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BACKGROUND

Homes for the dying or, as they were soon to be called, hospices, were established in Ireland and France in the nineteenth century. However, it was not until 1967 that the first modern hospice, Saint Christopher’s Hospice, was founded in London. There, Dr. Cicely Saunders, a former nurse and social worker who had earned a medical degree, helped establish the underlying philosophy of hospice and palliative medicine. She emphasized clinical excellence in pain and symptom management; care of the whole person, including physical, emotional, social, and spiritual needs; and the need for research in this newly developing field of medicine. Interdisciplinary team care became the norm, as it became clear that no one physician, nurse, social worker, or chaplain could address all the needs of the terminally ill person. Further, although the focus of care was clearly on the dying individual, the needs of the family were also addressed.

In 1982, the Congress created the Medicare Hospice Benefit (MHB), and in 1986, the benefit was made permanent. By 2007, 4700 hospice programs were providing healthcare services to the terminally ill and their families throughout the United States.

Eligibility criteria for hospice enrollment through the MHB require that patients waive traditional Medicare coverage for curative and life-prolonging care related to the terminal diagnosis and be certified by their physician and the hospice medical director as having a life expectancy of 6 months or less if the disease runs its usual course. Recertification periods within the MHB allow for reexamination of hospice eligibility. If the hospice medical director believes that the patient has a life expectancy of ≤6 months if the disease runs its usual course, the patient may be recertified as eligible for the MHB even if the patient has already been receiving the benefit for 6 months or longer.

The goal of hospice care is to relieve suffering and improve the patient’s and family’s quality of daily life. To achieve those goals, hospice care has come to be defined as holistic, patient-, and family-centered rather than disease-centered. Hospice provides a team composed of those trained to care for problems in a holistic manner: physician, nurse, social worker, chaplain, bereavement counselor, nursing assistant, and volunteer. The hospice team meets weekly, under the direction of the hospice medical director, to review the care plans of all patients. The hospice program is charged with providing medications for the relief of physical distress, durable medical equipment, supplies, a multidisciplinary team to provide care, and bereavement support before and after the patient’s death.

Palliative medicine has developed as a medical subspecialty in the United States since the mid-1990s, bringing a “hospicelike” approach to patients with serious illnesses regardless of prognosis or their interest in pursuing life-prolonging treatments. The goals of palliative care programs are similar to those of the hospice: pain and symptom control; emotional, social, and spiritual support of patients and families; and facilitation ...

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