2.4 Palliative & Hospice Care
According to the National Institute on Aging (2021), many Americans die in facilities such as hospitals or nursing homes, receiving care inconsistent with their wishes. All adults, especially older adults, need to plan ahead and let their caregivers, doctors, or family members know their end-of-life preferences in advance. For example, suppose an older person wants to die at home, receiving end-of-life care for pain and other symptoms, and makes this known to healthcare providers and family. In that case, it is less likely he or she will die in a hospital receiving unwanted treatments. If the person can longer make healthcare decisions for themselves, a caregiver or family member may have to make those decisions. Caregivers have several factors to consider when choosing end-of-life care, including the older person’s desire to pursue life-extending treatments, how long he or she has left to live, and the preferred setting for care. The tension involved in making these decisions can be relieved from the caregiver if the ill person has their wishes in writing.
Patients in palliative care may receive medical care for their symptoms to provide comfort, along with treatment intended to cure their serious illness. Palliative care is meant to enhance a person’s current care by focusing on the quality of life for them and their family. Palliative care is a resource for anyone living with a serious illness, such as heart failure, chronic obstructive pulmonary disease, cancer, dementia, Parkinson’s disease, and many others. Palliative care can be helpful at any stage of illness and is best provided soon after a person is diagnosed. In addition to improving quality of life and helping with symptoms, palliative care can help patients understand their choices for medical treatment. Finally, the organized services available through palliative care may be helpful to any older person having a lot of general discomforts and disabilities very late in life (National Institute on Aging, 2021).
A palliative care team comprises multiple professionals that work with the patient, family, and the patient’s other doctors to provide medical, social, emotional, and practical support. The team comprises palliative care specialist doctors and nurses, and others such as social workers, nutritionists, and chaplains. A person’s team may vary based on their needs and level of care. To begin palliative care, a person’s healthcare provider may refer him or her to a palliative care specialist. If he or she doesn’t suggest it, the person can ask a healthcare provider for a referral. Palliative care can be provided in hospitals, nursing homes, outpatient palliative care clinics, and certain other specialized clinics, or at home. Medicare and Medicaid may cover palliative care. Veterans may be eligible for palliative care through the Department of Veterans Affairs. Private health insurance might pay for some services (National Institute on Aging, 2021).
2.4.2 Hospice Care
Hospice offers patients and their families physical, emotional, social, and spiritual support. The main goal of hospice care is to control pain and other symptoms of illness so patients can be as comfortable and alert as possible. It is usually given at home but may also be given in a hospice center, hospital, or nursing home (National Cancer Institute, n.d.).
Increasingly, people are choosing hospice care at the end of life. Hospice care focuses on the care, comfort, and quality of life of a person with a serious illness who is approaching the end of life. At some point, it may not be possible to cure a serious illness, or a patient may choose not to undergo certain treatments. Hospice is designed for this situation. The patient beginning hospice care understands that their illness is not responding to medical attempts to cure it or to slow the disease’s progress (National Institute on Aging, 2021).
Medicare pays hospice agencies a daily rate for each day a patient is enrolled in the hospice benefit. Medicare makes this daily payment regardless of the number of services provided on a given day, including days when the hospice provides no services. (The hospice Medicare benefit, however, does not cover expenses related to room and board when a patient is in a nursing home or hospice inpatient facility.) The daily payment rates only cover the hospice’s costs for providing services included in patient care plans. Examples of hospice-covered services include doctors service’s, nursing and medical services, durable medical equipment for pain relief and symptom management, medical supplies, drugs for pain management, aide and homemaker services, physical therapy services, etc. Medicare makes daily payments based on one of four levels of hospice care (Centers for Medicare and Medicaid Services, 2022):
- Routine home care: A day the patient elects to get hospice care at home and isn’t getting continuous home care. A patient’s home might be a home, a skilled nursing facility (SNF), or an assisted living facility. Routine home care is the level of care provided when the patient isn’t in crisis.
- Continuous home care: A day when both of these apply:
- The patient gets hospice care in a home setting that isn’t an inpatient facility (hospital, SNF, or hospice inpatient unit)
- The care consists mainly of continuous nursing care at home. Patients can also get hospice aide, homemaker services, or both on a continuous basis. Hospice patients can get continuous home care only during brief periods of crisis and only as needed to maintain the patient at home.
- Inpatient respite care: A day the patient elects to get hospice care in an approved inpatient facility for up to 5 consecutive days to give their caregiver a rest.
- General inpatient care: A day the patient elects hospice care in an inpatient facility for pain control or acute or chronic symptom management, which can’t be managed in other settings.
Like palliative care, hospice provides comprehensive comfort care and support for the family, but in hospice, attempts to cure the person’s illness are stopped. Hospice is provided for a person with a terminal illness whose doctor believes he or she has six months or less to live if the illness runs its natural course. Therefore, it is important for a patient to discuss hospice care options with their doctor. Sometimes, people don’t begin hospice care soon enough to take full advantage of the help it offers. Perhaps they wait too long to begin hospice and are too close to death. Or some people are not eligible for hospice care soon enough to receive its full benefit (National Institute on Aging, 2021).
In the United States, people enrolled in Medicare can receive hospice care if their healthcare provider thinks they have less than six months to live should the disease take its usual course. Doctors have a hard time predicting how long an older, sick person will live. Health often declines slowly, and some people might need a lot of help with daily living for more than six months before they die. What happens if someone under hospice care lives longer than six months? If the doctor continues to certify that that person is still close to dying, Medicare can continue to pay for hospice services. It is also possible to leave hospice care for a while and then return later if the healthcare provider still believes the patient has less than six months to live (National Institute on Aging, 2021).
2.4.3 Palliative Care vs. Hospice Care
Review infographic (CMS, n.d.): Palliative Care vs. Hospice Care
Then, test your understanding by taking the following Knowledge Check quiz.
Knowledge Check
Select the type of care that the statement represents.
