Two hospice patients and the roles of the physician and the physician executive. (Hospice Care).

Patient I

P.C. was a relatively young man-- just 55 years old. But he was a smoker and he had incurable lung cancer. He was dying. But he still had hope, so much so that he stopped traditional chemotherapy and traveled to Tijuana, Mexico for Laetrile treatment. Since neither his oncologist nor his closest relative, his sister, could dissuade him from this journey, they supported him. But it was to no avail--P.C died two weeks after returning home and less than one week after entering a hospice program.

Patient 2

A.R. was a 78-year old woman, also a smoker, with end stage lung disease. She was dyspneic at rest, had cor pulmonale, was losing weight, dependent on oxygen supplementation, had seen her physician twice in recent months for exacerbations of chronic bronchitis and had one hospital admission for respiratory failure. Her physician determined that, in spite of the best medicine had to offer her, she was likely to die within a few months. After discussion with A.R. and her close relatives, it was decided that she was eligible for and would benefit from hospice services. She was admitted to a hospice program where she initially stabilized for several weeks, but then resumed her downhill course and died four months after admission.

What is wrong with scenario 1, and what is right with scenario 2? The answer is the same for both: timing.

P.C. had little opportunity to benefit from what his hospice had to offer. He died too soon after admission. It was really. no one's fault, certainly not the hospice's, nor his sister's, nor his oncologist's. And P.C. was young enough that he probably did not want to admit, by accepting hospice early on, that he was dying.

A.R., on the other hand, did benefit from hospice. She had regular attention from her attending physician in addition to the hospice team of nurses, volunteers, home health aides, social workers, therapists and ministers. Her symptoms were controlled with oxygen and medications and she had counseling and opportunity to arrange her affairs and to say her farewells.

She was not subjected to the inconvenience and discomfort of additional hospitalizations and she died in the surroundings of her own home. Neither did she have concerns about depleting her remaining financial assets. Medicare covered her hospice care, including medications used to treat the symptoms associated with her terminal illness.

Why do these two scenarios, and thousands like them on both sides of the spectrum, exist? Again, the answer is the same for both: education and understanding. In the case of P.C., it was the lack of these. In the case of A.R., it was their presence.

The hospice movement

The hospice movement began in Great Britain in the 1960s. Hospice programs have been available in the United States since the 1970s. Medicare's hospice benefit, which serves a large majority of all hospice patients, began in 1983. It has expanded to include over 2,000 Medicare-certified hospice agencies serving nearly 600,000 beneficiaries annually, with recent growth rates exceeding 12 percent each year.(1)

That growth has particularly represented patients with non-cancer diagnoses. Nationally, there are some 3,100 hospice agencies providing care to 700,000 patients: While the number of beneficiaries served in hospice has steadily increased, until recently the average and median lengths of stay were decreasing toward that of P.C. and away from A.R. These lengths of stay have now stabilized at approximately 42 and 18 days respectively for Medicare patients.

What might explain why the median length of stay, a more accurate indicator of appropriate timing of admission to hospice than the average length of stay, is so short?

* Patients may be in denial or unrealistically hoping for cures with modern medical miracles and refuse to acknowledge the inevitability of their approaching death.

* Physicians, families and patients may not be aware of hospice care and its benefits.

* Referring physicians may be concerned with running afoul of Medicare regulations.

Physicians may not be initiating discussions with patients and their families regarding matters of mortality, possibly in some cases because they are unable to confront their own.

The pivotal role in making hospice work to the best advantage of the dying patient and his or her family is that of the attending physician.

It is the physician who can best predict and discuss the life expectancy of the patient based on underlying diagnosis, associated conditions and progression of disease. It is the physician who can counsel the patient and family in a timely manner regarding hospice. And it is the physician who is most likely to be aware of the availability of and how to access local hospice services.

Physicians trained in past decades may well not have been exposed to a curriculum on death and dying during which palliative care and hospice would have been core elements. Of note, a recent study by Rabaw, Hardie and others concluded that "top selling textbooks generally offered little helpful information on caring for patients at the end-of-life" in a 1998 review of how well medical textbooks address end-of-life care. (2)

During a similar time period, only a small number of medical schools in the United States included a course in the care of terminally ill patients in their curriculum. (3)

This situation may be changing, particularly for those more recently trained in family practice, pediatrics, internal medicine and geriatrics.

