Late referrals = less hospice care
When a patient is referred to a hospice with a week or two (or even less) to live, there is a strong likelihood that they will receive crisis intervention, rather than true hospice care. This is because hospice care is a holistic approach to care, delivered by an interdisciplinary team trained to deal with the physical, spiritual and emotional care of the patient and their family. Good hospice care requires time to deal with the myriad issues that arise at end of life.
Those of us in hospice work continually wonder why we receive so many referrals so late in the dying process. We do realize that prognostication of a terminal illness is far from an exact science, and that some physicians are reluctant to attach a time line to a diagnosis’ progression. This may well lead to a late hospice referral.
We also know that federal regulators have increased scrutiny over the last several years in a number of different areas, including the validity of hospice referrals. Recently, the federal body that administers the Medicare program has been reviewing its position on referrals and has concluded that past practices have resulted in reluctance on the part of physicians to refer patients to hospice, with the end result being that otherwise eligible patients had not been referred to hospice service in a timely manner. This means that people may not be receiving hospice services as early as they should.
The regulators have now begun trying to inform physicians that there is no danger in referring patients to hospice even though they may live beyond the required, initial six-month prognosis.
A recently published article by the Medicare regulators said:
“Increasing numbers of Americans – and their physicians – now recognize that much of the pain and sense of hopelessness that accompany terminal illness can be eased by services designed specifically to help them: services that are covered by Medicare. End-of-life care offers the satisfaction of easing physical and emotional pain through effective palliative treatment when cure is not possible.
“Physicians and other health care practitioners, who also confront a sense of loss with terminally ill patients, can be encouraged that the Medicare program includes a hospice benefit that provides coverage for a variety of services and products. When properly certified and appropriately managed, hospice care is a valuable and legitimately covered treatment option.
“Many physicians also appreciate the fact that end-of-life care enables family and loved ones to participate in the experience and to get help from the hospice in managing their own feelings and reactions to the ailment.”
The article further states that despite a growing appreciation for end-of-life care both as a philosophy and as a fully covered Medicare benefit, there exist two perceived barriers to its broader acceptance. First is an understandable reticence to contemplate the end of life.
A 1999 survey conducted by the National Hospice and Palliative Care Organization (NHPCO) found that Americans generally are reticent to discuss end-of-life care with their elderly parents. According to the survey, fewer than one in four of us have put into writing how we wish to be cared for at life’s end. About one in five have not contemplated the subject at all, and a slightly smaller number told the surveyors they have thought about it but have not shared their thoughts with others.
The second perceived barrier is a less-than-full awareness on the part of both patients and practitioners that the covered hospice benefits are both broad and readily available virtually everywhere in the country.
Hospice care has been a fully reimbursable Medicare Part A benefit option for beneficiaries and providers since 1983, and it is also a Medi-Cal covered benefit.
Working with the dying is very rewarding work. And although there is frustration in seeing patients referred late, we are optimistic that we will see a change – an improvement that results with appropriate care at end of life. With the renewed sensitivity by federal regulators, we are left hopeful that the medical community will follow this lead and not be as concerned with length of time for eligible hospice patients, but concerned only with the best end of life care we can deliver together to our community.
Since becoming a Medicare certified hospice in 1994, Hospice of the Foothills has been vigilant about not allowing Medicare to define what hospice is. It has been a challenge to maintain the heart of our care when more and more regulation is heaped upon us.
Although hospice care is reimbursed by Medicare, it is important to point out that our services are delivered equally to all patients regardless of ability to pay. In order to perform the best hospice care possible, we must be licensed and certified, and in order to maintain our mission we must perform our care from the heart. In the past, we have experienced undue scrutiny over the appropriateness of a terminal prognosis. Thankfully, we are now seeing a reversal on that position and seemingly a recognition of the importance of an early hospice referral.
As we mature as a society, we will see a change in how we treat our dying. We have a long way to go in order to reach an acceptable level of caring for our elderly and dying, but there is evidence all around that we are beginning to normalize the end of life process. Even our Federal regulators are now trying to provide some guidance in this area.
We need to reach a level of change similar to that which transformed the birthing movement. Ideally, the process of dying, like being born, should happen while we are surrounded by loved ones, in a homelike setting, When we all can view dying similarly and realize that it is not a medical event, but a spiritual process, we will realize the value of good end of life care. Only then will we be able to deal realistically with this difficult topic and to provide the very best care possible to our loved ones.
Dennis Fournier is executive director of Hospice of the Foothills in Grass Valley.
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