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Am Fam Physician. 1998;57(3):424-425

See article on page 491.

A renewed interest in the United States in appropriate health care and decision making at the end of life has focused attention on hospice programs. Additionally, the aging of our population along with efforts of third-party payers to shorten inpatient lengths of stay have resulted in more acutely ill patients being treated in nursing homes. Nursing homes now house some of the most frail and chronically ill patients in the community. These factors have contributed to the recent integration of terminal care and hospice programs in nursing homes. In the related article in this issue,1 Keay and Schonwetter do an admirable job of describing the ways in which hospice care can be integrated into the nursing home setting.

The modern hospice movement began in London in 1967 and emphasized the interdisciplinary approach. The first hospice in the United States opened in New Haven, Conn., in 1974.2 Later, the National Hospice Study and the resulting Medicare hospice benefit led to the growth of the hospice movement in the United States.3 Under Medicare, hospice is funded in a capitated manner allowing for the programs to provide medications, case management and bereavement services to the family. In 1993, nearly 250,000 patients with terminal illnesses and their families were served by hospice programs in the United States.4

One of the goals of the hospice movement is to allow patients to die at home without pain. As Keay and Schonwetter note, “As early as 1986, Medicare recognized that nursing homes were residents' homes, and, therefore, hospice services should be covered in this setting.”1 The resident must meet two criteria to qualify for the hospice benefit: (1) The resident must be entitled to Part A of Medicare, and (2) a physician must certify that the resident has less than six months to live if the primary illness runs its normal course.5

Hospice care has typically been associated with cancer patients. There is, however, an increasing number of hospice patients in homes and in nursing home settings with non-cancer diagnoses. In the nursing home setting, hospice might be an appropriate adjunct to routine care for patients with dementia, end-stage congestive heart failure or incapacitating pressure sores.

The hospice caregivers can add to the care of terminally ill patients in the nursing home not only by direct services to the patient and the family, but also by enhancing the skills of the nursing home staff through education and mentoring. The potential exists, however, for conflict between the hospice staff and the nursing home staff. This can be avoided by clearly defining the role of the hospice staff within the nursing home and encouraging teamwork among all the caregivers toward the goal of providing quality, compassionate care for the patients.

As Keay and Schonwetter state, the attending physician is responsible for the services used in the care of the patient. Care of the dying patient, whether in the home or the nursing home, is best attained using an interdisciplinary approach. Care is directed toward the patient and the family, and seeks to address physical, psychologic and spiritual issues. The comprehensive palliative care provided by hospice will assist the physician and the nursing home staff in the care of terminally ill patients and help in easing the dying process for the patient and the family. As the acuity of patients in the nursing home setting continues to increase, it behooves the attending physician to utilize all appropriate services in the care of the patient. This would include using a hospice team trained in palliative, end-of-life care.

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