Earlier this week, while conversing with a group of hospice volunteers, a question germane to hospices arose: why are families so often referred too late?
Here and elsewhere, hospices complain that their patients come to them within a week or two of dying, so that just when services begin to get coordinated, death intervenes. That's a pointless loss, considering what hospices have to offer in the way of personal and family counseling, symptom control, and respite. In continuing medical education sessions, we docs are repeatedly encouraged, cajoled, and begged to refer people earlier. Yet this tardiness persists, and one has to wonder why.
Around here, you're eligible for hospice care when your physician certifies that you'll likely die within six months. (Of course, some patients outlive the six-month prediction, and "graduate" from hospice.) Third parties, including Medicare, pay for hospice services only when that's the exclusive intervention. In other words, you can't receive treatment that's hopefully curative while you're in hospice. The decision to enter hospice, then, means letting go of every thought of recovering.
Hardly anyone looks forward to that eventuality. Doctors' reluctance to recommend hospice can derive from the notion that doing so might connote medical failure. Patients and their families don't want to hear the H word, either, as it can dash hope and fracture protective denial. All parties, then, may understandably conspire to avoid hospice until the Reaper is pounding on the door.
It doesn't have to be that way.
Hospices are founded on the principle of palliation, sometimes called "comfort care." The message is, "We've done what we can to cure you; now we'll do our best to make you comfortable." That's a humane thing to do, of course, but one wonders why we need to choose between cure and comfort. Why don't we apply palliation even when lives aren't threatened? Are not hospice services like counseling and expert pain control useful for virtually every patient and affected family?
For that reason I look forward to the day when there are no more hospices, and all care is palliative.