Hospice Polishes Its Image

Eleanor Browning lived a singular life, traveling into her 80s to places like Bhutan and Afghanistan. In 2007, at age 96, she also died a singular death, and in so doing, offered a compelling case for what hospice care aims to be for people nearing the end of life.

A year before she died, when she’d become frail and legally blind, her daughter, Pam, moved her out of an assisted living facility and into her own Chevy Chase, Md., home, quitting her job to become her mother’s full-time caregiver. But Browning’s health continued to flag: She fell twice and had trouble swallowing. Her heart rhythm became irregular, her blood pressure spiked and she suffered several small strokes. As her dementia worsened, she spoke only a few sentences a day. After a series of trips to the emergency room led to aggressive, invasive treatments, a doctor gently suggested that Pam call hospice. She did. Within days, a team of doctors, nurses and home aides from Montgomery Hospice began providing medical, emotional and practical home-based care and support for Eleanor Browning and her family right up through her peaceful death.

The Brownings’ experience illustrates the hospice concept at its best—a joint venture between family and an interdisciplinary team of medical professionals. Hospice teams include doctors, nurses, social workers, home aides, chaplains and sometimes physical therapists and nutritionists, who work with the whole family, not just the terminally ill patient. Now, prompted by new Medicare rules, the hospice industry has launched a major effort to see that all hospice patients get the same high-quality end-of-life care that the Browning family received.

Hospice care, which can be delivered at home or in a hospital, nursing home or other facility, focuses on giving comfort to terminally ill patients. Traditionally, hospice has accepted patients who are likely to die within six months and wish to stop seeking a cure for their illness. Recently, however, some hospices have begun to offer “open access” and “transitional” programs that allow certain patients to continue disease-fighting treatments, such as chemotherapy, while in hospice care. Those bridge programs can ease a family’s transition from curative to palliative care as their relative nears death.

For most hospice patients, who receive care for a few weeks or months before dying, hospice is a one-way street. But Art Buchwald’s high-profile case spotlighted the exceptions. His kidneys failing, the humorist entered hospice in February 2006 and left five months later to resume writing and spending time with friends and family before he died in January 2007. Almost 16 percent of hospice patients leave before dying, say experts. Some leave out of dissatisfaction with staff or in search of new treatments; some return when their health deteriorates.

A competitive $10 billion a year industry, hospice began in the United States in the 1970s as a largely volunteer movement—a reaction against hospitals’ costly reliance on technology to prolong life for those terminally ill. In 1983 Medicare established a hospice benefit covering home-based care for the dying and greatly expanding hospice’s reach. Today, state Medicaid programs and many private health plans cover hospice care. And for-profit hospice centers—both small, family-owned facilities and large, publicly traded chains—are now the fastest-growing segment of the industry.