News and Views

U.S. Government and Hospice Care in Nursing Homes

In reports released in the fall of 2009, the U.S. Office of the Inspector General (OIG) found 31% of all Medicare patients receiving hospice services lived in nursing homes. The federal government spent $2.5 billion in 2006 for that “home” hospice care. This is interesting because, in the United States, despite all the rhetoric about government take-over of health care, there is essentially a single payer for health care over the age of 65: Medicare. In addition, much of nursing home care is also paid for by the government through Medicaid. Since hospice care is primarily a program of home care in the United States, it follows that the federal government often pays twice for patients enrolled in hospice programs living in nursing homes. It should be no surprise that the OIG is looking to see if the federal government is getting its money's worth, or if it is being double-billed for the same services.

Oprah and Caregiving

Sometimes the most influential medical writing appears not in medical journals, but in the popular media. Oprah Winfrey, with her television show and eponymous magazine, is one of those trendsetters. Therefore, it was interesting to note that her magazine described the syndrome of compassion fatigue in regard to the more than 50 million Americans caring for an elderly, disabled, or chronically ill loved one. The piece acknowledged the constant demands on caregiver time and energy—for months or years on end—as well as the stress and frustration involved. The article described the syndrome of feeling emotionally and physically exhausted, angry, and even unable to care anymore. The piece acknowledged that the feelings are embarrassing to admit: they seem selfish, shameful, indecent.

Liverpool Pathway

It seems to be a law of nature; today's solution becomes tomorrow's problem. The Liverpool Pathway was meant to facilitate application of basic end-of-life care treatment in a reliable way. It was adopted by the National Health Service (NHS) in Great Britain. Yet, there has been a continued concern, reported in the Times, that such a “tick box” pathway is sometimes inappropriately used. A national audit of the pathway in the NHS was reported to show that one in four families is not informed when the patient is put on the pathway. Less than half are offered religious or spiritual support and a quarter of doctors serving in the NHS and using the pathway are not trained in palliative care. One way to look at this is the bar has been raised. There is a call for yet better decision making, better care, and more palliative medicine skills. This is something to celebrate. It makes the heart glad to note that New Zealand is planning to institute the pathway in its health services.

Canadian Caregivers

The Province of Nova Scotia is giving a financial allowance to informal family caregivers. Eligible caregivers received financial assistance from the government, which recognizes their important role and supports their efforts to assist loved ones and friends. Although politicians are expressing concerns that too many Nova Scotians are being rejected for the program, it is noteworthy that this program exists at all. It has been widely noted that care at home relies on an enormous number of people providing volunteer labor. If that was not present, many of those patients would need to be in nursing homes at much higher cost.

Israel Law

Orthodox rabbis have frequently interpreted Talmudic teaching that life is so precious as to prevent any effort that would shorten biologic human life, no matter how compromised. Consequently, rabbinical figures around the world were surprised by the Chief Rabbinate Council's decision that a proposed bill being considered by the Knesset equating brain death with the end of life is consistent with traditional Jewish law. The new bill would permit organs to be taken from a brain dead person before the heart has stopped beating. While such laws are common in Europe and North America, they are uncommon in other parts of the world. Not surprisingly, the Rabbinate's decision followed an extended period of discussion between the rabbinical and medical communities in Israel.