Treating many patients with terminal illness comes down to this: Throw the hospital's resources into providing all possible lifesaving measures or put the patient into a hospice program to die.
Increasingly, though, doctors and hospitals are coming to believe there's a third option: Manage the patient's symptoms with aggressive treatment and sophisticated diagnostic tests while trying to minimize suffering and improve the patient's well-being.
"Hospice is thought of as a finish line you cross before dying," says Leslie Bricker, M.D., medical director of the palliative-medicine service at Josephine Ford Cancer Center, part of Henry Ford Health System in Detroit. But palliative care should be added gradually as a disease progresses rather than suddenly at the end of a patient's life.
Bricker's service is one of many such programs across the country that try to manage symptoms as hospices would while providing more-traditional acute inpatient care.
In palliative-care programs, patients with terminal illnesses receive the acute care and diagnostics they need-such as surgical or radiation therapies, chemotherapy, blood gases or treatment for fluid buildup in the lungs.
But they also are seen by a team made up of nurses and physicians, a social worker, a chaplain and others who provide pain management, counseling and psychosocial support.
Usually patients are not in imminent danger of dying. But patients admitted to such programs generally acknowledge that their illness will eventually cause their death, whether in months or years.
"If you define palliative care as the interdisciplinary branch of medicine that focuses on relieving suffering and improving the quality of life, it applies to a lot of people who are not necessarily dying," says Charles Von Gunten, M.D., director of the palliative-care and home hospice program at Northwestern Memorial Hospital in Chicago.
Cost-conscious care. There is no definitive count of palliative-care programs, but there is consensus in the industry that growing consumer interest in end-of-life care is increasing the number of such units.
Financial pressures have likewise prompted some hospitals to consider such units.
Hospitals recognize that dying patients use a disproportionate share of resources. A quarter of Medicare's $228 billion annual budget is spent on caring for patients who die each year.
Hospice care accounts for only about 1% of Medicare's budget. More-efficient care of terminal patients could directly affect hospitals' bottom line.
The Josephine Ford service, established late last year, includes a consultant service and a four-bed inpatient unit.
The service has had only 20 consults so far, but Bricker is confident the pace will pick up.
Bricker's "diagonal" approach allows patients to control their symptoms earlier in their illnesses, he says, well before they might be eligible for hospice care.
No hard figures are available, but evidence is mounting that such programs can generate savings.
Many hospitals already run hospices. The number of hospital-based Medicare-certified hospices rose to 561 in 1997 from 182 in 1989, when Congress raised payment rates by 20%.
Lately, however, lengths of stay at hospices have plummeted, depressing revenues and squeezing margins.
Meanwhile, patients with terminal illnesses often spend their last days in intensive care without having had the option of a less-aggressive, less-costly approach.
Patients who receive palliative care generally do not meet the criteria for admissions to hospices.
Some have prognoses of more than six months but could benefit from hospices' focus on symptoms and social support.
For others, particularly those with congestive heart failure or chronic obstructive pulmonary disease, new medicines can improve the quality of life while masking what would once have been the signs of an approaching end.
Providing palliative care outside of hospice care can help resolve what one program administrator calls the "dilemma of the unpredictably dying patient," who may live with a fatal condition for months or even years.
Still other patients have more limited prognoses but do not want to relinquish all hope of a cure. Palliative-medicine services can address their end-of-life needs while they receive surgical or other aggressive treatments that usually would not be part of hospice care.
Hospitals run their palliative-care services differently. But most provide consultation services and inpatient beds.
Because they supplement rather than replace acute-care services, palliative-care units initially might increase the cost of hospital care. Some, in fact, stay solvent only with the help of grants or subsidies from other hospital units.
Administrators of these units say palliative care reduces long-term costs.
Researchers at the Center to Improve Care of the Dying, which is at George Washington University in Washington, have attempted to quantify the financial implications of palliative-care programs. They have evaluated payment options in four settings: home health agencies, hospices, hospitals and skilled-care facilities.
Nicole Makosky, who co-authored the resulting paper with noted end-of-life researcher Joanne Lynn, says they were responding to providers' requests for advice about how to start dedicated units for patients with chronic fatal illnesses.
Investigations magnet. The paper, which is in draft form, notes that palliative-care programs may attract billing investigations. Hospitals that provide services usually associated with hospice care risk denial of payment by Medicare fiscal intermediaries, they say.
Some in the hospice community are hesitant about palliative care for other reasons. Board members of the Michigan Hospice Organization, who recently voted to add the phrase "palliative care" to the organization's title, have expressed reservations about the quality of care such programs might offer.
Laurie Orlando, MHO president, says palliative-care units might offer "a wider range of quality of care" than hospice agencies, which follow national standards of care.
"The hospice is the Cadillac of palliative care," says Timothy Quill, M.D., professor of medicine and psychiatry at the University of Rochester (N.Y.) School of Medicine and Dentistry. He also runs a palliative-care program at Genesee Hospital in Rochester.
"We probably are not going to be able to provide a Cadillac to this broader population-maybe a Taurus," he says.
Just because palliative-care units offer different care than hospices doesn't make palliative units any less legitimate, Quill and others say.
A new point of care. Marcos Pappagallo, M.D., a neurologist and a pain specialist at Johns Hopkins Hospital in Baltimore, says good palliative care can help stabilize patients and perhaps prevent frequent crises requiring emergency care.
In fact, he says, hospitals can benefit from palliative-care programs because the programs allow for the admission of patients whose conditions cannot be treated under traditional acute-care approaches.
For example, a patient who has multiple sclerosis or amyotrophic lateral sclerosis and is in severe pain could be admitted for a few days, stabilized and sent home. Without a specialized unit, the hospital might not be able to provide that kind of treatment-or reap those revenues.
