What is a Terminal Illness?
Terminal illness is medical terminology for an active and malignant disease which cannot be cured and is expected to lead to death. Palliative Care is often prescribed to manage symptoms and improve quality of life. A patient who has such an illness is referred to as a terminal patient or terminally ill. Certain types of cancer, emphysema, liver failure, kidney failure, asbestosis, mesothelioma, some mental illness and heart disease may be considered fatal, although liver failure, kidney failure and even heart disease could possibly prolong life with an organ transplant.
A patient is considered to be terminally ill when he/she has a medical prognosis of a life expectancy of six months or less. Though a patient may be considered terminal, it doesn't always guarantee that he/she will die.
What is the History of Hospice?
Hospices were originally places of rest for travelers in the 4th century. In the 19th century a religious order established hospices for the dying in Ireland and London. The modern hospice is a relatively recent concept that originated and gained momentum in the United Kingdom after the founding of St. Christopher's Hospice in 1967. It was founded by Dame Cicely Saunders, widely regarded as the founder of the modern hospice movement.
Recently, the hospice movement has grown dramatically. Hospice Care in the United States has grown from a volunteer-led movement to improve care for people dying alone, isolated, or in hospitals, to a significant part of the health care system. In 2005 more than 1.2 million individuals and their families received hospice care. Hospice is the only Medicare benefit that includes pharmaceuticals, medical equipment, twenty-four hour/seven day a week access to care and support for loved ones following a death. The majority of Hospice Care is delivered at home. Hospice Care is also available to people in home-like hospice residences, nursing homes, assisted living facilities, veterans' facilities, hospitals and prisons.
The first United States hospital-based Palliative Care programs began in the late 1980s at only a handful of institutions such as the Cleveland Clinic and Medical College of Wisconsin. Since then there has been a dramatic increase in hospital-based palliative care programs, now numbering more than 1200. Over 55% of U.S. hospitals over 100 beds have a program. Hospital palliative care programs today care for non-terminal patients as well as hospice patients. Palliative Care programs in hospitals can be difficult to financially support given the multiple employees on a palliative care team and the time-intensive involvement with patients without adequate reimbursement. Therefore, strategies for funding palliative care programs typically focus on cost-savings for the hospital as opposed to revenue-generating models.
What are Hospice and Palliative Care Differences?
Palliative Care (from Latin palliare, to cloak) is any form of medical care or treatment that concentrates on reducing the severity of disease symptoms, rather than providing a cure. The goal is to prevent and relieve suffering and to improve quality of life for people facing serious, complex illness. Hospice Care which delivers palliative care to those at the end of life.
Though the concept of Palliative Care is not new, most physicians have traditionally concentrated on aggressively trying to cure patients. Available treatments for alleviation of symptoms were viewed as hazardous and seen as inviting addiction and other unwanted side effects.
Over the past twenty years, the focus on a patient's quality of life has gained substantial ground. Today in the United States, 55% of U.S. hospitals with over 100 beds offer a palliative care program and nearly one-fifth of community hospitals have palliative care programs. A relatively recent development is the concept of a dedicated health care team that is entirely geared toward palliative treatment, called a palliative care team.
There is often confusion between the terms Hospice Care and Palliative Care. In North America, hospice services and palliative care programs share similar goals of providing symptom relief and pain management. However, the most important distinction between hospice and palliative care programs is that hospice is a Medicare Part A benefit, thus requiring many aspects of hospice care such as enrollment to be regulated by the United States federal government. Non-hospice palliative care, however, is appropriate for anyone with a serious, complex illness, whether they are expected to recover fully, to live with chronic illness for an extended time, or to experience disease progression.
While Palliative Care may seem to offer an incredibly broad range of services, the goals of palliative treatment are extremely concrete: relief from suffering, treatment of pain and other distressing symptoms, psychological and spiritual care, a support system to help the individual live as actively as possible, and a support system to sustain and rehabilitate the individual's family.
In the United States, Hospice Care and Palliative Care represent two different aspects of care with similar philosophy, but with different payment systems and location of services. Palliative Care services are most often provided in acute care hospitals organized around an interdisciplinary consultation service with or without an acute inpatient palliative care ward. Palliative Care may also be provided in the dying person's home as a "bridge" program between traditional US home care services and Hospice Care or provided in long-term care facilities. In contrast, over 80% of hospice care in the US is provided in a patient's home, with the remainder provided to patients residing in long-term care facilities or in free standing hospice residential facilities.
In most countries, Hospice Care and Palliative Care is provided by an interdisciplinary team consisting of physicians, registered nurses, social workers, hospice chaplains, physiotherapists, occupational therapists, complimentary therapists, volunteers and, most importantly, the family. The focus of the team is to optimize the patient's comfort. Additional members of the team are likely to include certified nursing assistants or home health care aides, volunteers from the community (largely untrained but some being skilled medical personnel as well), and housekeepers.
In the US, palliative care services can be offered to any patient with no restrictions on disease type or expected prognosis. However, Hospice Care under the Medicare Hospice Benefit requires that two physicians certify that a patient has less than six months to live, if the disease follows its usual course. This does not mean, however, that if a patient is still living after six months in hospice, he or she will be discharged from the service.
Hospice Care is provided as Medicare benefit; similar hospice benefits are offered by Medicaid and most private health insurers. Under the Medicare Hospice Benefit (MHB), a patient signs off their Medicare Part A (hospital payment) and enrolls in the MHB with direct care provided by a Medicare certified hospice agency.
Under terms of the MHB, the Hospice agency is responsible for the Plan of Care and may not bill the patient for services. The hospice agency, together with the patient's primary physician, is responsible for determining the Plan of Care. All costs related to the terminal illness are paid from a per diem rate that the hospice agency receives from Medicare - this includes all drugs and equipment, nursing, social service, chaplain visits and other services deemed appropriate by the hospice agency; Medicare does not pay for custodial care. Patients may elect to sign-off the MHB and return to Medicare Part A and re-enroll in hospice at a later time.