Thought-provoking article on "hospice abuse"

Long Term Care Columnist / Guide · Jan 7, 2012

Well, I can't say for certain that situations like this never happen in good hospices, but I personally have never seen anything like it, and I've worked with many hospice patients---and many different hospices---for many years. I've even seen people "graduate" from hospice when their conditions stabilized and they no longer met the criteria for hospice care. The worst breach of conduct I personally have observed was committed by a hospice nurse who I witnessed handing out business cards to mourners at the memorial service of her client; and even that was merely tacky, not abusive or illegal (or even immoral in today's business climate).

I would HATE to see an entire philosophy of care destroyed by stories such as this. It's taken the hospice movement several decades to become established as an alternative to the type of EOL care that's become standard in this country---worn-out souls yearning for freedom only to be trapped inside broken shells, more dead than alive, hooked up to machines that keep their organs working long past the time when they would've given up the ghost if left to their own devices.

There are, undoubtedly, a widely scattered handful of hospice agencies where corruption and greed drive the decision-making processes, and they should be exposed for the charlatans they are. I would simply caution that the general public can be rather lazy in sorting the wheat from the chaff, and it would awful if people based their judgments about EOL issues on one or two particularly egregious examples of bad hospice care.

leslie :-D · Jan 8, 2012

this story is a travesty for eol care and the services that hospices provide for those who are dying.

i was both saddened and sickened for various reasons...

mainly because this man, a victim and product of a corrupt environment, died a tortured soul in dire straits.

i read every single comment, following the article...

and was taken aback mostly by those who lambasted the author of the article, for perceivably denouncing hospice as a vital and honorable service.

no one wants to hear these stories.

they cut right through our souls, as we try and conceive the inconceivable.

i too, am guilty of vocalizing my disgust towards these abhorrent monsters such as groomes.

these types feed on pulverizing any residual pleas for veracity and relief...no matter what or who the sacrifice.

no one wants to hear these stories...esp when the dying are the prey.

i am not certain if the author's intent was to disparage hospices...

or to make people aware, that even hospices, are capable of a, b, and/or c.

consciousness is truth...and truth is knowledge made powerful.

and so, whatever the reason was for this article, the message remains omnipotent.

let us keep our eyes and ears opened, for the sake of upholding the hospice philosophy and preserving the care our dying folks need and deserve.

you don't automatically give morphine to a pt when it isn't indicated.

you don't keep them bedbound.

not only do our pts have a voice, it should be the loudest in the room.

there's no reason to resent the article or its author.

this article should serve as a potent reminder of everything hospice should be/is, and shouldn't be.

at the very least, let's keep hospice, alive and kicking.

leslie

Esme12, ASN, BSN, RN · Jan 8, 2012

It the recklessness of the journalists that REALLY annoy me. Let's not punish the offenders but negate the entire system. :mad:

heron, ASN, RN · Jan 8, 2012

On the other hand, let us not indulge in denial that there's a dark underbelly to our industry. There's a fair bit of information out there that delineates the higher revenues of for-profit hospice companies ... and it ain't all due to "better management". Nor is the hanky-panky limited to for-profits.

I'm currently working in a non-hospice ltc setting. I'm enjoying the job and the people I'm working with, but it's been interesting to see the DON and ADON snarl whenever hospice is mentioned. Much of that is dysfunctional grieving, I'm sure ... but they have made some points that I can't counter. They are on the receiving end of the games that some hospice organizations pull to jack up their head-count while keeping their costs down. One result of that is whenever I raise eol comfort issues, I'm dismissed because "we didn't hire you to be a hospice consultant". Because I'm a hospice nurse whether I work for a hospice or not, I'll continue to address these things ... but it's hard, hard, hard right now.

This dynamic is not a result of reading biased articles ... it's a result of working with a number of hospice organizations that claim to be "all about the patient" but are really about something entirely different. I believe it behooves us to stay aware of the badness that can happen when we allow ourselves to be insulated from the consequences of our companies' policies and business strategies.

curiousauntie · Jan 8, 2012

Please, let's not start that "not-for-profit=goodness and light, and for-profit=the dark side" argument again. We all must abide by the regulations of Medicare, neither side gets a pass on elegibility requirements or basic service requirements. My hospice requires AT LEAST one RN visit a week, where Medicare says one visit every 2 weeks. We provide incontinence products (pull ups and diapers, with 4 different sizes available), basic care supplies, and ANY supplies that the patient needs for wound care...we have patients with homehealth aide visits 2 times a day, 7 days a week. And I work for a FOR PROFIT hospice. One large not-for-profit hospice in my area only gives a modified chux with tabs to use for incontinence...that is supposed to fit a cachexic or obese patient.

I refuse to believe that one hospice is better just on the virtue of an accounting form and paying less taxes as a not-for-profit.

leslie :-D · Jan 8, 2012

I refuse to believe that one hospice is better just on the virtue of an accounting form and paying less taxes as a not-for-profit.

i totally agree with you.

it'd be a dangerous presumption to think that all for-profits provide substandard care.

just like it'd be dangerous to presume all hospices are out to kill their pts, and take the money and run.

interesting that i came across this thread today.

and again, while not representative of the majority, it sends chills down my spine.

https://allnurses.com/nursing-issues-patient/pt-safety-question-659327.html#post6034147

leslie

heron, ASN, RN · Jan 9, 2012

Jan 8 by curiousauntie
Please, let's not start that "not-for-profit=goodness and light, and for-profit=the dark side" argument again.

