Hospice Care Versus Palliative Care

  1. 11

    Confusion abounds concerning hospice care and palliative care. Although very similar in philosophy and goals, these two specialty areas are not necessarily synonymous. To help clear up the confusion, this article highlights the similarities and differences.

    Hospice Care Versus Palliative Care

    Hospice care is defined as support and care for terminally ill persons to help them achieve maximum comfort and the greatest satisfaction possible with remaining life. Its services are designed to optimize the care experience at end-of-life.

    The focus is on the quality of remaining life rather than life extension or the hope for a cure. Hospice neither speeds up nor slows down the dying process, as this philosophy of care accepts the fact that dying is a normal part of life.

    With hospice, there are valid concerns of underutilization and ineffective use. Even though almost 42 percent of eligible terminally ill patients receive hospice services at some point before they die, the median duration of hospice services is only 19.7 days.

    This means that half the patients are enrolled in hospice care for just under 3 weeks. This median length of service is a decrease from 26 days in 2005. Such short stays in hospice do not give health care professionals enough time to develop and implement a patient centered plan or adequately prepare families to take care of their loved ones at home.

    Many physicians are slow to refer people to hospice, waiting to acknowledge with certainty that the patient is terminal. This may be due to the fact that most physicians traditionally concentrate on trying to cure patients. The concept of treating symptoms without curing the underlying disease is often foreign to them. As a result, the majority of patients enroll in hospice in the very end-stages of their diseases, often at a point when death is imminent, much too late to optimize the benefits of hospice services.

    Palliative care had its inception in the hospice movement but is now widely used outside of hospice locations. Palliation is a broad term that focuses on the relief and prevention of suffering in patients whose diseases or conditions are no longer responsive to curative treatment, due to life-limiting illness.

    The goal of palliative care is to prevent, manage, and relieve unpleasant symptoms and to promote the best possible quality of life for patients as they near life's end. The point at which palliative management eclipses curative treatment is not an exact science, but must be decided on a case by case basis with considerations of the unique circumstances of each individual patient.

    Although similar, palliative care and hospice are not necessarily synonymous. Both healthcare specialty areas use an interdisciplinary approach to treat patients with life-limiting diseases, chronic illness, or progressive neurological conditions who are nearing the end of life. Both focus on providing these patients with the best quality of life possible by maximizing functional capacity and by relieving distressing symptoms such as pain, shortness of breath, fatigue, nausea, anorexia, and constipation.

    Palliative care is most often provided in the hospital, whereas hospice most often takes place within a patient's home.

    With palliative care, therapies intended to prolong life may still be provided, since palliative care does not require the patient to give up the fight for a cure. Unlike hospice, palliative care does not always indicate end-of-life, as it may be provided at any stage during serious illness, from diagnosis through death. And, it can be used in conjunction with curative treatments.

    In sharp contrast, patients receiving hospice care must give up any treatments that are deemed curative or life sustaining, if they wish to receive coverage. Costs and reimbursement venues differ also.

    Hospice care is paid in full by the Medicare benefit and/or Medicaid. However, in order to qualify for Medicare or Medicaid hospice benefits, patients must be determined to be within the last 6 months of life. Palliative care, instead of being reimbursed in full, is often underfunded. As a result, hospice programs far outnumber palliative care programs, with palliative care being difficult to access in some areas.

    References:

    Hospice and Palliative Care
    NHPCO facts and figures: Hospice care in America (2011 ed.)
    Last edit by Joe V on Jan 13, '15

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  2. Visit  VickyRN} profile page

    About VickyRN

    VickyRN is a certified nurse educator (NLN) and certified gerontology nurse (ANCC). Her research interests include: the special health and social needs of the vulnerable older adult population; registered nurse staffing and resident outcomes in intermediate care nursing facilities; and, innovations in avoiding institutionalization of frail elderly clients by providing long-term care services and supports in the community. She is faculty in a large baccalaureate nursing program in North Carolina.

    VickyRN has '16' year(s) of experience and specializes in 'Gerontological, cardiac, med-surg, peds'. From 'Under the shadow of His wings...'; Joined Mar '01; Posts: 12,046; Likes: 6,466.

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    23 Comments so far...

