Improving the End-of-Life Experience

April 7, 2009

Hospice care continues to be underutilized. Indeed, owing to untimely referrals, many patients who begin hospice care unfortunately die shortly thereafter, having never received the full benefits provided by hospice. In her excellent article, Dr. Prince-Paul provides a case example that demonstrates the familiar multifaceted issues faced by cancer patients nearing end of life and discusses how hospice care could be of tremendous benefit to the patient, family, and professional.

Hospice care continues to be underutilized. Indeed, owing to untimely referrals, many patients who begin hospice care unfortunately die shortly thereafter, having never received the full benefits provided by hospice. In her excellent article, Dr. Prince-Paul provides a case example that demonstrates the familiar multifaceted issues faced by cancer patients nearing end of life and discusses how hospice care could be of tremendous benefit to the patient, family, and professional.

In describing hospice the author begins with an explanation of what it is not; hospice is not intended to prolong life, nor is its purpose to hasten death. Rather, the goal of hospice is to maximize the patient’s quality of life until death occurs. As Dr. Prince-Paul points out, when certified by his or her physician as having 6 months or less to live, the patient ultimately decides when hospice is appropriate and which type of program is best based on personal wishes and needs.

While many insurance providers include hospice as a benefit, she emphasizes that other resources are available for patients lacking sufficient finances. Dr. Prince-Paul nicely describes the Medicare and Medicaid hospice benefits core services provided as well as additional services that may be offered by hospices based on the size of their programs. Three notable hallmark characteristics of hospice care are trained volunteers, around-the-clock on call accessibility, and bereavement support for 1 year. Care is available in the patient’s home or in an inpatient facility.

The author highlights key reasons that hospice is essential to good patient care, while outlining factors in underutilization of this service by dying patients that were identified in the 1995 SUPPORT study (Study to Understand Prognosis and Preferences of Outcomes and Risks of Treatment) and the 2006 Institute of Medicine (IOM) report, namely overuse of technology, aggressive treatment, inadequate control of symptoms and pain, and patients’ perceived lack of emotional support and fear of abandonment.

Certainly, lack of knowledge about the patient’s end-of-life preferences regarding treatment and medical crises resulting in futile treatment are other barriers to the use of hospice. As a result, healthcare providers may face moral, ethical, or professional dilemmas regarding treatment decisions, and family members may be further burdened by having to make decisions about their loved one’s treatment and care.

Dr. Prince-Paul reviews several common barriers and misconceptions about hospice and offers possible responses that a nurse might use to reassure patients and encourage them to take advantage of the benefits of hospice care. She nicely ties in the case example using the responses in this section as well as information about hospice provided previously in the article.

Nurses are in a unique position to help improve the end-of-life experience for cancer patients. In fact, as the author points out in the article, the American Nurses Association states that nursing care is directed toward meeting the comprehensive needs of the patient and families across the continuum of care, especially at the end of life, to prevent and relieve common symptoms and suffering. Time is of the essence when facing death. Nurses not only have the responsibility but also the gift of opportunity to help ensure patients get the best possible care at the end of life.