 | Tom Welk
DMin is Director of Pastoral Care & Professional Education at Harry Hynes Memorial Hospice. He also teaches at the University of Kansas School of Medicine-Wichita. He has certification with the American Association of Pastoral Counselors in Clinical Pastoral Education. His memberships include Park Ridge Center for Study of Health, Faith, and Ethics, and St. Louis University Center for Health Care Ethics, Charter Board Member Kansas Health Ethics, Inc., and Ethics Committee Member for National Hospice Organization. He has received the President's Award of Excellence for Public and Community Awareness, for the "Dying Well" project from The National Hospice Organization. Tom's group presentations include: Association of Kansas Hospices, Midwest Congress on Aging, and Kansas Health Ethics Conference. Tom Welk can be contacted by fax at (316) 265-6066, by e-mail at: twelk@hynesmemorial.org, or at his office at (316)219-1791. |
Hospice
2003-09-01 15:42:00
Who decides if hospice is needed?
: Is it best to wait until the doctor recommends hospice for a patient, or is it proper to bring it up to the doctor?
ANSWER: Before dir-ectly answering this question, let me give a reflection on a couple of related issues. One of the basic ethical principles in medical care is autonomy. This principle holds that the patient is in charge of her/his health care, and must give permission before any medical intervention can take place. (In the case of medical emergencies, patient permission is presumed.) Medical providers who act counter to patient-permission are in jeopardy for civil and/or criminal prosecution. Closely related to autonomy is the issue of informed consent. In legal terms, this means that in order for a patient to give permission or consent for a medical intervention, the patient must have all the necessary and pertinent information, i.e., she/he must be "informed." So, who makes the decision as to when hospice services are initiated? This question needs to be expanded to include other medical services. A patient cannot access medical care which will be reimbursed through third party payers (Medicare/Medicaid and commercial insurance) unless a medical doctor orders that care. For example, patients cannot check themselves into a hospital, get home health care or skilled medical care in a nursing home without a doctor's order. This is also true for hospice services that will be reimbursed by third party payers. In this regard then, the answer to the question posed above is simple. A doctor has to order (write a prescription) for hospice services. And just as a doctor must make an assessment as to the appropriateness of other medical care (hospitalization, home health, etc), so also the doctor must make an assessment for the appropriateness of hospice services for a particular patient. Is it proper to bring it up to the doctor? Yes. This is where the issue of autonomy comes in to play. Modern medicine has an almost endless array of curative medical interventions. No matter how serious the injury or disease, it seems "there is always something more" that can be done to try to reverse the life-threatening situation. Physicians are highly trained in curative interventions. This, along with their dedication, might make it difficult for them at times to determine when "enough is enough." Because of this, a doctor might not always think about moving a patient from curative to comfort care, or in other words, from the sick to the dying role. A doctor might not always be the first one to recommend a patient to the care of a hospice program. As I stated above, autonomy is the basic right of a patient to accept or refuse medical interventions. No one who is considered competent can be forced to undergo any kind of medical treatment, even if that refusal should allow an underlying life-threatening condition to run its course resulting in death. This right has been spelled out by a number of court cases, including several decisions by the U.S. Supreme Court. Hence, it is quite proper for the patient and/or the patient's loved ones to initiate the discussion of hospice being involved. The physician, however, must still make the official determination that the patient is appropriate for hospice, i.e., the patient will likely die within six months or less without further curative intervention.