And for those who missed the opportunity for training in end-of-life care in medical school or residency, CME programming is becoming more available, an increasing number of medical journal articles focus on the topic and hospice issues are addressed on Web sites such as the National Hospice and Palliative Care Organization at www.nhpco.org.

Physician's role in hospice

What, then, is the role of the attending physician in hospice care?

For the Medicare patient it includes the following:

1. Certifying that the patient meets eligibility criteria

2. Recertifying for continuing stay in hospice

3. Establishing a plan of care for the patient and revising it as needed

4. Responding to the patient's clinical needs for diagnostic testing and palliation of symptoms such as pain, dyspnea, nausea and depression

5. Working with other members of the hospice team to fulfill these responsibilities

All Medicare certified hospices have medical directors to oversee the clinical components of care and who often assume the role as the hospice patient's attending physician if the patient's regular physician feels this is appropriate. Medicare does, however, provide separate payment for the services of attending physicians who are not under contract with a hospice agency.

A crucial, yet possibly untapped role in palliative care and hospice, may be that of the physician executive. Palliative care and hospice are not identical, although there is considerable overlap. The distinction, however, is important, since currently there is not a palliative care benefit category in Medicare as there is for hospice.

In selecting the hospice benefit, the patient waives curative care and fee-for-service care for any medical services associated with the terminal illness. The patient may, however, switch back to fee-for-service care at any time and has no limit on hospice benefit periods for doing so.

An important advantage of hospice care is that medications used for palliation of the terminal illness are covered by the benefit. The Medicare hospice benefit by definition is limited to patients whose life expectancy is six months or less if the terminal illness follows its normal course. This does not mean, however, that the patient becomes ineligible for hospice after six months or that the physician who certified the patient as hospice eligible is jeopardized if the patient does live over six months.

To quote from a recent Medicare announcement: "As the governing statute says: 'The certification of terminal illness of an individual who elects hospice shall be based on the physician's or medical director's clinical judgment regarding the normal course of the individual's illness.' The statute further notes that 'making medical prognostication of life expectancy is not always exact.'" (4)

Palliative care refers to those services provided to a terminal patient, regardless of life expectancy, to address physical, spiritual, social and emotional needs. It aims for the best quality of life as determined by the patient and family by clarifying the goals of care, reducing symptoms, improving function and supporting the patient and family care givers.

These services, although not defined as a comprehensive benefit by Medicare, may be covered in appropriate circumstances, such as those of a geriatrician serving as a consultant on a hospital palliative care team.

The physician executive's role

What, then, are the roles and the opportunities for physician executives? They are to:

* Raise the awareness of palliative care and hospice in the minds of both medical and administrative staff

* Encourage and provide education on these topics

* Assess the need and identify resources for these services

* Facilitate communication between hospital staff and hospice providers

As described by Diane Meier, MD, in The Physician Executive, (5) the opportunity may also be to consider developing a hospital-based palliative care consultative team. The services provided by such teams save hospital resources, improve the care of patients with terminal illnesses and increase satisfaction of patients and their families.

Palliative care programs may also, due to their kinship with hospice, facilitate timely admission of dying patients into hospices, while full advantage can be taken of the special services they offer.

It is in everyone's best interest if practicing clinicians initiate discussions on palliative care and hospice with patients and their families in appropriate circumstances and physician executives address these services with medical and administrative staffs.

References

(1.) Centers For MMS Websire Medicare Utilization for Part A www.HHS.CMS.gov/statistics/feeforservice

(2.) Rabaw, MW Hardie, GE, Fair, JM, McPhee, SJ. End-of-Life care content in 50 Textbooks from Multiple Sources. JAMA 2000, 283: 771-778.

(3.) Emanuel, LL, Von Gunten, CF, Ferris, FD. "Gaps in End-of-Life care." Arch of Family Medicine 2000, 9:1176-1180.

(4.) Centers For Medicare and Medicaid Services Paid Advertisement. End-of-Life care Enhances Dignity and Peace As Life Nears Its End. The Physician Executive, March-April 2002, 34-35.

(5.) Meier, DE. 'Palliative care Programs: What, Why, and How?" The Physician Executive, Nov-Dec 2001, 43-47.

John W. Olds, MD, CPE, FACPE, is a Medicare medical director with Cababa GBA Midwest in Des Moines, Iowa. He can be reached by phone at [phone] or by email at [e-mail].