In June Pappagallo will become director of a comprehensive pain treatment center at New York University Medical Center's Hospital for Joint Diseases.
Some hospitals have found that palliative-medicine units help shorten lengths of hospital stay or allow the use of less-expensive pain drugs.
In addition, many hospitals with palliative care are recording longer lengths of stay in their hospices.
Palliative medicine overlaps with hospice services, Bricker notes, "but patients don't have be dying to get it."
Treating symptoms early makes sense financially and clinically.
"We felt that if we could manage people who had (untreatable) pain, we would be able to save money," says Cheryl Martin, administrator at Josephine Ford.
"The earlier in the course of the disease you can catch something and treat it appropriately and keep it under control, the less financial impact it will have," she says.
At the Ford center, about 30% of patients are on capitated contracts, Martin estimates.
One way palliative care helps control costs is by managing the cost of pain medication. In a review of pain drugs used by the hospital, Martin found that a dose of roughly equivalent pain medicine ranged from $1.18 to $35, depending on the medicine.
The service has developed information about equal analgesic doses, which it makes available to hospital doctors. "Patients should be put on the least expensive drug that takes care of the problem," Martin says.
Shorter stays. A palliative-care service also can save money for hospitals by decreasing lengths of hospital stay.
Mary Ann Gill, director of hospice and palliative-care services at Mount Carmel Health System in Columbus, Ohio, was able to show that patients receiving palliative care stayed in the hospital an average of one day less than patients with similar diagnoses who did not receive such care.
The three-hospital, 929-bed system, sponsored by the Congregation of the Sisters of the Holy Cross, opened its first palliative-care unit at Mount Carmel East Hospital in 1997. A second unit, at Mount Carmel Medical Center, opened in 1998, and St. Ann's is set to get its unit in June.
Each unit contains a half-dozen beds.
Gill's data have not yet been replicated in other settings. In a 1998 study of claims data, HCFA found no significant differences in length of stay or in hospital charges for patients with or without the coding for palliative care.
But administrators believe that as palliative medicine becomes more of a standard of care, hospitals will begin to notice changes in patterns of care.
"The intent (of palliative medicine) is to give people functional status so that they can be at home," Martin says.
Another measure of the success of palliative care-and its impact on a hospital system's bottom line-is the length of hospice stay.
Medicare's hospice benefit, established in 1982, greatly fueled hospice growth. Still, only 17% of dying patients nationwide are actually referred to hospices.
Length of hospice stay is critical to the financial well-being of a hospice program. Medicare hospice reimbursement is a per-day flat rate, but hospice patients cost more during their first and last days. A hospice program can stay solvent only if patients stay longer than a week or two.
"The hospice benefit is a big problem," says Declan Walsh, M.D., director of the palliative-medicine program at 937-bed Cleveland Clinic.
"It was a benefit set up with the best intentions, but the way it has played out is that people are not referred until very shortly before they die," Walsh says. "This makes it impossible for many hospices to run a financially viable service."
Bricker's program at the Ford center is too new to have made a dent in hospice length of stay. At Mount Carmel's hospice program, however, length of stay has increased two days in the last six months, Gill reports.
At Beth Israel Medical Center in New York City, where a pain medicine and palliative-care department was established in September 1997, the median length of stay rose to 21 days from 18 in one year.
Most compelling were the results at Northwestern in Chicago. Von Gunten says median length of stay rose from 19 days in 1993, when his program was established, to 38 days in 1997.
Nationally, however, the length of hospice stay has been declining since 1994.
Right reasons. Palliative-medicine programs also create less-defined savings.
"Good palliative care leads to better resource allocation," Von Gunten says. "It is not about steering people away from expensive care but to make those decisions for the right reasons."
Patients may ask that everything possible be done because they do not want to feel abandoned, Von Gunten says. If a palliative-medicine consultation can address those fundamental concerns, patients may decide on a different, possibly less expensive, course of treatment.
Russell Portenoy, M.D., chairs the department of pain medicine and palliative care at the 1,234-bed Beth Israel system. The department, established in 1997, is the largest palliative-care program in the country.
In June the department will add a headache program.
Pairing the palliative-care program with a pain management program instead of with a hospice draws a sharper line between palliative and end-of-life care than many hospitals have done.
"We're working toward the idea that palliative medicine is a subspecialty and patients with tough clinical problems may have access to that," Portenoy says.
"Essentially we are trying to provide hospicelike service for patients who are not hospice candidates," Portenoy says.
The pairing confers some financial benefits as well.
The pain management program attracts patients to the hospital, Portenoy explains. Treating chronic illnesses brings in revenues, and the hospital repays the department with full-time equivalents for the palliative-care program.
The hospital has given Portenoy two years to make the program financially viable, he says, and so far the department's profit and loss overall "seem to be in balance."
As palliative-medicine units become standard features of the hospital landscape, they are likely to be seen as just one more piece in the post-acute-care continuum. That may be the case at Cleveland Clinic, where Walsh directs the palliative-medicine program.
The program, begun in 1987 as a consulting practice, has expanded to include outpatient clinics, an inpatient service, a hospice and home-care service, an inpatient acute-care unit, research and fellowship programs and, in 1997, an endowed chair in palliative medicine.
Now the hospital plans to bring the rest of its post-acute-care services under Walsh's direction.
Hospitals can maintain quality of care more easily if they control all parts of a post-acute-care continuum, Walsh explains. That control also makes it easier to manage costs.
"If we are able to control the entire post-acute-care piece we can most effectively control the length of stay on the acute-care side," Walsh says.