  3. Visit  Susie2310} profile page
    2
    Thank you for a very useful article.
    TJ'sMOM and VickyRN like this.
  4. Visit  Jessica Sikazwe} profile page
    1
    Interesting. Thank you. Would Hospice care be a good topic for an Informative Speech?
    tewdles likes this.
  5. Visit  TheCommuter} profile page
    2
    Quote from Jessica Sikazwe
    Would Hospice care be a good topic for an Informative Speech?
    Yes, it would.
    tewdles and VickyRN like this.
  6. Visit  Jessica Sikazwe} profile page
    2
    Ok great! It's for my Speech class.
    tewdles and VickyRN like this.
  7. Visit  cherryames1949} profile page
    3
    Elimination of suffering is a worthy goal no matter what the setting. Understanding and education is the way to advance this goal. Thank you for the information.
    TJ'sMOM, tewdles, and VickyRN like this.
  8. Visit  billyboblewis} profile page
    5
    I have one problem with both of these types of care and the way the agencies providing them do it. They rent out space in LTAC's and other facilities and the patients are cared for as part of the regular population. They do not recieve the attention they should because staff feels they have just been left there to die. They may get pain meds on occasion but often becuase of their debilitiation and inability to request help or complain they are just ignored for most of the day. I much prefer when these companies maintain their own facilities and hope I am never left in the position to rot away and die in a rented bed.....
  9. Visit  cherryames1949} profile page
    1
    Thanks for the heads up billybob. Years ago a loved one of mine was in a nursing home being managed by hospice. I was UNimpressed. My friend was in agony when I arrived. I got the on call hospice nurse on the phone and got the situation worked out. I had to wonder what happened after I left. She mercifully passed away within the week. We can and must do a better job With end of life issues.
    Susie2310 likes this.
  10. Visit  VickyRN} profile page
    4
    Quote from billyboblewis
    I have one problem with both of these types of care and the way the agencies providing them do it. They rent out space in LTAC's and other facilities and the patients are cared for as part of the regular population. They do not recieve the attention they should because staff feels they have just been left there to die. They may get pain meds on occasion but often becuase of their debilitiation and inability to request help or complain they are just ignored for most of the day. I much prefer when these companies maintain their own facilities and hope I am never left in the position to rot away and die in a rented bed.....
    I agree. Same with skilled nursing/ rehab or "swing-bed" patients. These patients will receive a much higher quality of care in a hospital-based program or stand-alone inpatient hospice or palliative care facility than they ever will in a LTC or LTAC facility. There is a big difference in a ratio of 6 patients per nurse as opposed to 25 residents to nurse in the typical LTC or LTAC facility. One can't possibly give quality attentive care with these horrendous ratios.
    tewdles, Tragically Hip, Susie2310, and 1 other like this.
  11. Visit  Maremma} profile page
    6
    Indeed it is very distressing to me to have hospice patients mixed in with my LTC and rehab patients. They absolutely do not get the attention they need, at least not on second shift. I have several down my hall right now making it even more complicated and nerve racking.

    It certainly creates a lot more work for me with no additional help from anyone. They seem to all only come on day shift. If something changes in one of these patients I have to first call hospice to tell them and get their recommendations. wait for their return call. Wait again for them to call me back the second time to tell me what their RN super says to do. THEN I may call he Dr and ask him for whatever it is that they decided should be done or changed etc. Sometimes the Dr does not agree and I have to call them back again and go through the whole ordeal again. Mind you all the while still trying to get my med pass done and deal with all my other problems etc. Of course this is taking even more of my precious little time away from the patients.

    God forbid they admit someone to hospice on day shift, don't have the hospice sticker on the chart yet and haven't warned the poor nurse coming in on the second shift. It is the end of the world if you follow the orders still in place and call the Dr when x y or z happens, wind up with a new order for a med hospice won't pay for. Amazingly the hospice nurse will suddenly appear on second shift the next day to rip you a new one for not calling them first and getting their permission to call the Dr!

    Often the families seem to be misled or simply cannot understand when they agree to put family members on hospice too.They become very upset and some get outright nasty when their family member no longer can have things they were allowed to have before (there are almost always multiple med changes as soon as the patient goes hospice) They don't understand that their family member can no longer receive certain treatments they were before going hospice etc. Of course I am the nurse right in front of them so I get the backlash for this too.

