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NEW ENGLAND JOURNAL of MEDICINE Volume 357, July 26, 2007, Number 4, pp.321- 428 Article Summaries Understanding Hospice — An Underutilized Option for Life's Final Chapter G. Gazelle Letting Go of the Rope — Aggressive Treatment, Hospice Care, and Open Access A. A. Wright and I. T. Katz A Day in the Life of Oscar the Cat D. M. Dosa A Multicenter, Randomized, Controlled Trial of Dexamethasone for Bronchiolitis H. M. Corneli and Others High-Dose Chemotherapy and Stem-Cell Rescue for Metastatic Germ-Cell Tumors L. H. Einhorn and Others Partial Thrombosis of the False Lumen in Patients with Acute Type B Aortic Dissection T. T. Tsai and Others Rofecoxib and Cardiovascular Adverse Events in Adjuvant Treatment of Colorectal Cancer D. J. Kerr and Others The Spread of Obesity in a Large Social Network over 32 Years N. A. Christakis and J. H. Fowler Skin and Soft-Tissue Infections Caused by Methicillin-Resistant Staphylococcus aureus R. S. Daum Positive-Pressure Ventilation with a Face Mask and a Bag-Valve Device R. Ortega, A. K. Mehio, A. Woo, and D. H. Hafez Metastatic Germ-Cell Cancer J. Menke and E. Grabbe Ascending Aortic Aneurysm in a Young Adult P. D. Harris and C. Cokis Case 23-2007 — A 9-Year-Old Boy with Bone Pain, Rash, and Gingival Hypertrophy C. P. Duggan, S. J. Westra, and A. E. Rosenberg Therapy for Bronchiolitis: When Some Become None C. B. Hall Network Medicine — From Obesity to the "Diseasome" A.-L. Barabási Cancer and the Constitution — Choice at Life's End G. J. Annas PCI for Stable Coronary Disease Diabetic Gastroparesis Case 15-2007: A Woman with Asthma and Cardiorespiratory Arrest Folate Deficiency and Plasma Homocysteine during Increased Oxidative Stress Radiofrequency Ablation of a Tumor Causing Oncogenic Osteomalacia Culturing Life: How Cells Became Technologies Bioethics in Law Survival of the Sickest: A Medical Maverick Discovers Why We Need Disease Diabetic Gastroparesis Posaconazole or Fluconazole for Prophylaxis in Severe Graft-versus-Host Disease The NEW ENGLAND JOURNAL of MEDICINE Perspective july 26, 2007 Understanding Hospice — An Underutilized Option for Life’s Final Chapter Gail Gazelle, M.D. t was Mr. G.’s third exacerbation of congestive many aspects of hospice care are heart failure in the past 6 months. Eighty-three still misunderstood by both phy- I sicians and patients. years old, he had New York Heart Association class For instance, many would not IV heart failure, end-stage coronary artery disease, consider Mr. G. to be a candi- date for hospice care. He did not and insulin-dependent diabetes. of life. Relieved, Mr. G. acknowl- have cancer, and his death was Although he had never wanted edged that he would prefer to probably months, not days, away. to be put on a ventilator, this avoid rehospitalization. The fact is, however, that slight- time his shortness of breath was Introduced in the United States ly less than half of hospice pa- so terrifying that he felt he had as a grassroots movement more tients have terminal cancer; near- no choice. After having a good re- than 30 years ago and added as ly 40% of hospice admissions are sponse to diuresis, he was success- a Medicare entitlement in 1983, for end-stage cardiac disease, fully extubated and transferred hospice care is now considered end-stage dementia, debility, pul- out of the coronary care unit. part of mainstream medicine, as monary disease, and stroke.1 Two days later, a hospitalist evidenced by growing patient en- Patients and clinicians may suggested to Mr. G. and his wife rollment and Medicare expendi- also not realize that hospice care that given his advanced disease, tures (see table). In 2005, more at home is free. Medicare is the he should consider going home than 1.2 million Americans re- primary payer for hospice care and receiving hospice care there. ceived hospice care, and between in approximately 80% of cases, Sensing the couple’s fear, she re- 2000 and 2004, the percentage with care most often provided assured them that death was not of Medicare decedents that had in the patient’s home. Commer- imminent and that members of been enrolled in hospice pro- cial insurers also provide hospice the hospice staff would work to grams increased by almost 50%. benefits, but the specifics of cov- ensure the best possible quality But despite its increased use, erage vary. Under Medicare, most n engl j med 357;4 www.nejm.org july 26, 2007 321 PERSPECTIVE understanding hospice — an underutilized option for life’s final chapter possible in the face of advanced Use of Hospice Care among Medicare Beneficiaries from 2000 to 2004.