Friday, February 19, 2010
Decline in Hospice Stays and Duration?
Suddenly, many hospices are admitting fewer patients. Others are increasingly caring for people for just days or hours before they die. The result: cash-strapped hospices are cutting back on nurses and aides, and patients are missing out on critical end-of-life care.
It is not clear why it’s happening, but some hospice officials blame both a bad economy and Medicare rules that unintentionally discourage doctors from referring all but those who are about to die.
Even though hospices have been operating in the U.S. for three decades, they remain widely misunderstood. Hospices provide medical care, pain management, spiritual and social care and volunteer support for those nearing the end of their lives. And their patients often live longer than if they were still receiving full-blown medical treatment.
Nearly all hospice care is paid by Medicare, but unlike most providers, hospices are paid a fixed daily rate (on average about $140-a-day for home care patients). If a hospice provides care for less, it keeps the difference. If a patient requires very costly care, the hospice can lose money.
The number of patients served by hospices increased from about 1 million in 2004 to nearly 1.5 million in 2008, while the number of hospices grew from 3,600 to almost 5,000. Most of this explosive growth has been driven by for-profit companies.
Elsewhere, hospice officials blame the bad economy. Patients who have lost jobs–and insurance—may be waiting longer to visit the doctor and consequently are diagnosed with terminal illnesses at a very late stage.
Some hospice executives say the poor economy may also be driving doctors to hold on to patients longer.
Here’s why: Once a patient joins hospice, she’s likely to see her physician far less often. Her doctor can usually order tests and treatments only to keep her comfortable, and not to try to cure her terminal disease.
And while it may still be appropriate for, say, cancer patients to receive costly drugs or even radiation therapy to relieve pain, hospices must pay for these treatments out of their daily Medicare rate.
That inevitably can create tension between the hospice and the physician.
And it may add up to less money for doctors at a time when they are already feeling squeezed. One physician I spoke to strongly rejected this argument, insisting that declining compensation does not slow referrals.
But another—an oncologist who frequently refers to hospice—acknowledged the problem. “There is a financial deterrent,” she says.
At the same time, new Medicare rules may be further discouraging physician referrals. Medicare has begun cracking down on a handful of hospices that are making big profits by taking on chronically ill, but not terminally ill, patients.
While hospice patients are normally expected to have six months or less to live, some hospices have many on their rolls for a year or more.
In one attempt to stop this practice, Medicare now requires doctors to write a brief narrative describing why a patient is appropriate for hospice. Trouble is, says one hospice official, “We’re getting a lot of pushback” from doctors.
In 2008, more than one-third of patients were enrolled in hospice for a week or less, and some organizations are seeing the number of short stays increase, perhaps because these requirements may be making already reluctant doctors even less willing to refer to hospice until their patients are actively dying.
Mark Murray, president of the Center for Hospice and Palliative Care in South Bend, Ind., says that in the past year, eight percent of his referrals died before they could even be admitted, and 20 percent died within 48 hours.
Those last-minute decisions put enormous financial pressure on hospices and make it impossible for patients to get the full benefit of end-of-life care.
These disincentives come on top of a long-standing reluctance on the part of many doctors to even talk about hospice. In a 2009 study, more than half of patients with stage IV lung cancer said their physicians never even raised the option.
I am a huge fan of hospice: My wife is a hospice chaplain and both my father and father-in-law were hospice patients. These organizations are a model for coordinated care that other health care providers would do well to copy.
But doctors need to be persuaded to use hospice. And that may mean changing a payment system that may be discouraging them from using this valuable service.
AIDS and Aid in Dying.
