Historically, some tension has existed between those working in hospice and those involved in palliative care outside formal hospices.18 While both groups are trying to improve care for suffering patients and their families, the fears and concerns of the two camps are instructive.
At the risk of oversimplification, some working in hospice have been concerned that palliative care may represent a return to a mechanistic form of medicine. Pain, for example, might become its own disease to be cured like any other.19,20 There is concern that physicians may try to dominate care again, as too often happens in traditional medicine, thereby negating the progress that has been made by clinicians in other disciplines who work in an interdisciplinary fashion.
The counterargument by some in the palliative care movement is that hospice, while wonderful in many regards, has been too narrow in focus, serving too few suffering and dying patients. Hospice has become less a philosophy of care and more a social organization of home care. Hospices have been reluctant to address flaws in the Medicare Hospice Benefit in part because home hospices are dependent upon the benefit for their very existence. Historically, hospices in the United States have done a poor job of advocating for physician education and wider availability of good end-of-life care for those unable to die at home.
I believe there is some truth to both sides of the argument. It would be terrible if palliative care became mechanical symptom management - if suffering became a disease. Those involved in palliative care must keep close to heart the lessons and wisdom that have evolved in the hospice movement lest we succumb to such a fate. There is also truth in the fact that hospice, at least in the United States, has become bureaucratically encrusted and is due for reform.
The tension between hospice and palliative care has been largely productive. Hospices are providing a moral conscience necessary for the modern palliative care movement. In turn, palliative care is invigorating the hospice movement. In the end, I believe both hospices and those involved in palliative care will be stronger and better for this tension and the ensuing debate.
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Palliative Care Perspectives
James L. Hallenbeck, M.D.
Copyright © 2003 by Oxford University Press, Inc.
The online version of this book is used with permission of the publisher and author on web sites affiliated with the Inter-Institutional Collaborating Network on End-of-life Care (IICN), sponsored by Growth House, Inc.