EXPLORING MEDICAL OPTIONS FOR END-OF-LIFE CARE

END OF LIFE CARE

Unlike even 10 years ago, families facing cancer today are often expected to make difficult medical decisions related to cancer treatment, including the setting in which they prefer to have someone receive end-of-life care. There is no one right place in which to die. Some people favor the security of the hospital, while others select the comfort and familiarity of their homes. This Brief will provide you with a description of end-of-life care in the hospital and in the home, with some guidelines for decision-making. No matter which setting you choose, high quality medical care, dignity, and psychological support are essential components that you should expect.

The Hospital

Most people with cancer will spend their last weeks in a hospital, for several reasons. A person with cancer may become attached to the health care team, especially if the illness has been prolonged, and may elect to die under its care. Hospital treatment is generally provided by a team of experts who can coordinate medical care using the latest technology. The health care team can monitor side-effects around the clock, provide pain relief and symptom management, and offer immediate help in coping with the process of dying. In this way, hospital care at the end of life relieves loved ones of some of the burden of caring for a terminally ill person at home. Finally, hospital care is generally well covered by health insurance.

The disadvantages of dying in the hospital include a sense of isolation from loved ones and familiar things; lingering in an impersonal, scientific environment; lack of control over hospital routines; lack of privacy, and the risk of receiving unwanted medical treatment. The pros and cons of spending one's final days in the hospital setting need to be thoroughly discussed with the health care team and the family, with the full participation of the person with cancer.

The Home

Home care at the end of life can take several forms. The major types of home care available are hospice and home health care.

In the United States, hospice care is generally provided to people at home at the end of life. Inpatient hospice units also exist. Hospice (also known as palliative) care is appropriate when the goal of treatment shifts from active treatment and cure to comfort and relief of suffering. Hospice care is characterized by three key components: comfort rather than cure; interdisciplinary team care; and involvement of the patient and family as the unit of care.

The hospice philosophy places equal emphasis on the family's physical, emotional, and spiritual needs through its comprehensive team approach. In this way, the hospice team provides families with assistance and support so that they can care for their loved one in the home.

Hospice treatment is based upon continuity of care, which means that short-term backup care can be provided in the hospital or a palliative care unit as the need arises; 24-hour help is available by telephone seven days a week, and bereavement counseling is provided as part of the service after the death has occurred.

Many people experience hospice home care as comforting and less isolating than hospital end-of-life care; the ill person can remain involved in aspects of family life, and family life can continue with less disruption. In addition, hospice care is covered by Medicare for people who are disabled or over age 65 on a nationwide basis, by Medicaid in some states, and by most private insurance companies.

On the other hand, caring for a terminally ill person at home is difficult for many families; end-of-life care can produce exhaustion for caregivers, and families can experience panic, distress, and financial strain of planning a funeral in New York. For all these reasons, the process of caring for a loved one at home in the final stage of life must be thoroughly discussed with health care professionals before a family selects the end-of-life care setting.

Home health care is another alternative for providing medical services to people with cancer at all stages of the illness. These services can allow the ill person to remain at home while easing the burden of care for the family.

Home health care may consist of the following :

Visits from a Registered Nurse (RN), for administration of chemotherapy and injections, supervision of dressing changes and wound care, monitoring of IV lines, drawing blood and taking blood pressure, supervision of medication regimen, and coordination of medical with the doctor, pharmacist, or homecare agency.

1. A physician can prescribe home visits by an RN for skilled nursing procedures.

2. Visits from home health aides for help with bathing, feeding, cooking, light household chores, shopping, and laundry

There is no need for physician referral for these services, which may be covered by health insurance in some cases but not others. Many homecare agencies adjust fees according to a sliding scale, while Medicaid will sometimes reimburse for this service.

These are the most common questions that families ask in relation to end-of-life care:

1. How will I know when hospice or palliative care is appropriate?
When the goals of treatment change from cure to comfort care, you should be able to discuss the issue openly with your health care team.

2. If patients join a hospice program, don't they lose hope?
People always have hope, it's just that their hopes change to dignity, comfort, and the relief of suffering.

3. Do people with cancer have to know when the medical team wants to refer them to a hospice program?
It is always best to give people accurate information about their condition. That way, they can make meaningful decisions and choices about the time they have left.

4. How can I find out about insurance coverage for these services?
You can ask your insurance company directly or you can have your nurse or social worker find out on your behalf.