Position Statements

Statement on Access to Palliative Care and Hospice

Approved by the Board of Directors
March 11, 2008

Access to palliative care and hospice is currently uneven and inadequate.(1)  For many Americans, this is part of a larger problem of inadequate access to any medical care.  For those with access, referrals for palliative care consultation or hospice are sometimes withheld by physicians or refused by patients and families because of an incorrect association with death or  with forgoing potentially life-prolonging treatments.(2)

Access to palliative care consultation is further limited by daunting physician manpower issues.  Although the number of palliative care consultation programs is growing rapidly and the field of Hospice and Palliative Medicine has recently been granted subspecialty status, there remains a huge gap between the need for palliative care services and the supply of trained palliative care professionals.  As of 2005, only 25% of hospitals and 70% of academic medical centers offered  inpatient palliative care consultation, and these services varied significantly in their comprehensiveness.(3)  The availability of palliative care consultation in outpatient settings or skilled nursing homes has been even more limited. 

Access to hospice is further limited because of its restriction to patients expected to die within the next 6 months and because of its focus on palliative rather than curative treatment. These eligibility requirements often create prognostic (“How can I be sure my patient has under 6 months?”) and practical (“I would like to keep my options for future treatment open”) barriers to hospice enrollment. Although hospice is the most comprehensive program providing palliative care to seriously ill patients available in the United States and enrollment has been increasing,(1) only  30% of patients are enrolled in hospice at the time of death and the median length of stay for those who have been referred has remained approximately 30 days for at least a decade.
 

1. AAHPM believes that all seriously ill patients who have symptoms that are difficult to treat or who face challenging decisions about goals of care should have access to palliative care consultation and/or hospice. Efforts to enhance quality of life should be offered alongside curative and/or restorative medical care in all medical settings. Patients, families and health care professionals should consider palliative care a fundamental component of excellent medical care, not an alternative after other approaches have been pursued.  AAHPM will continue to support the development of palliative care consultation programs in acute care hospitals, skilled nursing facilities, and outpatient settings, and will continue to advocate for predictable, fair reimbursement for consultative activities with all major insurers. 
2. AAHPM supports continued efforts to inform the public and healthcare professionals about hospice as the premiere program providing comprehensive care for patients with life-limiting illnesses and their families. AAHPM promotes the inclusion in hospice programs of more patients with advanced stages of non-cancer diagnoses such as heart failure, chronic obstructive pulmonary disease and dementia.(4)  AAHPM also supports “open” or “expanded access” programs that allow  hospice access for patients with life-limiting illness who could benefit from palliative treatments such as quality-of-life-enhancing chemotherapy or intravenous cardiac agents.(5)  A better understanding of the economic, public policy, and clinical implications of including these types of treatment in hospice care might allow more patients to gain access to hospice in the advanced stages of their illness. 
3. AAHPM supports public and private funding mechanisms to ensure the growth and development of ACGME (Accreditation Council of Graduate Medical Education) certified fellowship programs. Such programs are essential to train greater numbers of palliative care and hospice clinicians to close the substantial gap between need and availability. 

References

1. Approaching Death:  Improving Care at the End of life. Washington, DC: National Academy Press, 1997.
2. Quill TE. Perspectives on care at the close of life. Initiating end-of-life discussions with seriously ill patients: addressing the "elephant in the room".[see comment]. JAMA 284(19):2502-7, 2000.
   
3. Morrison RS, Meier DE. Clinical practice. Palliative care.[see comment]. [Review] [62 refs]. New England Journal of Medicine 350(25):2582-90, 2004.
   
4. Gazelle G. Understanding Hospice - An Underutilized Option for Life's Final Chapter. N Engl J Med 2007; 357:321-324.
   
5. Wright AA, Katz IT. Letting Go of the Rope - Aggressive Treatment, Hospice Care and Open Access. N Engl J Med 2007; 357:324-327.