One of the skilled nursing facilities I work with has a hospice unit.  We occasionally have patients on the hospice unit who might benefit from physical therapy.  The physical therapists that see patients in the skilled nursing facility say they will talk with the patient about their goals, and if their goals are to maintain their current level of functioning, they will work with the patient.  If the goals are to improve their physical function, they cannot offer that type of support.

This seems ridiculous.

If someone has pain, we don’t say, “We will keep your level of pain where it is, but we can’t  help you if you want to improve.”

If someone has social or spiritual issues, we don’t say, “We want to maintain your current level of distress, but can’t help you if you want to be less distressed.”

Why is this happening?  It may be that a part of the problem has to do with resource allocation.  The physical therapists don’t have the resources, nor are they reimbursed for their time the same way, for seeing hospice patients as for patients cared for under the Medicare skilled nursing facility benefit, a comparatively high payment.

Another part — and this may be related — is that we don’t prioritize functional improvement as much as symptom/social/spiritual improvement for hospice patients.  I guess the idea is that hospice patients will inexorably decline functionally and die.  It’s as if physical therapy to improve function has been lumped in with life-sustaining treatments.  When did that happen?  Did I miss a meeting?

Granted, most patients on hospice will have an inexorable decline in physical function — something we’ve written about both on the GeriPal and in journals.  And many hospice patients do not have the ability or motivation to participate in physical therapy to the extent needed to recover function.  Wanting extensive physical therapy to recover function, when there is no possibility of recovery, is often a red flag that goals of care and prognosis need to be discussed in more depth.

But to me hospice, at it’s core, is about making each day as good as it can be, for the time that remains.  Being as independent as possible is an important part of quality of life for many people.  And for a very small number of people in hospice, there is a potential for recovery of some function.

I have a patient now who might benefit.  He’s been delirious in the hospital, but is pulling out of it.  He might benefit from physical therapy to recover some of the additional disability he acquired from lying in bed in the hospital confused for days on end.  Though his family is starting to discuss hospice, they want him to have the best opportunity to improve functionally.  I think they’re going to say no to hospice.  And that’s unfortunate.  Our system should be flexible enough to accommodate him.

Alex Smith is an assistant professor of medicine, University of California, San Francisco who blogs at GeriPal.