Entering the golden age of hospice care

Friday in my office is like happy hour for the oldest of the old.

They come. 90, 95, 100. Always on Fridays. Some come in wheel chairs. Others walking. Some alone. Others with family. 5,6, 7 sometimes even more in just one short morning. And we talk about life, about their children, about growing old. I apologize that at that age I really have little to offer. After all, they know more about health then I — they made it to their ninth decade. Some I offer comfort, others medicine, on rare occasion tests. Mostly I just listen.

It is fair to say that I am used to dealing with geriatric issues. And it is also fair to say that I work closely with hospice and find it one of our best resources in dealing with end of life care.

In reality, my medical training started with hospice. My first clinical experience with real “live” patients was as a hospice volunteer at the beginning of medical school. I started in the inpatient hospice unit. I did everything from laundry, to comforting families, to helping the nurses place dead patients in bags in preparation for transport to the funeral home. Eventually I traveled to patients houses to help with chores and run errands.

Yesterday I signed three death certificates. One died in the hospital of acute illness. Another died in his home with his wife and family present. The last died in an assisted living. They were all hospice patients but each for less then a week.

And I figure these numbers are about accurate. Probably 95 percent of my patients die in hospice. Likely only 10 percent die in the hospital. The other 90 percent die at home or in a nursing home or assisted living. Most of these patients have only been in hospice for a short period of time.

Often when I talk to my hospice colleagues I feel a slight sense of reproach. The conversation ends with a statement to the extent of, “to bad your patient couldn’t have enjoyed these services for a longer time period.”

I understand these sentiments. I do , in fact, believe that patients with terminal diagnosis live longer with hospice care then traditional management. I do believe the quality of life is better. But the truth is that most of my cases are not so black or white.

Some die of acute illness and the time period from decompensation to death is short: hours to days.

Often my elderly patients and their families are not emotionally ready early in the disease process. It can sometimes take months of conversations to help a family understand that their elderly loved one is slowly fading away from dementia.

Sometimes a patient has chronic illness like COPD or CHF and it is unclear if death is around the corner or a few blocks away. Often I avoid hospice to allow for the agility to move from palliative mode to acute aggressive care without having to explain to a hospice administrator why I want to spend money ordering tests on a patient who they think should have a less aggressive course.

And sometimes I hold off on hospice because the patient is comfortable. The family understands and every ones needs are being met.

I will continue to value hospice services. As time goes on I see the movement flourishing. It is becoming more agile. Moving from palliative to comfort care and back again.