What I learned as a hospice director

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We all practice medicine for different reasons. Of course, it’s almost reflexive to say we practice medicine because we care about people. I’m sure this is true for many physicians. However, if I were being honest, I think I went into medicine more because of the educational challenge. In addition, the profession yielded respect, status, money (back in the day!) and yes, an opportunity to help. I won’t challenge my classmates’ values or the values of those who taught me, but in hindsight, my guess is that these other factors were significant motivators in many of those I ran across during my training.

I am now at the end of a career, far fewer years left than I have put in. Sadly, cynicism and burn out are better descriptors of my relationship to medicine than anything else lately. However, one of the greatest and most unexpected joys has been to be associated with a hospice service. I was very fortunate to be asked to join a hospice team. For someone with the aforementioned burnout and early career motivations hospice seems like the last place I would be.

Hospice is unlike any other discipline in medicine. Outcomes are pre-determined. In fact, to qualify life expectancy must be reasonably less than six months. No dramatic cures, little in the way of intellectual investigation of medical issues in the traditional sense (although it can have its management challenges). Often our patient’s course is laid out before us with death as the inevitable end.

Ultimately the root of medicine is the elimination of suffering, a goal that can be easily lost in filling out pre-authorizations, meeting HgA1c goals, completing the proper ICD-10 list for billing and the myriad concerns that plague modern practice.

Going to hospice weekly is like a breath of fresh air. We begin with a non-denominational reflection. They range from serious to funny, sad to uplifting, meaningful to a light commentary on the human condition. These reflections are about so much more than our patients’ needs and concerns; they address the staff, patients’ families, and even the staff of the care facilities in which many of our patients reside. Caring for the dying is recognized as a community concern. Isn’t this a lesson we should bring to our other care?

Then we move on to remembering those who have passed. Sometimes the passage is easy, a timely and fitting end to a life well-lived. But then, too, we have remembrances of patients who had difficult lives, with demise characterized by fear, confusion or anger. Not all are Hollywood endings. Not all families reconcile at the last minute. Not everyone is forgiven. But, through it all, the hospice staff treats each patient with kindness, looking for the smallest opportunity to improve the patient’s time left. Often the remembrances invoke laughter, and, with that amazing human capacity to hold two emotions simultaneously, sadness at the same time. Some patients are with us for just a few days, the rare patient only hours. Even at these times families often express how much comfort hospice provided.

Only then do we discuss the clinical status of our patients. Pre-eminent concerns are often clinical issues such as pain, dyspnea or agitation. But equally dignity, maintenance of capacities and helping families choose well for their loved ones are discussed. Clinical decisions are not just for the prescribers, but everyone, from the medical director to the CNAs, have input which is valued. Social work, pastoral care, and volunteers present their own concerns and accept the same team wide input into their functions.

I highly recommend practitioners to engage with their hospice providers. The care and compassion they provide spreads beyond their patients and serves as a reminder of how we engage in one of the most human endeavors possible, caring for others.

Robert J. Tilley is a palliative care physician and can be reached on Twitter @RTilleyMDMBA.

Image credit: Shutterstock.com

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