The irony that is San Diego Hospice

One of my good friends is a palliative care specialist, the kind of physician who might work at San Diego Hospice. When he rushes off the phone, I typically say, “What’s the hurry? Afraid someone will live?” I thought I was joking. If their investigation into San Diego Hospice is any indication, the federal government doesn’t.

If you haven’t encountered hospice care, you’re either very lucky or very unlucky. Lucky that none of your loved ones face the difficult choice between pursuing heroic and sometimes toxic life-prolonging measures and allowing death to come more naturally. Unlucky if someone, wanting the latter, didn’t have anyone to ensure their remaining days were comfortable and dignified. Hospices, like the nationally respected San Diego Hospice, provide that tender care.

In recent months, San Diego Hospice has sought bankruptcy and it appears to be closing because of an audit by Medicare, who funds much of their work. The crux of the complaints against San Diego Hospice is that patients lived too long. If that sounds absurd en face, it only gets worse when you begin to understand the facts.

In their own pamphlet on Medicare Hospice Services, the Centers for Medicare and Medicaid Services (CMS) note that you are eligible for Hospice if, “Your doctor and the hospice medical director certify that you’re terminally ill and have six months or less to live if your illness runs its normal course.” It goes on to note that in hospice, “The focus is on comfort, not on curing an illness.”

Now consider the cirrhotic patients I frequently refer to hospice. They don’t die because their liver suddenly explodes. The “normal course” is for cirrhotic patients to become susceptible to infections, fluid retention and stomach erosion (leading to bleeding). Each of these sequelae are uncomfortable, so treatment with antibiotics, diuretics and acid suppressors is consistent with the focus of hospice care. Any extension of life could be considered a side effect, one that the comfortable and typically very satisfied hospice patient doesn’t mind at all.

Since none of the therapies fix the cirrhosis, however, the patient will continue to meet the hospice criteria. If that weren’t enough to confuse the 6 month timeline, consider the increasing body of evidence that good palliative care can prolong life. Add the fact that the medical degree doesn’t come with Batphone-like access to God’s plan, and you begin to see how the length of a hospice stay can vary.

CMS apparently understands this. Otherwise, why allow hospice care to be certified for “two 90-day periods followed by an unlimited number of 60-day periods?” It can’t be the money, because when hospice happens to prolong life, it does so on the cheap. According to Voice of San Diego, a day of hospice costs between $153 and $896. Compared to chemotherapy, intensive care unit days and nursing home stays, hospice is a bargain. Also, as death is still as certain as taxes, even when the curative approach works, the costs are in addition to, not in place of, eventual end of life care.

So what we appear to have is San Diego Hospice, an organization devoted to providing a comfortable and dignified death, suffering its own painful demise because their patients didn’t die fast enough, with the accidental extra days costing the system much less than therapy actually designed to prolong life.

The irony itself is almost terminal. If CMS needs to punish San Diego Hospice for not filing all the necessary paperwork, get on with it. Then let them get back to work.

When death stops for me, I hope San Diego Hospice will be there to ensure it does so kindly, as it has for so many of my patients.

A few of them even lived longer than expected, and didn’t seem to mind at all.