    They become ugly because their family member is not receiving all the "extra" care they were "promised" by the hospice nurse. I take the backlash for that too. We simply do not have the time and staffing to provide extra care for some patients over the others and the hospice nurses and aids only get a few hours a week so they are rarely the ones there when family is. it is beyond frustrating to deal with the backlash when I was not even present for the intake. I have no clue what they are told or who was present etc for these meetings. I had a family member screaming at me because she walked into her mothers room and no one was sitting there to keep her mother company till she got off work and could come in?! She was convinced we were required to do this?

    Frustrating indeed. To many cooks in the kitchen only makes things worse for the actual patient.
    caliotter3, TJ'sMOM, cherryames1949, and 3 others like this.
  12. Visit  Tragically Hip} profile page
    4
    My mother entered hospice care in 2004 in a long term care facility that offered several levels of care. As a hospice patient, she was in the lowest care level unit. That meant that her care was always the lowest priority in an understaffed LTC facility. My father was pretty obsessive about helping my mother, but the more he helped the less he'd to, to the point he provided most of her care when she was there — the aids saw him as a volunteer 1:1 aid. The problem was that he himself had terminal cancer and was getting progressively weaker. There were numerous incidents of neglect. The only way to make it work was to hire someone to be with her around the clock, or at least, during her waking hours.

    Another great disappointment was the lack of attention to my mother's psychological needs. If I remember correctly, she had a visit by a social worker once or twice a week. The rest of the time she spent in virtual isolation when neither my father or I were there. In fact, having a roommate just made things worse. (The room was virtually indistinguishable from a semi-private hospital room.)

    The staff was not able to keep clothing from getting lost. Each week you never knew what you were going to get. It sounds like a small think, but it's one of the few things that gives a patient a sense of identity, other than her wrist bracelet.

    That was at a facility that is an adjunct to a hospital with a good reputation. (In this area, "good" means mediocre at best, unless you're very wealthy.) Talking to the ADoN and DoN would merely garner excuses, until they finally admitted what the problem was: an insufficient budget and insufficient staffing. I'm sure there were a lot of Medicaid patients in the facility, and I don't know what the answer is, but it's clear that there is a terrible lack of concern for the elderly and terminally ill in this country. It's a moral scandal.

    In some poor countries, it is expected that family members will provide for all the non-medical needs of the patients, from food to clean sheets. Given our country's social structure, that would be very hard to do here, and given our wealth, it shouldn't be necessary, Ron Paul zealots notwithstanding.

    It would have been far better if she could have remained at home. She did not need sophisticated care; she need assistance with feeding and walking, and simple psychological counseling. There was no coverage for that, though. It was also difficult, given my father's declining condition. In retrospect, regardless of coverage, I'd have found a way to make home care work.

    I live in an area of the country that is particularly deficient in health care quality and availability, and my mother's facility does not represent all facilities in this area (though I know that there are worse, which is hard to imagine). Still, my own experience with hospice care can be summed up in one word: Neglect.

    As a society, we just don't give a d**n.
    tewdles, cherryames1949, Susie2310, and 1 other like this.
  13. Visit  VickyRN} profile page
    3
    Quote from Tragically Hip
    My mother entered hospice care in 2004 in a long term care facility that offered several levels of care. As a hospice patient, she was in the lowest care level unit. That meant that her care was always the lowest priority in an understaffed LTC facility. My father was pretty obsessive about helping my mother, but the more he helped the less he'd to, to the point he provided most of her care when she was there — the aids saw him as a volunteer 1:1 aid. The problem was that he himself had terminal cancer and was getting progressively weaker. There were numerous incidents of neglect. The only way to make it work was to hire someone to be with her around the clock, or at least, during her waking hours.

    Another great disappointment was the lack of attention to my mother's psychological needs. If I remember correctly, she had a visit by a social worker once or twice a week. The rest of the time she spent in virtual isolation when neither my father or I were there. In fact, having a roommate just made things worse. (The room was virtually indistinguishable from a semi-private hospital room.)

    The staff was not able to keep clothing from getting lost. Each week you never knew what you were going to get. It sounds like a small think, but it's one of the few things that gives a patient a sense of identity, other than her wrist bracelet.

    That was at a facility that is an adjunct to a hospital with a good reputation. (In this area, "good" means mediocre at best, unless you're very wealthy.) Talking to the ADoN and DoN would merely garner excuses, until they finally admitted what the problem was: an insufficient budget and insufficient staffing. I'm sure there were a lot of Medicaid patients in the facility, and I don't know what the answer is, but it's clear that there is a terrible lack of concern for the elderly and terminally ill in this country. It's a moral scandal.

