Tuesday, November 16, 2010

Some Thoughts On Hospice

Friday in my office is like happy hour.....for the oldest of the old. They come. 90, 95, 100. Always on Fridays. Some come in wheel chairs. Others walking. Some alone. Others with family. 5,6, 7 sometimes even more in just one short morning. And we talk...about life, about their children, about growing old. I apologize that at that age I really have little to offer. After all... they know more about health then I....they made it to their ninth decade. Some I offer comfort, others medicine, on rare occasion tests. Mostly I just listen.

So it is fair to say that I am used to dealing with geriatric issues. And it is also fair to say that I work closely with hospice and find it one of our best resources in dealing with end of life care.

In reality, my medical training started with hospice. My first clinical experience with real "live" patients was as a hospice volunteer at the beginning of medical school. I started in the inpatient hospice unit. I did everything from laundry, to comforting families, to helping the nurses place dead patients in bags in preparation for transport to the funeral home. Eventually I traveled to patients houses to help with chores and run errands.

Yesterday I signed three death certificates. One died in the hospital of acute illness. Another died in his home with his wife and family present. The last died in an assisted living. They were all hospice patients but each for less then a week.

And I figure these numbers are about accurate. Probably 95 percent of my patients die in hospice. Likely only 10 percent die in the hospital. The other 90 percent die at home or in a nursing home or assisted living. Most of these patients have only been in hospice for a short period of time.

Often when I talk to my hospice colleagues I feel a slight sense of reproach. The conversation ends with a statement to the extent of, "to bad your patient couldn't have enjoyed these services for a longer time period."

I understand these sentiments. I do , in fact, believe that patients with terminal diagnosis live longer with hospice care then traditional management. I do believe the quality of life is better. But the truth is that most of my cases are not so black or white.

Some die of acute illness and the time period from decompensation to death is short...hours to days.

Often my elderly patients and their families are not emotionally ready early in the disease process. It can sometimes take months of conversations to help a family understand that their elderly loved one is slowly fading away from dementia.

Sometimes a patient has chronic illness like COPD or CHF and it is unclear if death is around the corner or a few blocks away. Often I avoid hospice to allow for the agility to move from palliative mode to acute aggressive care without having to explain to a hospice administrator why I want to spend money ordering tests on a patient who they think should have a less aggressive course.

And sometimes I hold off on hospice because the patient is comfortable. The family understands and every ones needs are being met.

I will continue to value hospice services. As time goes on I see the movement flourishing. It is becoming more agile. Moving from palliative to comfort care and back again.

The possibilities are endless.....

We are entereing the golden age of hospice care!


KimberFNP said...

I agree. I work as a hospitalist NP and have a huge amount of cancer patients that we end up referring to hospice. I find that oncology patients are often not informed of their prognosis and oncologists keep pushing the chemo and radiation because they think that's what the family/patient expect them to do; when in reality, I often see relief when they are told we are recommending hospice. Thanks for the idea, I think I'm going to blog about this :)(at some point).

Christian Sinclair said...

Thanks for your great post. Found it on Kevin MD and then linked back to you here. Had not stumbled upon you before but looks like you have been blogging for a long time. Keep up the good work. Your voice is needed.

And dont worry about the 'reproach' about patients maybe getting on hospice sooner. In hospice , we realize the decision to choose hospice is complex and has many turning points. If we talk about the delay it is more of a grumble against the system as a whole that forces patients into these tough decisions. I wish more people could get more help in the concurrent model you describe using with your CHF and COPD patients.

hospice services said...

As a person living comfortably without any feeling of physical pain, I hate to see folks suffering from that kind of condition. I worked in a hospice care center everyday but looking at them every hour will only make me feel weak.

Anonymous said...

I think that hospice is more often than not the better choice. Places like Hospice in Hingham are sometimes the only brief help a person gets through their decline in age and health. They have a lot of great people there to help out. My grandmother has dementia and it really makes me grateful for places like that.

Unknown said...

I agree with you in the fact that the need for hospice care is growing. There is a big need for home care workers. I know my grandparents appreciate all of the care they receive! http://www.HospiceCalumet.org