Gosling's admission and his ensuing arrest was certainly shocking. But it also confirmed what assisted-suicide experts already knew: legal issues of hastening death have long plagued AIDS patients and their doctors. "Certainly, we know it's a community where this type of bootleg assisted suicide occurred throughout the 1990s," says Ian Dowbiggin, the author of A Concise History of Euthanasia and an expert on the right-to-die movement. "This specific example of assisted suicide, I don't know how common it is, but it is likely more common in this particular community than elsewhere."Much of it has to do with the nature of the disease, which began to disproportionately affect gay men in the 1980s and early 1990s. AIDS patients were ravaged by tumors, seizures, and paralysis, and doctors had little to offer by way of a cure. Early treatments often merely prolonged this suffering. "People who suffered from AIDS were naturally interested in assisted suicide, whether it was legal or not," says Dowbiggin. As Gosling explained on the BBC of his own partner's disease, "Doctors said, 'There's nothing we can do'; he was in terrible pain." Legally, there was nothing his doctors likely could have done: in the United Kingdom, as in the United States (except for Washington and Oregon), physicians are barred from assisting a patient's suicide.
Jill Stanek and Not Dead Yet Shake Their Fingers At Me, I Respond.
Pro-abort Ann Neumann at Alternet is tying the fight to legalize euthanasia and assisted suicide in the UK to the fight to advance abortion rights in the US. Of course. The common denominator: Death, death, death.
Anyway, if you're here and you're reading this - it's obvious who she left out. Disability advocates and activists - in the US and the UK - oppose legalization of euthanasia and assisted suicide. The "practical" issues she and Beresford refer to are exactly the economic, social and support factors that disability advocates constantly bring up as being central to any discussion of assisted suicide and euthanasia.
And Neumann already knows this - or she should. She found her way to Bill Peace's Bad Cripple blog last month, but shied away from engaging from the critique of her initial attacks on what she termed "slippery slope" arguments on the blog. Not long after that, she announced the news of the Disability and Health Journal Issue on Assisted Suicide on her own blog.
So she knows that disability activists and advocates are out there, talking about the "practical" things. The trouble is, we think legalization of assisted suicide and euthanasia is bad policy.
In other words, she's fostering and promoting the very polarization that she bemoans. Maybe it's because she really isn't sorry that assisted suicide is seen as a "culture wars" issue after all.
She's wrong about that DMZ - we live in it. And neither the pro-euthanasia activists nor the highly political "pro-life" organizations want to acknowledge our place in the debate, because we'd distract from their Culture War. Neither side really sees people with disabilities as having a place in their respective cultures, so it's easy to marginalize us - and both sides do it with abandon and ease.
Georgia Bill Seeks to Make Artificial Nutrition and Hydration Obligatory.
ATLANTA, Feb. 18/Christian Newswire/ -- This past week H.B. 1178 "The Patient's Right to Nutrition and Hydration Act" was introduced in the Georgia House by Representative Martin Scott and co-sponsored by Rep. Tim Bearden and Rep. Mark Butler to help provide more protections for Georgian citizens in end of life care.
This legislation seeks to insure that no patient shall be denied food and hydration. It has been brought to the attention of Georgia Right to Life and our legislature that there have been cases where patients have been denied basic food and hydration in order to speed up the dying process.
Mike Griffin, Legislative Director of GRTL noted, "We live in a time where it is illegal to deny a dog or cat food or water, but it is legal to deny a person food and water. We must value every person's life, especially in the final moments of life."
Attorney David Gibbs, counsel for the Schindler family in the Terri Schiavo case, has provided legal counsel on this bill. Mr. Gibbs noted, "Food and water should not be considered 'life support,' in my opinion. If this bill is passed into law, Georgia would recognize that important distinction to protect its citizens."
This bill seeks, among other things, to establish the fact that the feeding tube should be considered ordinary care, not medical care. The bill does allow for exceptions under an advanced directive. Currently in Georgia physicians and administrators can override a patient's wishes in an advanced directive.
"Ultimately, this bill seeks to strengthen patient's rights in Georgia. Under existing law, a doctor can override a patient's desires to have the basic essentials of food and water. No medical establishment should take away the right from a patient or their family the right to make the very private and tough decisions about end of life care," stated Dan Becker, President of Georgia Right to Life.
Georgia Right to Life promotes respect and effective legal protection for all human life from its earliest biological beginning through natural death. GRTL is one of the number of organizations that have adopted Personhood as the most effective pro-life strategy for the 21st century.