NEW YORK--About 60% of the US population dies in the hospital, and many have questioned whether hospitals are the best place to care for the dying. However, the hospital setting offers many advantages, Myra Glajchen, DSW, said during a teleconference sponsored by Cancer Care Inc.
"Hospitals have gotten short shrift in the debate. They have been unfairly portrayed as the bad guys," said Dr. Glajchen, educational coordinator of the Department of Social Work, Memorial Sloan-Kettering Cancer Center.
The greatest advantage hospitals have to offer the dying is clinical competence, she said. A high level of clinical competence includes both management of the physical symptoms that are typical of the end of life (pain, fatigue, dyspnea, and nausea and vomiting) and management of the psychological symptoms (anxiety, depression, agitated delirium, dysphoria, and a sense of loneliness).
Access to Latest Technology
"Hospital care at the end of life offers access to the latest medical technology, a team of experts available 24 hours a day, constant monitoring of side effects and immediate treatment if they occur," Dr. Glajchen said.
Families benefit from the social support of being in the hospital. "When I walk through the waiting room at Sloan-Kettering, I see families sitting together for hours, going together to the cafeteria," she said. "There is something comforting and safe about being there--and also about having the option of leaving at the end of the day, going home, and getting some rest and respite, which one doesn't always have when caring for an ill relative at home."
A hospital can also offer families a more rapid sense of closure after a loved one dies. "They can leave the hospital and never come back, and many of them really don't like to step back into that environment," she said, "whereas when a loved one dies at home, closure may take more time."
Finally, in terms of financial issues, insurance coverage is usually better for patients dying in the hospital rather than at home or in a hospice, she said.
Disadvantages of Hospital Care
Dr. Glajchen acknowledged that hospitals also have some shortcomings when it comes to care of the dying. For example, patients in a teaching hospital have little privacy. "There are always groups of students and specialists and members of the team coming and going," she said.
Lack of control and lack of regard for patients' preferences are the most often cited reasons patients do not want to spend their last days in a hospital. "They feel they get unwanted medical attention in the hospital, even when they have advance directives and have been very clear about what they do and do not want at the end of life," she said.
Dr. Glajchen believes that much of this concern is due to miscommunication and misunderstanding. "It's sometimes difficult to achieve a good fit between what the patient states is his preference, what the family hears, and what the team members hear and can provide."
Finally, she said, patients can feel isolated in the hospital if families are not allowed to stay over or if patients are not encouraged to bring in items of comfort and familiarity from home.
Recommendations
As both health care professionals and the public have become aware of these problems, she said, many recommendations for improvement have been made. Dr. Glajchen outlined what she considers the most important.
- Advance directives. Opportunities must be created to discuss dying and advance directives with patients and families. Family members should be referred to organizations like Choice in Dying that have trained experts who provide counseling and explain the documentation necessary for advance directives.
The patient's wishes must be honored, she stressed. In cases of family or ethical conflict, the rest of the multidisciplinary team should be brought together to help solve these dilemmas.
Aggressive Palliative Care
- Palliative care. Aggressive palliative care and symptom management must be provided. There should be codes for palliative care available on insurance forms so that inpatient palliative care can be reimbursed. Hospital charts should also provide a section for palliative treatment.
- Support for families. "This is an excellent time to offer pastoral counseling and bereavement counseling," Dr. Glajchen said. "And for the patient who is dying, it is comforting to know that there will be help for their family members afterward."
Hospitals also need to provide a mechanism for getting feedback from families so they can evaluate the quality of care and support they provided, and learn from this information where more work is needed.
- Staff support groups. A staff support group should be implemented to prevent burn out, facilitate shared learning, and give staff a sense of closure when patients die after a lengthy hospital stay.
