Doctors' Misconceptions about Hospice Care
Slomski, Anita J., Medical Economics
"George" was in bad shape. Sick with C prostate cancer, he'd been bed bound for a year with metastatic and arthritic bone pain. Believing George's time was almost up, internist Charles Sasser referred him to hospice. The cancer then spread to George's penis, and Sasser ordered radiation therapy to try to shrink the tumor and relieve the pain.
Sasser doesn't have an explanation for what happened next, although he has seen it many times. Suddenly George got out of bed and started socializing. He was still incontinent, but it didn't embarrass him anymore. Two years have ticked by, and he's still in hospice.
"He should have been dead a year ago. And he would have been, if I'd kept him in the hospital," says Sasser, who is also medical director of Mercy Hospice of Horuy County in Conway, S.C. "One of our happy dilemmas in hospice is that patients often improve physically, once we stabilize their environment, reduce their economic worries, and relieve their pain. Many doctors don't understand the difference between curing and healing, so they don't think hospice does much for the patient. But it's awesome to witness a terminal patient heal for a time because he's no longer suffering."
When hospice medical directors such as Sasser talk about dying as a rich and profound experience, other doctors squirm. Death, for many physicians, is the ultirmate failure, and hospice is viewed by some as an anti-medicine, touchy-feely establishment that hastens rather than postpones life's final insult.
That many doctors keep death--and their dying patients--at arm's length is hardly surprising, says FP Ira R. Byock, medical director of Hospice of Partners in Home Care in Missoula, Mont. "The medical model is built on illness and injuly, and the goal is cure and prolonging life. Medical students get hundreds of hours of obstetrical training, but no training in care of the dying. And yet most physicians will encounter more dying patients than pregnant ones."
Lately, though, dying and hospice appear to be edging out of the closet. The national debate on physician-assisted suicide has led patients to challenge their doctors' philosophies on aggressive end-of-life hospital care. Payers are also championing hospice, since palliative home care is cheaper than inpatient treatment. According to a recent study commissioned by the National Hospice Organization, Medicare saves $1.52 for evety dollar it spends on hospice care. Physicians, too, are beneficiaries of a "good death"; hospice gives them help in meeting the needs of dying patients and their families.
For the past five years, the number of patients in hospice has increased an average of 16 percent annually, rising to approximately 340,000 in 1994. Only about 15 percent of all deaths in the country were tended by a hospice program. Why don't physicians refer more patients? Ingrained, never-say-die attitudes are a significant barrier. More easily remedied, however, are doctors' misconceptions. We talked with several hospice medical directors, who sought to eliminate some of the confusion.
You won't be penalized for a wrong prognosis
If a physician knows nothing else about referring a patient to hospice, he generally has a vague notion that he must certify that the patient will die within six months. The prognosis requirement has kept many physicians from consid!rering hospice, since it's impossible to predict death with 100 percent certainty.
A few years ago, however, Medicare (and other payers, who tend to copy Medicare's hospice rules) softened the certification requirement. Now physicians are asked to confirm that the patient is expected to die within six months, the disease follows its normal course. "You give it your best guess, but it's not fraud if the patient happens to live longer than you thought," says Ira Byock. "We've had oatients in hosoice for two years and insurers keep paying. That six-month guideline is unfortunate, because it scares physicians and inhibits appropriate referrals. …