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Much attention has been focused on the importance of making end-of-life (EOL) care decisions before one is in a crisis situation. Some older adults, however, are ambivalent about what they want at the end of life and may change their minds about treatment options when actually threatened by an illness that can cause death. An option that allows for realistic EOL supportive care without rescinding all efforts at treatment is palliative care. Palliative care is focused on symptom management and relieving suffering and improving quality of life of individuals rather than focusing on cure and lengthening of life. Avoidance of unnecessary, and potentially harmful, tests is initiated, and care is focused on comfort. Palliative care is a philosophy of care that is provided simultaneously with all other appropriate medical management of the patient.

Hospice differs from palliative care. Hospice is a comprehensive care system for patients with limited life expectancy who are living at home or in institutional settings. Hospice is a Medicare benefit that was established in 1982. To be eligible for hospice the patient must have Part A of Medicare and two clinicians must determine that the patient has 6 months or less to live if the disease runs its normal course. For the first 90-day period of care, the primary care clinician and the hospice medical director/hospice physician are required to certify terminal illness. For subsequent certification periods, only the hospice medical director/hospice clinician is required to certify terminal prognosis, unless otherwise specified by state hospice regulations. The clinician must include a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the certification and recertification forms, or as an addendum to the certification and recertification forms. A face-to-face encounter is required for patients entering the third benefit period recertification (at 180 days) and every subsequent benefit period. Services provided through hospice are shown in Table 18-1. Hospice services also include coverage of necessary supplies such as a bedside commode or medications.

TABLE 18-1.Hospice Services

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