Understanding Hospice — An Underutilized Option for Life's Final Chapter (NewEngJourMed)

Article is by a physician at Boston's Brigham and Women's Hospital - a leader in hospice care approaches.

Understanding Hospice — An Underutilized Option for Life's Final Chapter
Gail Gazelle, M.D.

It was Mr. G.'s third exacerbation of congestive heart failure in the past 6 months. Eighty-three years old, he had New York Heart Association class IV heart failure, end-stage coronary artery disease, and insulin-dependent diabetes. Although he had never wanted to be put on a ventilator, this time his shortness of breath was so terrifying that he felt he had no choice. After having a good response to diuresis, he was successfully extubated and transferred out of the coronary care unit.

Two days later, a hospitalist suggested to Mr. G. and his wife that given his advanced disease, he should consider going home and receiving hospice care there. Sensing the couple's fear, she reassured them that death was not imminent and that members of the hospice staff would work to ensure the best possible quality of life. Relieved, Mr. G. acknowledged that he would prefer to avoid rehospitalization.

Introduced in the United States as a grassroots movement more than 30 years ago and added as a Medicare entitlement in 1983, hospice care is now considered part of mainstream medicine, as evidenced by growing patient enrollment and Medicare expenditures (see table). In 2005, more than 1.2 million Americans received hospice care, and between 2000 and 2004, the percentage of Medicare decedents that had been enrolled in hospice programs increased by almost 50%. But despite its increased use, many aspects of hospice care are still misunderstood by both physicians and patients.

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With the growing number of baby boomers seeking more control over all aspects of their health care, the use of hospice care will probably continue to increase. It is especially important, therefore, that physicians become more familiar with what hospice care offers and work to overcome barriers in talking frankly with patients about what lies ahead.


Source Information

Dr. Gazelle is a member of the Division of General Medicine and Primary Care at Brigham and Women's Hospital and president of MD Can Help — both in Boston.

The New England Journal of Medicine is owned, published, and copyrighted © 2007 Massachusetts Medical Society. All rights reserved.

http://content.nejm.org/cgi/content/full/357/4/321?query=TOC

organization that helped my family immensely in our time of need.

up hope - no matter what the doctors say.

Cardiologists (at a top hospital) gave my brother 3 years to live and its 7 years later. They recently dropped him from their heart failure program as they needed the spot for people who were worse off and declared him "cured" and released him.

I don't wish anyone to ever have to go there, but too many people have had to. And will have to. Learning about the benefits of hospice will help a lot of people.

Prognosis is a topic discussed often in hospice programs as are the concepts of hope.

Usually a physician's prognosis is based on the average life expectancy with the condition, factoring in a patient's overall health, family history, etc etc. And as often, the patient's perception of a prognosis is a part of the picture. The common phrase "I've been given x years to live" is taken as a surety of sorts. And it's not the case. Physician's don't know for sure, everyone's different, and physicians obviously can't "give" a certain amount of time, except in real short periods. Your brother has shown that a prognosis is not written in stone. Docs know that, yet people tend to read it as such. I'm glad he has lived beyond the statistics.

Hospice tends to look at hope on a broad scale, as well. Many people think hospice care means "giving up hope". Programs work to support realistic hope not the absence of hope. Hope for a cure, hope for an extended lifespan, hope for a chance to wrap up some loose ends, hope for a full life - regardless of time, hope for effective pain management, and hope for an exit supported by loved ones.

Elisabeth Kubler-Ross took up the metamorphosis of caterpillar into a butterfly as a sort of trademark for her pioneering of the hospice movement. She had seen images of butterflies scrawled on to bunk bed posts in the death camps of Europe by children who realized they were going to die. Hope never dies. Nor love.



Once saying of her impending death, "I am like a plane that has left the gate and not taken off. I would rather go back to the gate or fly away."

Should you shield the canyons from the windstorms, you would never see the beauty of their carvings. - EKR

he was in a very nice care facility where he was in charge of what happened to him. he needed kidney dialysis 3x week and he lived near the center. it was a courageous decision on his point even though he understood no more exceptional means would be used to prolong his life. did not make the ending any better tho of course.

Msongs
www.msongs.com