Hospice Care

Noncurative medical and support services for patients with terminal illnesses (life expectancy <= 6 months) and their families.

Every state has at least one certified hospice program, and the care may be provided by home health care agencies, freestanding programs, hospitals, or skilled nursing homes. Currently, 42 states include hospice care under Medicaid, but hospice accounts for only about 1% of the Medicare budget.

In Medicare-certified hospice programs, core services include nursing and physician services (a physician must be a salaried member of the team); medical social work; counseling (including dietary and pastoral); physical, occupational, and speech therapy; home health aide and homemaker services; short-term inpatient care (including respite care and pain control or management); medical appliances and supplies; and drugs. Bereavement counseling services for family members are provided for up to 12 months after the patient's death.

The team develops and coordinates an individualized care plan together with the patient and family members. Hospice physicians review the care plan, visit the patient regularly, prescribe drugs for palliative care, review the patient's condition and prognosis with hospice personnel, and sign the death certificate. The patient's own physician can retain primary medical responsibility. However, many often willingly relinquish responsibility to the hospice physician because they do not have as much experience in pain management and symptom control and do not have regular contact with hospice team members for home visits and problem solving.

Patients who elect the Medicare hospice benefit must waive standard Medicare benefits for conditions related to the terminal illness. Eligibility to receive care for other intercurrent problems is not affected (eg, a hospice patient with lung cancer can be treated for injuries sustained in an automobile accident). The Medicare hospice benefit is divided into an initial 90-day period, a subsequent 90-day period, and an unlimited number of subsequent 60-day periods as long as the patient continues to meet eligibility requirements. Physicians must certify at the beginning of each period that the patient's illness is terminal with a life expectancy of >= 6 months. The average number of days in hospice has increased from 37 days in 1988 to 59 days in 1995. This increase indicates a greater acceptance of hospice services by patients, their family members, and physicians; however, duration of hospice care is often not long enough to help patients and their family members prepare for death.

Before choosing hospice care, patients and their family members are told that the hospice agency will take only limited action, if any, to prolong life. Hospice patients decide the number and kinds of treatment they will receive. Advance directives, including appointment of a health care proxy and durable power of attorney for health care, ensure that patients' choices are followed.