Can hospices participate in hospital palliative care?
An open attitude needs to replace paranoia
Palliative care experts describe a potential opportunity for U.S. hospices to contribute to the development of hospital palliative care programs. (See related story, p. 121.)
Given hospice’s track record in caring for over 400,000 dying patients per year, it is uniquely situated as the only current source of targeted, large-scale expertise in caring for dying patients which should be invaluable to other settings, even if the current hospice benefit structure does not translate as well. Involvement by community hospices in hospital palliative care could take such forms as joint ventures, education, or consultation by hospice staff, even the direct provision of services by the hospice in the inpatient setting.
Successful joint ventures "require partnering, which is always a bit of a challenge," says John J. Mahoney, president of the National Hospice Organization in Arlington, VA. "You can’t control everything in a partnership. Another stumbling block is organizational or managerial egos, which can get in the way of working together." In some communities, it may be possible for hospices to establish collaborative relationships as independent entities, rather than becoming part of the larger health system.
"There are a lot of opportunities for a more systematic approach," says Connie Zuckerman, JD, project director of the Hospital Palliative Care Initiative of the United Hospital Fund in New York City. "Hospice can play a larger role. I would hope the linkages go both ways, not just more referrals to hospice but also the hospice becoming more involved in what happens in the hospital."
"I’m no medical economist, but I really think the challenge is to be creative. In today’s marketplace, everything is so variable," adds Russell Portenoy, MD, director of a new palliative care program at Beth Israel Hospital, also in New York.
"This is a tremendously interesting time in end-of-life care, being acted out in many domains," observes David E. Weissman, MD, director of the Palliative Care Program at the Medical College of Wisconsin in Milwaukee and medical director for Care United Hospice. "Some old line hospices feel threatened that mainstream medicine is suddenly interested in end-of-life care after screaming for 20 years that it wasn’t. They need to look at palliative care as a potential partnership and say, How can we help you so we can help each other?’" he says.
Come out and embrace palliative programs
"My message for hospices is that they need to come out and embrace hospital-based and academic palliative care and work to form stronger linkages. These palliative care programs will be the new trainers of doctors and nurses in what hospice medicine is all about."
J. Andrew Billings, MD, heads a new palliative care service at Massachusetts General Hospital in Boston. "Essentially, we’re a hospice team doctor, nurse, social worker, and chaplain with a bereavement unit folded in and a volunteer program starting up. We’re using the hospice model and these are all people who’ve been around in hospice. We want to apply that care to a broader group of patients without worrying about all the eligibility stuff in hospice," he explains. "We try to be flexible, starting with what the patient needs and wants. If it’s already there in the patient’s medical care, great, we’ll be consultants. If it’s not there at all, we might take over the care."
Billings believes a program like his could help community hospices, providing medical backup when this is not available from the attending physician. "Hospices can call me and get good prompt medical orders [for their hospitalized patients] because I’m backing up the house staff," he says. "Here we are letting people know about hospice, talking about it early, doing transition work, raising awareness about the end of life. There might also be reasons why our social worker should stay involved in a case," he says.
"We’d like to do more collaborative care with hospice and home care programs." For those hospices willing to commit to collaborating, the palliative care program could even rotate hospice referrals, so as not to play favorites.
"But there is so much upheaval in the hospice market locally and so much variability, it makes it hard to get things going. We developed a plan with the hospices in town to have joint functioning. We’d be liaisons, and see their patients in the hospital," he says. But the collaboration never got off the ground. Some hospice directors seemed enthusiastic, but by the next month they would be gone from their jobs.
"I didn’t have the time to start the whole process all over again. My sense is that a lot of people supposedly in charge of hospice programs don’t really have the authority," from their parent organizations to negotiate collaborations. "I think we could really help hospice. Who wants to start another hospice? I’ve done it often enough already, and besides, the catchment area for this hospital is much too large," Billings says.
Robert L. Fine, MD, FACP, chairman of the Ethics Committee at Baylor University Medical Center in Dallas, is preparing to launch a pilot palliative care program which he hopes could serve as a bridge to hospice care and encourage earlier hospice referrals. The program will be more of a consulting team than a formal medical service or department. Its genesis lies in the fact that "a lot of patients in the acute care hospital who are hospice appropriate don’t get referred to hospice until the last 24 to 72 hours of life," he says. "We also do about a hundred ethics consults a year here, and for a lot of them, the end result is referral to hospice, for example, to discontinue treatment." There are also patients who aren’t quite ready for a hospice referral, for emotional reasons or because they are still pursuing aggressive treatments.
Fine’s program has developed a list of medical terms and diagnoses which can cue hospital staff to start asking key questions on admission and perhaps contact the attending physician. Could this patient benefit from palliative care while still in the hospital or from a transfer to hospice? The program has also developed palliative care protocols or standing orders to aid physicians.
Baylor currently provides contract inpatient beds to the Dallas Vitas hospice program and works primarily with Vitas on hospice referrals. "We’re not trying to take patients away from hospice. We hope more would go into hospice. We talk about this program as a bridge to hospice, to finesse’ patients toward what we think is in their best interest," Fine adds.
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