Many Americans die in facilities such as hospitals or nursing homes receiving care that is not consistent with their wishes. To make sure that doesn’t happen, older people need to know what their end-of-life care options are and state their preferences to their caregivers in advance. For example, if an older person wants to die at home, receiving end-of-life care for pain and other symptoms, and makes this known to healthcare providers and family, it is less likely he or she will die in a hospital receiving unwanted treatments.
Caregivers have several factors to consider when choosing end-of-life care, including the older person’s desire to pursue life-extending or curative treatments, how long he or she has left to live, and the preferred setting for care.
Understanding Palliative Care
Doctors can provide treatment to seriously ill patients in the hopes of a cure for as long as possible. These patients may also receive medical care for their symptoms, or palliative care, along with curative treatment.
Palliative care is a resource for anyone living with a serious illness, such as heart failure, chronic obstructive pulmonary disease, cancer, dementia, Parkinson’s disease, and many others. Palliative care can be helpful at any stage of illness and is best provided from the point of diagnosis.
In addition to improving quality of life and helping with symptoms, palliative care can help patients understand their choices for medical treatment. The organized services available through palliative care may be helpful to any older person having a lot of general discomfort and disability very late in life. Palliative care can be provided along with curative treatment and does not depend on prognosis.
A palliative care consultation team is a multidisciplinary team that works with the patient, family, and the patient’s other doctors to provide medical, social, emotional, and practical support. The team is made of palliative care specialist doctors and nurses, and includes others such as social workers, nutritionists, and chaplains.
Palliative care can be provided in hospitals, nursing homes, outpatient palliative care clinics and certain other specialized clinics, or at home. Medicare, Medicaid, and insurance policies may cover palliative care. Veterans may be eligible for palliative care through the Department of Veterans Affairs. Private health insurance might pay for some services. Health insurance providers can answer questions about what they will cover. Check to see if insurance will cover your particular situation.
In palliative care, you do not have to give up treatment that might cure a serious illness. Palliative care can be provided along with curative treatment and may begin at the time of diagnosis. Over time, if the doctor or the palliative care team believes ongoing treatment is no longer helping, there are two possibilities. Palliative care could transition to hospice care if the doctor believes the person is likely to die within 6 months. Or, the palliative care team could continue to help with increasing emphasis on comfort care.
Understanding Hospice Care
Increasingly, people are choosing hospice care at the end of life. Hospice can be provided in any setting—home, nursing home, assisted living facility, or inpatient hospital.
At some point, it may not be possible to cure a serious illness, or a patient may choose not to undergo certain treatments. Hospice is designed for this situation. The patient beginning hospice care understands that his or her illness is not responding to medical attempts to cure it or to slow the disease’s progress.
Like palliative care, hospice provides comprehensive comfort care as well as support for the family, but, in hospice, attempts to cure the person’s illness are stopped. Hospice is provided for a person with a terminal illness whose doctor believes he or she has 6 months or less to live if the illness runs its natural course.
Hospice is an approach to care, so it is not tied to a specific place. It can be offered in two types of settings—at home or in a facility such as a nursing home, hospital, or even in a separate hospice center.
Hospice care brings together a team of people with special skills—among them nurses, doctors, social workers, spiritual advisors, and trained volunteers. Everyone works together with the person who is dying, the caregiver, and/or the family to provide the medical, emotional, and spiritual support needed.
A member of the hospice team visits regularly, and someone is always available by phone—24 hours a day, 7 days a week. Hospice may be covered by Medicare and other insurance companies; check to see if insurance will cover your particular situation.
It is important to remember that stopping treatment aimed at curing an illness does not mean discontinuing all treatment. A good example is an older person with cancer. If the doctor determines that the cancer is not responding to chemotherapy and the patient chooses to enter into hospice care, then the chemotherapy will stop. Other medical care may continue as long as it is helpful. For example, if the person has high blood pressure, he or she will still get medicine for that.
Differences Between Palliative Care and Hospice:
Who can be treated?
- Palliative Care: Anyone with a serious illness
- Hospice Care: Anyone with a serious illness whom doctors think has only a short time to live, often less than 6 months.
Will my symptoms be relieved?
- Palliative Care: Yes, as much as possible.
- Hospice Care: Yes, as much as possible.
Can I continue to receive treatments to cure my illness?
- Palliative Care: Yes, if you wish.
- Hospice Care: No, only symptom relief will be provided.
Will Medicare pay?
- Palliative Care: It depends on your benefits and treatment plan.
- Hospice Care: Yes, it pays all hospice charges.
Does private insurance pay?
- Palliative Care: It depends on the plan.
- Hospice Care: It depends on the plan.
How long will I be cared for?
- Palliative Care: This depends on what care you need and your insurance plan.
- Hospice Care: As long as you meet the hospice’s criteria of an illness with a life expectancy of months, not years.
Where will I receive this care?
- Palliative Care:
- Assisted living facility
- Nursing home
- Hospice Care:
- Assisted living facility
- Nursing home
- Hospice facility
Although hospice provides a lot of support, the day-to-day care of a person dying at home is provided by family and friends. The hospice team coaches family members on how to care for the dying person and even provides respite care when caregivers need a break. Respite care can be for as short as a few hours or for as long as several weeks.
Families of people who received care through a hospice program are more satisfied with end-of-life care than are those of people who did not have hospice services. Also, hospice recipients are more likely to have their pain controlled and less likely to undergo tests or be given medicines they don’t need, compared with people who don’t use hospice care.
What does the hospice 6-month requirement mean?
Some people misinterpret their doctors’ suggestion to consider hospice. They think it means death is very near. But, that’s not always the case. Sometimes, people don’t begin hospice care soon enough to take full advantage of the help it offers. Perhaps they wait too long to begin hospice; they are too close to death. Or, some people are not eligible for hospice care soon enough to receive its full benefit.
In the United States, people enrolled in Medicare can receive hospice care if their healthcare provider thinks they have less than 6 months to live should the disease take its usual course. Doctors have a hard time predicting how long an older, sick person will live. Health often declines slowly, and some people might need a lot of help with daily living for more than 6 months before they die.
Talk to the doctor if you think a hospice program might be helpful. If he or she agrees, but thinks it is too soon for Medicare to cover the services, then you can investigate how to pay for the services that are needed.
What happens if someone under hospice care lives longer than 6 months? If the doctor continues to certify that that person is still close to dying, Medicare can continue to pay for hospice services. It is also possible to leave hospice care for a while and then later return if the healthcare provider still believes that the patient has less than 6 months to live.
Source: National Institute on Aging: www.nia.nih.gov