Consider hospice when other options fail

CHF makes appropriateness difficult to determine

Tim Gallegos says when it comes to treating chronically ill patients, hospice care doesn’t get much discussion time, compared to high-profile clinical trials, procedures, and medication.

"There are tremendous breakthroughs," he says. "But the question no one wants to deal with is What happens if some of these options can’t help a particular patient?’"

The area administrator for Hospice of Integrated Health Services (HIHS) in Dallas says families should know about this option. It’s a good idea to know it’s available, should treatment priorities change from getting an upper hand on the disease to making patients feel comfortable.

Do doctors view hospice as giving up’?

"It’s real hard to get doctors on board with the option," says Carol Dux, RN, hospice team manager with HIHS. She notes doctors can be reluctant to stop trying to improve a patient’s condition, continuing different types of treatment. Physicians may consider referring a patient to a hospice as giving up on the patient.

Michael Galazka, director of the Hospice Education Institute in Essex, CT, says the nature of cardiac illness makes it more difficult to prepare for long-term outcomes. Hospice care usually is offered to patients with a life expectancy of six months.

For CHF patients, it is not always clear when a patient has entered that time frame. Fortunately, he says, if CHF patients have a crisis, they often can be treated aggressively and return to a health status "with some good life left."

In his conversations with patients and families about hospice care, Galazka says the cardiologist may be the one who advises the family: "It’s not time yet." But he says the doctors have a good idea of when that time is coming.

"The good cardiologists are very well aware of when it’s time to sit down with the patients and discuss it — and they do," he says. For the subset of CHF patients at this point in their disease, it may help to assess if patients are willing to be treated aggressively if their condition declines.

"We all have individual goals," Galazka says. Some patients may be very specific in wanting to be able to be present for upcoming family events or holidays, which can help set goals as well.

But when hospice care is appropriate, Gallegos says there are many included services, like counseling, that can be helpful to the patient and family. Medicare and most insurers have hospice benefits, he says, and facilities usually provide all care with what they get from the payer on a per-diem basis.

Gallegos says that HIHS cares for patients who are in nursing facilities or the homes of family members.

That’s how 85% of the nation’s 3,000 hospice providers operate, according to Galazka. Relatively few own their own facilities, and those that do have limits on the patients they can accommodate on-site.

[Michael Galazka is part of a national information and referral service available for advice about hospice care. For more information, call Hospicelink at (800) 331-1620.]