And did you read this sentence: "Nor is the hanky-panky limited to for-profits."

I'm glad you work for a for-profit that's figured out how to provide great care. My inpatient unit is for-profit and, with all its management problems still provides superb end of life care to very complex patients. I write about for-profits because I worked for four of them and now care for some of their clients in a long term setting. As with any business, there's the good, the bad and the ugly. You're the one who set up the false dichotomy of which you are accusing me.

That being said, let's not be too, too disingenuous about the ethical pitfalls of needing to turn a profit on a revenue stream originally intended to provide flat-rate, low-cost care to people in their final decline. One of the companies I worked for lost its Medicare certification for a year because of its unethical business practices, and a second had to sign a consent decree for the same reason.

I've talked to nurses who have been disciplined for refusing to admit or discharging patients who clearly did not meet criteria. I've participated in inservices on how to gerrymander paperwork to make inappropriate admissions look less "iffy" on paper. I've watched my managers make decisions on financial grounds with no input from bedside caregivers on how they impacted the quality of our care. They simply didn't think it was important.

Reading your post, I'd be interested in learning if the client base of your respective hospices reflect the national stats that show that the length of stay of for-profits tends to run around twice that of non-profits. They tend to have a different case mix, as well. Some have wondered if for-profits cherry-pick patients with less complex non-cancer dx (COPD and dementia come immediately to mind), leaving the more complex, higher-cost patients for the non-profits. Not illegal if they do, but it does cast a different light on the economics of the debate.

However, I did not intend this to be a debate over the relative moral rectitude of non-profit vs. for-profit operations. I wanted to talk about unintended consequences. Painful as it is to think about, sometimes we make matters worse rather than better. I believe that we need to understand why that happens.

curiousauntie · Jan 10, 2012

No, we don't pick and chose patients with less complex diagnoses. If anything, we tend to jump fast as there are many competing hospices in our area. If we aren't the first ones there, the patient may go to another. The decision is not made on what the diagnosis is, but if they are eligible. We are lucky that our nursing director and administrator feel that if nurse A makes a determination that the patient is NOT eligible, they will not send another nurse to see the patient on the chance that nurse B will find eligibility. That is now, about a year ago the nursing director would just keep sending nurses until one said yes.

That said, I will say that the marketing director would have me admit her if she thought we could get away with it so her cap numbers would look good! I was acting nursing director for a couple of months (I'll NEVER do that again!) and the marketing director drove me to drink (literally...every day when I got home, shoes off, glass of wine in my hand). She covers a region of a few offices and has marketers working under her for each office. I love our Marketer, she has other healthcare experience and will discuss the case with the assessing nurse if she really feels we missed the boat. But she will not push us if we feel the patient is not eligible.

Do we have patients who after 4 or 5 months of service start to look too good? Yepper! Some patients just need someone to sort out their medications, start a medi-minder so they take their meds correctly, an aide to provide personal care and they begin to blossom. We had one with end stage CHF. Every symptom in the book, Stage 4 symptoms, O2 dependent, bed to chair only, unable to even stand without severe SOB and a significant drop of her pulse ox. In 4 months, after her case manager sorted out the mess that was her medications, started a medi-minder, did teaching with her family about elevating legs, energy conservation, diet...We just discharged her in better health than she had 10 years ago. Was she eligible 4 months ago? Yes. Is she eligible now? No. Could we have seen that she would improve so much in such a short time, actually never in a million years would I have thought she would be discharged. If she had continued on the course she was on she WOULD have died in a lot less than 6 months. But with good management (that no one else was doing) she lives on in a much better condition. We got her hooked up with a private social worker who provides help finding assistance in the home and her family now understands how important it is to make sure she takes her medications correctly. She said she didn't like or trust her doctor, so we talked to her family. They had no idea about that and changed her doctor who then made drastic changes in her medications. So we were able to do a good thing there...I could go on and on...how about the 106 year old I discharged last year? :)

There have been times I hate the company I work for and the only thing that kept me there was the lack of open jobs in my area. Over the past year the company had really gotten it together and I really do like my job now.

heron, ASN, RN · Jan 10, 2012

There's a study out there that suggests that people with lung cancer survive longer when they get good palliative care ... so totally not surprised to hear about your CHF client. Great work!!!

Am also glad to read of the changes at your organization. I tried for seven years to wait out the troubles at my site through four sales, seven unit managers and six executive directors ... each time thinking "maybe this time ..." Nope, didn't make it, so my respects for hanging in there. I know positive change is possible, regardless of the tax status of a hospice ... it just wasn't possible in my particular organization.

CrunchRN, ADN, RN · Jan 10, 2012

Unfortunately hospice is not immune to greed and corruption as is the case for all other care types.

However, it would be a shame for the relatively few bad ones to reflect badly or prevent use and relief from all the good ones that operate ethically.

MN-Nurse, ASN, RN · Jan 13, 2012

i call bs on this article.

many of us reading this article who actually have worked in hospice and/or performed end of life cares/comfort cares for people know these cases are extremely rare.

"robert spain jr., an unemployed boat captain, .... acknowledges a prior history of drug abuse."

"groomes's wife said she and her husband started using cocaine in 1996, when some childhood friends re-entered their lives and smoked crack with them"

yeah, sure, it was the hospice folks that caused these guys' problem with narcotics. cripes on a crutch.