Correspondence
A New Diagnosis-Related Group for Palliative Care
N Engl J Med 1997; 336:1029-1030April 3, 1997
- Article
To the Editor:
The National Hospice Organization welcomes the announcement of a new diagnostic code for palliative care and the possible development of a special diagnosis-related group (DRG) that would allow payment for end-of-life care in the hospital. Drs. Cassel and Vladeck correctly point out in their Sounding Board article (Oct. 17 issue)1 that the majority of people still die in hospitals (61 percent) or nursing homes (17 percent), despite the tremendous growth in hospice care (a 147 percent increase in the number of patients and their families served in hospices over the past decade, with 390,000 patients and families served in 1995). The establishment of codes for palliative care could be an important step toward providing more appropriate care for terminally ill patients in hospitals.
However, our support for this new code does not diminish our concern that the terminally ill not be forced to remain in hospitals when, with the proper support, they could be cared for in their own homes. A recent Gallup survey reported that 70 percent of people, if terminally ill, would want access to hospice care.
By encouraging and legitimizing the provision of palliative care for terminally ill people dying in hospitals, the Health Care Financing Administration will positively affect the end-of-life experiences of many Americans. But we should not accept the current rate of hospital deaths among the terminally ill as the best we can do. Such acceptance ignores people's stated desires and the growing opportunity to care for people outside the hospital.
The National Hospice Organization is also concerned that palliative care provided in hospitals under new codes could be too narrowly focused on a medical model of care, to the exclusion of an interdisciplinary team approach, and could emphasize physical care and address the emotional, psychosocial, and spiritual needs of the patient as problems to be solved or, worse, ignored.
Twenty years ago, hospice care was developed outside the inpatient hospital setting not because of the lack of appropriate hospital reimbursement but because of the limits inherent in the culture of hospitals that created obstacles to providing good care at the end of life. The SUPPORT study (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment) reinforces the view that those limits may still exist and casts doubt on the reasonableness of believing that tinkering with DRG codes will substantially alter the institutional culture that limits good care of the dying.
1 ReferencesJohn J. Mahoney
National Hospice Organization, Arlington, VA 222091
Cassel CK ,Vladeck BC . ICD-9 code for palliative or terminal care. N Engl J Med 1996;335:1232-1234
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Author/Editor Response
The authors reply:
To the Editor: A number of leaders in hospice care have expressed concern that an attempt to explicitly identify palliative care within the hospital setting will be detrimental to the hospice movement. In no way is that our intention, nor is it our expectation. Indeed, it is the example of hospice care that led us to believe that patients who, for any number of reasons, cannot be moved out of the hospital should be able to receive the same kind of care as patients who are able to go home at the end of their lives. We do not want to encourage unnecessary hospitalization for dying patients or prevent persons from electing the hospice benefit who are otherwise eligible to do so, but we do want to extend to patients who die in hospitals the opportunity to choose palliative care as an alternative to intensive medical interventions.
We have no illusion that simply creating a code or eventually a DRG for terminal illness will, by itself, improve the care of dying patients in acute care hospitals. We do believe, however, that an explicit acknowledgment of the care that is involved will play a part in changing the culture. We are optimistic that these changes will take place, since we already see programs around the country, supported by foundations, medical groups, medical societies, and hospitals, that are developing comprehensive interdisciplinary approaches to improving palliative care.
We hope that these activities will be developed in partnership with hospice organizations and that patients and families will benefit.
Christine K. Cassel, M.D.
Mount Sinai Medical Center, New York, NY 10029Bruce C. Vladeck, Ph.D.
Health Care Financing Administration, Washington, DC 20201
