Can hospice play a larger role?
Hospices take lead in palliative care development
One of the most celebrated of the new medical center-based palliative care programs is the ambitious, well-endowed Department of Pain Medicine and Palliative Care at Beth Israel Medical Center in New York City. Headed by Russell Portenoy, MD, the department also includes a research institute and an expanded, integrated role for the hospital's long-established Jacob Perlow Hospice.
"We've been gathering some amazing clinical experience since September," says hospice coordinator Paul Brenner, MDiv. "One key impact on hospice is that the overall proportion of our patients with lengths of stay of seven days or less has decreased. Patients coming to us through the palliative care program have already been transitioned to end-of-life care. As a result, there is less sense of crisis and more opportunity to pursue a hospice agenda of meaningful dying," he explains.
The latest development is expansion of the hospice's inpatient unit to an 18-bed, combined hospice and palliative care unit. This challenges hospice staff on the unit to pursue two different pathways for hospice or non-terminal palliative care patients, Brenner says. Another challenge for hospice staff, with their new proximity to the research-oriented palliative care department, is to learn a more evidence-based approach to care. "That has also empowered our nurses when they are dealing with physicians from the community."
Blending hospital, hospice philosophies
In Columbus, OH, another health system-based hospice has become the initiator and provider of palliative care for its system. Mount Carmel Hospice, formed in 1985 as a provider of largely home-based hospice care, last year opened palliative care units and consulting services in two of the hospitals in the Mount Carmel Health System. Planning is under way for the third.
Although the overall approach is more flexible than traditional hospice, the seven- and six-bed units have a do-not-resuscitate requirement, since crash carts would be contrary to the home-like atmosphere they are trying to achieve, Medical Director Ralph Roach, MD, explained in a presentation at the American Academy of Hospice and Palliative Medicine conference in New Orleans in June. Patients who want resuscitation can be on other units of the hospital and still enjoy the benefits of a palliative care consultation.
Even though the hospice was already part of the system, these units were carefully developed with input from medical leadership in the hospitals, Roach says. "When we opened our doors, there was quite a bit of interest within the facility. There has been an impressive amount of 'curb siding,'" or informal consultation by the program's staff, he adds. "The hospital is where you go to bump into doctors."
Initiating palliative care from the outside
Hospice-initiated palliative care programs are also possible when the hospice is independent and community-based. Yet palliative care experts urge hospices not to expect many such opportunities, and to be aware of new skills and knowledge they would need, for example, in the science of cardiac care. However, Hospice in Wichita, KS, is now trying to succeed as a community-based hospice initiating hospital-based palliative care.
"We've been in intensive discussion with the Via Christi hospital system on how best to address the needs of dying patients in their system," says Susan Mann, RN, CRNH, the hospice's vice president for medical and nursing services. "One component of that is to provide a specialized, eight-bed unit where the goals of care are palliative, focused on people in the end stages of life. A second component is to have people who staff that unit be available as teams throughout the rest of the hospital to do consultation work. Our model is that we will staff and manage it, and the hospital will provide everything else needed to run it," Mann says.
The collaboration was first suggested by staff from the hospital, who recognized that they were not providing the kind of care they wanted at the end of life, she relates. The hospice aims to blend its philosophy and skills with the hospital's. "We hired a person with strong ties to the hospital at the highest levels, to help bridge the gap. I don't think you can just transplant and plop hospice down in the hospital. What you don't want is to create an enclave inside the walls that isn't incorporated into the routines of the institution. So we're paying attention to how we go in - with sensitivity and relationship building."
No formal agreement has been signed with the hospital, and financial details are yet to be worked out, Mann says, although the hospice is earmarking a portion of its current capital campaign for start-up costs. Both sides hope to see the program become self-sufficient. "Neither side is looking to go to the cleaners, but neither expects to make money, either. We're also trying to look at the cost savings engendered by providing more appropriate care." Mann says she hopes to see the program open early in 1999. "We plan to open without a lot of construction. We'll focus on the meat of the program first, and redesign as we go."
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content