    In some poor countries, it is expected that family members will provide for all the non-medical needs of the patients, from food to clean sheets. Given our country's social structure, that would be very hard to do here, and given our wealth, it shouldn't be necessary, Ron Paul zealots notwithstanding.

    It would have been far better if she could have remained at home. She did not need sophisticated care; she need assistance with feeding and walking, and simple psychological counseling. There was no coverage for that, though. It was also difficult, given my father's declining condition. In retrospect, regardless of coverage, I'd have found a way to make home care work.

    I live in an area of the country that is particularly deficient in health care quality and availability, and my mother's facility does not represent all facilities in this area (though I know that there are worse, which is hard to imagine). Still, my own experience with hospice care can be summed up in one word: Neglect.

    As a society, we just don't give a d**n.
    This is terrible, Tragically Hip, but I suspect not uncommon in the scandalously understaffed LTC facilities across our nation. Thank you for sharing your poignant, heartfelt account. I agree - the way we value and treat the elderly in this nation is disgraceful. I am so sorry that your mother experienced such lack of care and attention. No human being should ever have to endure such neglectful treatment, let alone the elderly and vulnerable. It is difficult enough having a loved one who is terminally ill and on hospice (I know -both my mother and sister were on hospice before they died and experienced peaceful deaths in the familiar surroundings of their respective homes), but to have to continually fight for proper care on top of the stress of watching your loved one slowly fade into an inevitable death would be horrible indeed. We all need to be advocating for better staffing in LTC facilities. Changes need to be made in the state legislatures; most laws concerning staffing in nursing homes have not changed since the 1990s, whereas acuity levels have risen sharply and reimbursements (Medicaid and Medicare) have dropped. Again, so sorry you and your family went through this.
    Last edit by VickyRN on Jul 21, '12
  14. Visit  Tragically Hip} profile page
    4
    Thank you for your reply, Vicky. It's been difficult for me because I've replayed the scenario a thousand times in my head, and now I know there are things that I could have done better, things that might have really improved my mother's situation. Five months after that my father was hospitalized for three months — he died in the hospital. My father's own doctors (in a cardiology practice) had no idea what was going on on the hospital floor, though many of his patients were at the facility. During the last week of his life, after the DNR was signed, the staff doctor kept pushing to have my father moved to hospice care, which I resisted.

    There was absolutely no coordination of care. That is a big problem in palliative and hospice care, but it's a disaster in standard hospital care. I was the default coordinator. My father's PCPs were way above all that. And he had so many doctor, few of whom said a word to each other. The biggest disaster: my father had a stent in a ureter to keep it open against the pressure exerted by an abdominal tumor. (The other kidney had already failed.) It had to be replaced periodically, every few months. I'd lost track of it, and so did everyone else, including the urological surgeon who at the time was the primary doctor. It led to kidney failure, which led to a cascade of very bad sequelae. My father's urologist pretty much yelled at me for neglecting to have the stent changed. At that point I was so beaten down that all I could do was stare. The doctor may have been right, but with tens of thousands of dollars per week going to his care, I found it hard to believe that no one among the doctors and hospital staff was keeping track of such critical things. What about people who had no one to advocate for them?

    As far as the subject of this thread is concerned, my father spent the last few weeks of his life on a med/surg floor, and there were problems in that environment as well.

    Some time after that, I enrolled in a year-long patient advocacy program, and I learned quite a bit about the business of health care, the incredibly complex public system, medical ethics, and the importance of having a care coordinator. I now have a certificate, but have found that the people who really need help are those with few financial resources. Also, the career is difficult to pursue without an RN license or MSW. I have helped some people, some of whom are lost in a system foreign to them. (Some had never been hospitalized in this country.) I learned quite a lot helping an elderly man who, while needing help with some tasks, had a great understanding how to get things done. He had Medicare part A but not B, yet managed to get everything he needed with respect to in-home nursing and rehabilitation (at a very advanced age, he received a hip transplant). I learned a lot from him. Unfortunately, those without his moxie and knowledge are left to twist slowly in the breeze, especially if they have no family or close friends who are willing to be involved in his care.
    tewdles, cherryames1949, VickyRN, and 1 other like this.


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