Intravenous medications tackle pain but are also costlier than other forms. The appearance of new and costlier drugs blurs the fine line between life-saving and mere comfort-giving. Chemotherapy can shrink a tumor to allow swallowing and radiation can ease or reduce pain. If the hospice is not well financed, one or two patients who demand these procedures can bring cost problems to the hospice. Shareholders who fear that the return on their investment is jeopardized may decide to cut down on staff. They may also shed off community grief centers, extensive bereavement care, alternative therapies, and inpatient care centers. The multicultural view of death is another issue in hospices in the United States and Western Europe (Wexler & Frey, 2004). Migrants with Easter cultures have an entirely different perspective from those with Western cultures. The Chinese's concept of death is a sharp example. The views of death and end-of-life values of other cultures should be incorporated into the policies of hospice care programs (Wexler & Frey).

The low rate and significant increase of physician services are additional troubles for hospices (Carlson & Morrison, 2007). In most cases, hospice physicians participate only in care planning meetings, not in direct or actual patient care. The 6% increase in the number of patients receiving physician services was not considered significant. Still less than a third of these patients received hands-on physician services. This could be the offshoot of the original and non-medical concept of hospice care (Carlson & Morrison).

The range of hospice services provided in different regions has also been found to vary by region (Solnik, 2002; Wexler & Frey, 2004). Patients in the Northeast received a significantly narrower set of services than those in other regions. Alternative forms of palliative care for end-of-life patients are quite common in the Northeast. These forms have recently expanded as hospital-based palliative care programs more than in other regions. This trend could have influenced the role and scope of hospice care offered in that region (Solnik, Wexler & Frey).

One more issue or problem is regulation of hospices itself (Solnik, 2002). In order to pay for hospice care, Medicare or a private insurer requires two physicians to sign a document that the patient has only six months or less to live. It then pays only for palliative treatment or management of symptoms and pain, not for the cure of the disease. This compels the patient to choose comfort or care over cure. The hospice industry has been by lobbying for a change in the regulation to allow or include curative treatment in hospice care. In collaboration with this initiative, the National Hospice and Palliative Care Association has also been lobbying for increased insurance reimbursements to include payments for costly procedures, like chemotherapy and radiation therapy (Solnik).

Some approaches to these issues have been noted. Increased disease complexity, the diversity of diagnoses and symptom burden are likely to increase direct physician care (Carlson & Morrison, 2007). The patient's primary care physician may continue to monitor the patient's condition but he is also unlikely to possess appropriate training, knowledge and skills on palliative care (Carlson ^ Morrison).

Consolidation efforts in the industry has helped hospice care providers gain greater access to fund sources (Solnik, 2002). This is illustrated by the merging of hospice services among the Charles Hospital and Rehabilitation Center, Mercy Medical Center and Good Samaritan. They created Good Shepherd. They, however, found that reducing the costs of products and services would not sustain them without extensive financing or fund-raising (Solnik).

Some studies focused on the availability of hospice care to the elderly in the rural areas (Solnik, 2002). Findings showed that the range of hospice services in the areas were comparable with those in the urban areas. The probability of fewer services in the rural areas can be dealt with by increasing reimbursement to cover travel expenses and attract skilled health professionals (Solnik).

New York legislation would expand Medicaid payment for freestanding hospices in response to the six-month limit requirement (Solnik, 2003). The initiative encouraged the construction of freestanding hospices, such as the Visiting Nurse Service & Hospice of Suffolk, Inc. On Long Island and the Hospice Care Network in Manhasset. Freestanding hospices would create and provide facilities for the exclusive use of hospice care. Hospice beds in hospitals and nursing homes are currently only a small part of the overall facility. This would provide family support to take care of patients who do not have it and need it in their condition. Hospice care providers consider freestanding hospices a potentially important part of their industry (Solnik).

Community Assessment

The City of South Bend in Indiana is the seat of St. Joseph County in a region known as "Michiana (Answers.com,...

South Bend is famous for the University of Notre Dame and the winning football team, "The Fighting Irish." It has a 107,789 population as of 2000. The City's has nine medical centers, prominently the Hospice of St. Joseph County (McMahon, 2008). Employment in the health care and social services is 13.4% of the total.(McMahon).
The Indiana Hospice & Palliative Care Organization supervises hospice care in the City. Among the issues it confronts are treating the homeless at the end-of-life, the costs of end-of-life care to elderly patients, pain management, care-giving at the end-of-life, and futile care (2007).

Treating the homeless at the end-of-life is a major concern for the City. They can seldom access hospice service for lack of resources for inpatient hospice, a home or social support (Indiana Hospice & Palliative Care Organization, 2007). In addition, these homeless are already beset with substance abuse problems and mental illness. Their need for hospital care is 3-4 times greater than expected and 36% longer than poor patients who have homes and encounter similar health problems. Some organizations offer them medical respite, short-term shelter with basic services for those too sick to function on the street. These organizations cannot, however, care for those who are nearing death. (Indiana Hospice & Palliative Care Organization).

Keeping to a medication regimen is a critical problem among homeless patients. They lack the money to buy them, lose their belongings or suffer from symptoms of mental illness or substance abuse (Indiana Hospice & Palliative Care Organization, 2007). Other problems they confront are the control of pain, the inability to discuss death and dying at home. Because of drug abuse, they may be opioid-tolerant and, thus, may need higher doses. If they stop taking drugs, they need specific treatment to handle withdrawal reactions. The homeless also less willing to discuss death on account of what they have been denied in life. A study found that the homeless expect to die suddenly and violently. This expectation affects their willingness to discuss death. The homeless are also unlikely to have a surrogate or confidant who can make decisions for them in the event of incapacitation. Ethics committees or court-appointed guardians take their place for the function. And dying at home is not an option because they have no home. They are also unlikely to observe house rules in hospices. Experts recommend that homeless patients at the end-of-life be encouraged to form trusting relationships to insure or enhance curative and palliative care at that period (Indiana Hospice & Palliative Care Organization).

City laws are slated for revision to respond to these issues ((Indiana Hospice & Palliative Care Organization, 2007). One will direct the Health Department to name a commission, which will "enact rules for physicians to order for life-sustaining treatment." The other revision will further strengthen healthcare powers of attorney. Living wills merely provide instructions concerning life-sustaining treatment. Powers of attorney concerning the end-of-life wishes of a patient belong to the spouse as first priority, followed by adult children and then close friends ((Indiana Hospice & Palliative Care Organization).

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