by Barbara Karnes, R.N.

Barbara, There is much in today’s media about the negative aspects of hospice care. Is not-for-profit better than for-profit? What about quality of care issues?  It is very sad to see hospices turned more and more into corporate business models with less and less care for, and response to, patient needs. Far more is focused on corporate bottom lines. Please comment.

Over the years I think Hospice service has changed from its original intent. When hospice started, choosing it was for the patient and family, almost like walking away from the medical establishment. They returned home to live the best a person could until they died. No blood draws, no lab values, few procedures, but a lot of education, support, guidance, and presence.

Today’s hospice is much more medically oriented. It has more protocols, more policies, more regulations, more money.

The not-for-profit vs. for-profit argument has waged since for-profits entered the hospice arena.  What people don’t seem to understand is that the care is not about the legal classification of the agency (they all make a profit). It is about the philosophy of the individual hospice and how that philosophy is dictated by the administrative principles of management. It starts at the top. You can have an office full of caring, dedicated staff but it is the leaders who set the tone.

The end of life avocation that hospice originally presented is becoming a gift of the past. Now it is a business with high censuses, detailed and often confusing regulations, and marketing staff and strategies separate from clinical staff.

There are more and more inpatient facilities being created but only to serve for symptom control, because that is where the reimbursement lies. Most end of life symptoms can be managed at home but not everyone has a caregiver in the home as death approaches. We need inpatient facilities that provide care during the last weeks/days of life, but at present there is no reimbursement for just dying in a facility.

Maybe the recent negative attention hospice has gotten in the Washington Post and other media sources will bring about change. More regulatory action is not necessarily the answer for those changes. Enforcing the process that is already in place rather than adding to regulations. In fact, eliminating some of the micromanaging regulations while continuing to monitor quality of care and compliance would work very well. Unfortunately, this is not what appears to be happening.

Dying is not a medical event. It is a social, communal event. I would like to see less focus on the medical aspects of dying and more support in home care.  Sending someone from hospice to the home (clergy, social worker, an RN or LPN) who is trained to support and guide the family through the last moments of dying. Not for medical intervention but to support the family in the normal, natural dying process.  They would provide care and support through the death until the funeral home arrives. You can call this person a doula as that is the role they would be filling. At present there is no reimbursement for that kind of service. I would like to see inpatient facilities reimbursed through the death, not just for symptom management. Most symptom management can be done at home anyway.

What I really think will happen (and is happening to a small degree) is that other options to end of life care will emerge but not under the name of Hospice. I am seeing residential care facilities that only care for the dying springing up around the country. I see end of life doulas who can be hired to support and guide the family.

How we die doesn’t and won’t change. Physiologically our bodies will die the same way they always have. How we interpret and how we see that dying, and what we do and how we react to that process, can and will change.

There are many individuals who are trying to provide the original hospice philosophy of support, guidance, teaching, and knowledgeable end of life care in hospices throughout this country. Unfortunately they are frustrated by the current medical, regulatory, and corporate systems that impact their ability to provide the care they want to give.