The Hospice movement is a humanitarian, patient-centered protocol that is still striving for complete integration into main stream medical practice. Traditional medical regulations, policies, protocols, and cultural norms are geared toward improving the patient’s health and, at the very least, maintaining current levels of patient functioning. Even the metrics used by skilled nursing facilities to assess the quality of care are not congruent with end-of-life care.
Traditionally provided in the home or in a dedicated hospice facility, the underlying hospice care philosophy is:
“To provide interdisciplinary care for patients with a terminal illness and prognosis of six months or less, focusing on symptom management, comfort, and enhanced psychological and spiritual support.”
For the most part, hospice patients have chosen to avoid hospitalization unless there is an acute symptom management need that cannot be otherwise resolved and to forego unwanted diagnostic testing and aggressive treatments intended to extend life such as intravenous hydration and mechanical ventilation.
Conflict of “Good Intentions”
However, when terminal patients find themselves in a medical care facility toward the end of their lives a conflict of “good intentions” often arises. Presently there are 1.5 million people residing in nursing homes. According to a study, despite the fact that the number of nursing home residents receiving hospice has been growing, approximately 66% of decedents in nursing homes do not receive hospice services. Some may have chosen a more aggressive approach to care, and others may have died suddenly from an acute event, but, unfortunately, many barriers still exist when it comes to optimizing patient choice about hospice care.
“The reason we need hospice in nursing homes," says John Cagle, PhD, MSW, an associate professor in the School of Social Work at the University of Maryland, "is because nearly a quarter of deaths in the United States occur in the nursing home and hospices provide high-quality end-of-life care whereas nursing homes are designed for restorative care such as rehabilitation and stabilization."
Even having conversations about hospice care and end of life is often difficult in medical care facilities. Medical staff may not be familiar with the diagnostic and prognostic criteria used to identify potential hospice patients. Some often have negative perceptions that hospice means “giving up” or “withholding care”.
Hospice Care is Sound Medical Practice
A complete hospice care team comprises professionals such as an attending physician, registered nurse, social worker, chaplain, certified nursing assistant, and those in any other discipline specifically identified in the patient's care plan (such as a bereavement counselor).
- In an article for the Journal of Pain and Symptom Management, an interview of frontline employees working in nursing homes found that "staff comments were generally positive about involving hospice in the care of dying patients. Participants reported, for example, that hospice provides a welcomed layer of extra support, needed expertise in pain and symptom management, and helpful bereavement care for families."
- Hospice social workers facilitate delicate, often difficult conversations between family members, patients, and medical staff. Additionally, they are aware of resources available to patients and families in the community, both while on service and after a patient dies that can help in relieving feelings of abandonment or isolation that families may carry after a loved one dies.
- Hospice social workers often become links for families living at a distance by relaying information, giving updates, understanding the situation a family is in, and reassuring them that their loved one is comfortable and cared for.
- Finally, hospice social workers serve as a resource for nursing home staff to ensure that the person's wishes are being maintained in the absence of family, to connect patients with spiritual interventions as needed, and to continue to work with facility staff to promote a patient's dignity and self-worth.
The addition of hospice care in skilled nursing facilities completes the patient-centered care protocol modern medical practitioners are striving for every day with every patient.