Hospice Care vs Palliative Care

[VickyRN]

Hospice 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. It's 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

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.

Differences / Similarities

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.

[Tragically Hip]

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.

[NurseDirtyBird]

Part of me wants to balk at the accusations levelled against LTC facilities, like "Nuh uh, we don't do that." But yeah, you guys are right. LTC facilities are horrible places for hospice care. I try, as an LTC floor nurse, to do my best with my hospice patients, but in that environment, the squeaky wheel is always the one that gets the most grease. Hospice patients that come through my facility are often obtunded, bed bound, and unable to make their needs known. They are most often placed on the rehab unit (as they are considered short-stay), where fully A&O patients are able to verbalize their needs and have them met. It's so easy for me to get incredibly busy with my 21 other (vocal) patients before I realize that my hospice patient's morphine is overdue and they're probably very uncomfortable.

I also frequently see that hospice care is started a day late and a dollar short. The shortest time a patient stayed on my floor was a man who showed up around 3pm, got his PCA started by the the hospice nurse, and was gone by 8pm. The amount of pain that man was in was ridiculous, and if only his family would have accepted the prognosis, he would have been saved the suffering. I see it so often. I've had family members refuse to sign a POLST because they think it means we're just going to let their (mother/father/sibling/spouse) die. No amount of explaining that you can choose full treatment, and always change your mind will get them to sign. Their denial is so great, they don't even want to think about the possibility that their loved one could be in a situation that they may not survive. This denial and fear surrounding death is a social ill. People are so afraid of it, they refuse to think about it or discuss it until the very VERY last minute, and by then it's too late.

And don't get me started on the horrible things people say to dying family members! Gah!

[tewdles, RN]

There are many misconceptions and misunderstandings of what "hospice care" means. Palliative care is the portion of hospice care that can be shared with patients no matter their life expectancy.

No matter where the patient lives, the hospice care will only be as good as the people running it expect and plan for it to be.

[Jack Hazz, BSN, RN]

Just curious...you all know hospice care is a type of palliative care, right?

I do not understand why you are comparing a whole apple with a sliced apple.

The whole idea of palliative care is to treat the symptom of a disease that might or might not be treatable. The main idea of hospice is to treat the symptom of an otherwise untreatable disease to promote comfort during the end of life. That is still palliation, but with hospice, the patients are at the end of life or are given a period of time to live.

[toomuchbaloney]

Which came first, palliative care (as a specialty) or hospice?

[Jack Hazz, BSN, RN]

I do not know. But as far as i know, hospice care is a branch of palliative care...not the other way around. Not all palliative care is hospice but most hospice care is palliative.

Example? People with dementia under hospice care...normally, hospice nurses and MDs will recommend taking Namenda off the med list. What is the point? They are at the end of life and namenda will no longer treat it...instead, we try to palliate the obvious signs that might affect their comfort.

But for those with dementia that are not given a time frame to die in 6 months...yeah, give them namenda...thats palliating a disease.

[toomuchbaloney]

I do not know. But as far as i know, hospice care is a branch of palliative care...not the other way around. Not all palliative care is hospice but most hospice care is palliative.

Example? People with dementia under hospice care...normally, hospice nurses and MDs will recommend taking Namenda off the med list. What is the point? They are at the end of life and namenda will no longer treat it...instead, we try to palliate the obvious signs that might affect their comfort.

But for those with dementia that are not given a time frame to die in 6 months...yeah, give them namenda...thats palliating a disease.

The reality is that hospice has been around for much longer than Palliative care as a discipline and specialty. Palliative care was born out of the hospice moveme, hospice did not branch FROM palliative care. At this time they are "sister" specialties, sharing a philosophy of comfort as a goal.

Most gerontologists and Hospice Medical Directors and PharmDs I have worked with have advocated for discontinuing the Namenda if the patient has suffered a significant enough decline in cognitive and physical status to qualify for a hospice EOB. This is especially true if the dementia patient is experiencing anxiety or difficulty taking oral meds at time of EOB. Additionally, if the Namenda is not providing obvious relief from symptoms many hospice programs are not interested in spending their pharmacy dollars in that way.

[Jack Hazz, BSN, RN]

You are quite right about hospice not branching out from p

[MunoRN, RN]

The speciality of "palliative care" actually predates hospice, it just hasn't always been called "palliative care". Palliative care refers to speciality of treating a patient's response to a disease process, rather than treating the disease itself, which is also describes the specialty of "Nursing". A palliative care Physician is basically just someone who practices classic Nursing but with a medical license.

[Libby1987]

Damn, I thought a hospice patient was at a higher level of care as an inpatient but they just have more liberal prns.

I also thought with a LTC hospice bed that family would still participate as caregivers in the ways that they physically were able, but still remain at the bedside.

[toomuchbaloney]

The speciality of "palliative care" actually predates hospice, it just hasn't always been called "palliative care". Palliative care refers to speciality of treating a patient's response to a disease process, rather than treating the disease itself, which is also describes the specialty of "Nursing". A palliative care Physician is basically just someone who practices classic Nursing but with a medical license.

The philosophy of palliative care may predate hospice but the specialty itself does not. That is in large part semantics but is nonetheless true.

[toomuchbaloney]

Damn, I thought a hospice patient was at a higher level of care as an inpatient but they just have more liberal prns.

I also thought with a LTC hospice bed that family would still participate as caregivers in the ways that they physically were able, but still remain at the bedside.

A hospice patient on General Inpatient level of care (GIP) are at a higher level of care. The POC must reflect the higher standard in order to meet the criteria for billing at a higher rate.

The presence of a hospice patient in a LTC is not a guarantee that the patient is a GIP level of care, however. Most of the time the hospice care occurs in the LTC simply because that is where the patient resides full time. Similarly, not all LTC are capable of providing the nursing supervision necessary to qualify as a GIP level facility.

Dependent upon the policy of the LTC, the family may well participate in the ongoing physical and emotional care of the hospice patient.