages. Don't wait until the last days to seek hospice care. Since that time frame can be difficult to judge, even for doctors, it pays to discuss hospice care with a physician early, even if it is uncertain whether the condition is terminal. There's no obligation to asking.

Fear of dying alone or in pain is no longer necessary. When the time comes, hospice can provide life's final passage with peace and dignity.

For information on hospice services, payment and choosing a hospice, visit http://www.hospice-america.org/ , http://www.nhpco.org/ or http://www.hospicefoundation.org/ online.

Information on Medicare and hospice services is available at http://www.medicare.gov/publications/pubs/pdf/02154.pdf online.

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Last Updated March 19, 2009