* incurable disease. Variable 2000 2004 % Increase, 2000–2004 To determine eligibility, the Beneficiaries in hospice care 534,261 797,117 49 attending physician and hospice (no.) medical director must certify Payment (billions of $) 2.9 6.7 130 that to the best of their judg- Time in hospice care 26 52 101 ment, the patient is more likely (millions of days) than not to die within 6 months. Decedents who had been in 22 31 — Responsibility for determining hospice care (%) ongoing eligibility rests with the director. To assist physicians in * Data are from the Center for Medicare and Medicaid Services and the Medicare Payment Advisory Commission (MedPAC) and include Puerto Rico. prognosticating, Medicare pro- vides broad guidelines for many medical conditions (see box), expenses related to the terminal length of hospice service is only but these guidelines do not rep- diagnosis are paid in full, includ- 26 days, with one third of pa- resent hard-and-fast require- ing all medication and equip- tients referred to hospice care ments. Coexisting conditions or ment and all visits by hospice during the last week of life.1 a particularly rapid functional de- nurses and home health aides. (Ex- Factors contributing to late re- cline can outweigh strict adher- penses related to other diagnoses ferral include application of a ence to written requirements. remain covered by the patient’s curative model to end-stage in- After enrollment, a plan of primary insurance provider.) Oth- curable illnesses; Medicare’s per care is developed in accordance er hallmark hospice services in- diem hospice reimbursement, with the needs and wishes of clude intensive emotional and which precludes costly, aggres- the patient and family, often spiritual counseling, 24-hour cri- sive therapies; and the mistaken tempered by the presence or ab- sis management, and bereave- view that patients must have a sence of caregivers to participate ment support for at least 1 year do-not-resuscitate order. in day-to-day care. The primary after the patient’s death. However, the most important goal is to ensure that pain and Hospice care can successfully factors in delayed referrals ap- such symptoms as insomnia, address the critical end-of-life pear to relate to physician atti- dyspnea, depression, constipa- concerns that have been identi- tudes. In its first position paper tion, agitation, nausea, and fied in numerous studies: dying on the topic of cancer and dy- emotional and spiritual distress with dignity, dying at home and ing, the American Society of are aggressively addressed. Most without unnecessary pain, and Clinical Oncology acknowledged clinical care is provided by a reducing the burden placed on that many oncologists and other hospice nurse, and the vast ma- family caregivers.2-4 Evaluation physicians regard the death of a jority of patients are not seen by studies reveal consistently high patient as a professional failure.5 a physician. Mr. G.’s plan of care family satisfaction, with 98% of Many also fear that they will de- included continuing high-dose family members willing to rec- stroy their patients’ hope, which furosemide, adding low-dose ommend hospice care to others physicians may believe lies only lorazepam for the anxiety that in need.1 And the extensive ex- in efforts to increase the quan- typically accompanies shortness pertise of physicians specializ- tity rather than quality of life. of breath, and initiating low- ing in hospice and palliative Furthermore, physicians receive dose liquid opioids, a mainstay medicine was recognized in little training in the compas- in the management of dyspnea. 2006, when the field was ac- sionate discussion of bad news. To address Mr. G.’s nonmedi- credited as a fully independent But perhaps the most critical cal needs, a home health aide medical subspecialty. factor is that physicians view provided assistance with per- Despite these benefits and hospice care as something re- sonal hygiene and dressing for the general understanding by served for the imminently dying an hour each day, 5 days a week. clinicians that at least 6 months instead of as a service designed The hospice social worker of- of care are provided, the median to help people live as well as fered to have a volunteer shop 322 n engl j med 357;4 www.nejm.org july 26, 2007 PERSPECTIVE understanding hospice — an underutilized option for life’s final chapter Medicare Hospice Eligibility Guidelines for Selected Diagnoses.* Alzheimer’s disease Eligibility is based on Reisberg Functional Assessment Staging (FAST), stage 7 or greater. Stage 7 is defined by the following criteria: need for assistance with at least three activities of daily living increased frequency of incontinence of bowel and bladder ability to speak only six or fewer intelligible words in the course of an average day In addition to the FAST criteria, the patient must have one of the following: a history of upper urinary tract infection, sepsis, or pneumonia within the past 12 months multiple stage III
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