Dying, Death, and Bereavement

Abstract

Hospice is a word that can be tracked back to archaic times, it was considered an area that sick or tired travelers could find a place of rest, care, and shelter. Since feudal times hospice programs have developed into modern care that gives individuals confronted with life-ending illnesses psychological, medical, and spiritual care. This paper will discuss the origins of hospice care, patient and family care, and pain management.

Hospice Care

A doctor named Cicely Saunders initially suggested the concept of specialized care for terminally ill individuals in 1963 and in 1967 the first contemporary hospice was opened in a suburb of London (). This was the start of current era hospice care that supplies individuals the compassionate and humane concern that is advantageous to patients that are in their final stage of terminal illness, so they are able to live as contentedly as possible before their deaths.

Societies around the world are maturing at an extraordinary percentage. This tendency is notably evident in Russia, Japan, Western Europe, and the United States. Hospice care is provided to individuals of various age groups. Additions to hospice care respond to the need for modern developments with respect to this rapidly evolving medical treatment type. In its early years, hospice was a counterculture among the various clinical disciplines in its approach to care. A sign of the positive change that has occurred since that time is the approval in 2006 of hospice care as a new subspecialty by the American Board of Medical Specialties.

When a family member passes, the location of death can have important implications for the families’ experience of bereavement and death, though it is not the only factor that impacts this experience (Sidney, 2007). Hospice in the home aids the entire family and they are determined to take a vital role by providing supportive care to the patient. Family members tend to experience less helplessness and the individual does not rely solely on strangers for her/his support. The purpose of hospice is to accomplish the finest quality end of life care for the patient, but also for their families. Enabling death to occur at home, if it is the patient’s dying wish, is viewed as a guarantee of care at the end of a family member’s life.

Hospice care is distinguished by its orientation toward the needs of dying patients and their families. The mission of hospice care is to comfort the patient rather than to cure a disease. It has been called holistic care for the dying. Hospice is not necessarily a place but, rather, a program of caring. Hospice care can be provided in various settings, including a palliative medicine department within a hospital, a nursing home or residential-care facility, a community hospice, or the home.

There are also hospitals that have hospice programs that enable terminally ill patients’ access to support, aid and numerous health care experts. Various hospitals have distinctive hospice units. These special units administer comprehensive psychological and medical support to patients that require aggressive symptom management. While home hospice provides end-of-life care within a setting that is recognizable to the individual and family makes their last days beneficial and comfortable for all.

Hospices were founded primarily to alleviate suffering at the end of life. Quality improvement in hospices should target patients’ subjective assessments of their care and its outcomes. Terminally ill patients often have unmet psychological, physical, existential, and social needs. Practitioners of hospice care attempt to rectify this problem through a multifaceted approach to relieve suffering. Because the primary goal of hospice care is to relieve patients’ suffering, its success should be judged by the patients’ subjective assessments of the outcomes and processes of care (Tierney, 1998).

In the 1970s cancer patients made up the largest percentage of hospice admissions; today, they account for less than half of hospice admissions, 41.3% with the majority being patients with chronic illnesses, including heart disease, unspecified debility, dementia, and lung disease. More than 98% of families indicate they would recommend hospice services to others. The growth of hospice reflects changing expectations about end-of-life care.

The National Hospice Study, completed approximately 16 years ago, provided information ranging from analgesic usage in different hospice settings to the usage of health care resources for terminal cancer patients in different clinical settings. Despite this information, there was still a lack of information concerning whether primary care physicians, general internal medicine, general practice, family practice or general practice, do an adequate job of managing pain in terminal cancer patients. A United States study comparing oncologists with primary care providers in the care of home hospice patients found no differences were noted in the effectiveness of pain management between physician specialties. However, a European study reported both specialists and primary care physicians undertreated pain in cancer patients (Nowles, 1999).

For hospice care, the goal of medicine is to restore or sustain a sense of equanimity and personal integrity despite the disturbances caused by illness. The main aim is to control pain and other physical distress. It involves the active total care of patients whose disease is not responsive to curative treatment. The mission of hospice goes beyond the physical and seeks to relieve suffering by caring for all of a patient’s needs: physical, psychological, spiritual, and existential. At the end of life, a patient’s personal story is not adequately told by what’s written on the medical chart.

Hospice has increasingly become an avenue to administer care for deathly ill nursing home patients. The percentage of hospice enrollees residing in nursing homes increased from 9.9% in 1990 to 21.5% in 2002 (Kayser, 2006). The Medicare expenditure for hospice care in nursing homes increased dramatically from $ 9 million in 1991 to $ 22 million in 2001. Studies suggest that hospice programs are related to advanced quality of physical suffering management and residents registered in hospice programs are twice as likely to have a record of pain management and to receive regular treatment for pain (Kayser, 2006).

Pain management was assessed among forty-two hospice and sixty-five regular patients in a nursing home. A medication scale was implemented to account for the administration and prescription of analgesic medication. Although 72% of residents experienced pain, there was no difference in the ratio of hospice versus regular patients and those that were prescribed co-analgesics and opioids or those whose medications were given around the clock or as necessary. Lack of nursing staff pharmacologic knowledge with limited physician availability delayed pain management with each group of patients. While hospice care is beneficial, high-quality end-of-life care and pain management depends on the circumstances in which they are given (Kayser, 2006).

The relationship between the place of death and bereavement outcome remains unclear. Studies have found that, compared to caregivers of patients that died elsewhere, bereaved caregivers of patients that died at home were more psychologically distressed and likely to miss the deceased and have greater social isolation tendencies. They were also less likely to have come to terms with bereavement, feel that things were going well for them and look forward to things. Caregivers have also been found to have positive feelings about death, suffer less death anxiety guilt, depersonalization, rumination, and despair as well as general anxiety if the patient died at home compared to in a hospital. Studies also show that bereaved caregivers are more likely to state that the place of death was right after a home death compared to a hospital death, although one study comparing home with inpatient care found no obvious difference. Feeling that the place of death is right may not be directly associated with a better bereavement outcome (Grande, 2004).

In conclusion, dying is a natural course of life and any opportunity to assist in the quality of life for the patient, family and caregiver should be evaluated. The ultimate goal in hospice is to provide a comfortable and positive approach to improve the quality of life for individuals with a life limiting illness, their caregivers, and family, while reducing suffering and promoting understanding of bereavement and loss. Understanding the place of death, bereavement, and care provided is the best approach for patients and families facing difficult end-of-life decisions.

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