One of the profound impacts of population aging is health care. The health care industry has to provide the necessary resources for this aging population. For example, in Shanghai, which has the highest level of population aging in China, in 1992, 3% of the elderly over the age of 60 were seriously ill, and the elderly who could not take care of themselves, plus Alzheimer's patients, were estimated to be in need of care at 6.3% (120,000 people), some of whom were terminally ill. About 80% of the elderly who cannot take care of themselves rely on their family members for care.1 Families are facing great difficulties, and many dying elderly people are calling for end-of-life care. At the same time, there is a growing realization that traditional, institutionalized forms of health care may not be the most effective way to help and provide compassionate care for the terminally ill. For some people who are dying, the health-care system, despite ongoing technological innovations, has failed to emphasize the alleviation of patient suffering and the provision of dignity. Every society has different customs and attitudes toward death, yet there is unanimous agreement that people who are dying should spend their final days in comfort and dignity. It is in the midst of demographic and cultural changes that hospice care has emerged.
The term "hospice" goes back hundreds of years, when it was used to describe the sheltering of weak or sick travelers. It was first used in a contemporary sense to denote the affectionate comfort, good care, and assistance possible to an elderly patient who was dying, so that he or she could die peacefully. The earliest care for the terminally ill was provided in 1967 at St. Christopher's Hospice in London, England, pioneered by Saunders. To date, hospices have been developed and promoted in many countries.
2, the development of hospice care in the United States
In 1974, the first hospice was established in the U.S. In 1982, Congress enacted a law to add hospice care to the Medicare program (a health care program for the elderly), which provided financial support for patients to enjoy hospice care services, and at the same time laid the groundwork for the development of the hospice industry in the United States. The policy change led to an immediate wave of hospice care everywhere. For more than a decade, hospice services in the U.S. have progressively increased their capacity to manage compounded pain and symptoms, and services have grown from small, voluntary organizations to a variety of formal nonprofit and for-profit agencies.
Factors in the development of society have contributed to a significant increase in the demand for hospice care, such as the aging of the population, concerns about dying with dignity, and increased costs of end-of-life care for a variety of organizations. The hospice industry in the United States has grown rapidly, with the number of hospice programs increasing at a rate of nearly 17% per year. Today, the National Hospice Organization (NHO) has more than 3,100 active and planned hospice programs in all 50 states. In 1998 alone, approximately 540,000 patients and their families received such services in the United States. With the elderly population (now 40 million) expected to double over the next 30 years, the number of hospice patients in the United States will continue to grow.
3, The Rationale for Hospice Care
Hospice care in the United States is provided to those who are dying, i.e., patients who are usually diagnosed with a life expectancy of six months or less. As a rule, hospices do not provide treatment to patients. The purpose of hospice care is neither to cure disease or prolong life nor to hasten death, but in fact to improve the quality of the individual's remaining life by providing palliative care, pain management and symptom management. The dignity of the patient is a paramount concern. Hospice care emphasizes the emotional, psychological, social, economic, and spiritual needs of patients and their families. End-of-life care is provided primarily in the patient's home; when home care is not an option for the patient, hospice care may be provided in a hospital, nursing home, or other facility.
Typical hospice care is provided by a team of professionals, an interdisciplinary team of registered nurses, physicians, social workers, and chaplains or other legal counselors. When needed, the care service also provides aides, pharmacists, physical therapy, speech therapy and trained volunteers. Patients and their families receive services 24 hours a day, seven days a week. Upon the death of a patient, relatives and friends may receive annual funeral services.
In 1995, according to the National Hospice Organization, 60 percent of hospice patients had cancer, 6 percent had a heart-related condition, 4 percent had AIDS, 1 percent had kidney disease, 2 percent had Alzheimer's dementia, and 27 percent had some other disease.
4, Current Status of Hospice Care in the United States
(1) Demographics
According to the National Hospice Organization, in April 1998, 65% of hospices in the United States were nonprofit, 16% were for-profit, 4% were governmental organizations, and 15% were of indeterminate type. In terms of organizational structure, in 1998, approximately 28% of hospices were independent legal entities, 59% were not hospices (e.g., hospitals or home health agencies) but were agencies affiliated with a legal entity, and 13% were indeterminate.
In 1995, 52 percent of hospice patients were male and 48 percent were female. Of the male patients, 71 percent were 65 years of age or older, 17.2 percent were 50 to 64 years of age; 10 percent were 18 to 49 years of age; and 1 percent were under 17 years of age. Of the female patients, 74% were 65 and older, 16.7 were 50 to 64 years old; 8.6% were 18 to 49 years old; and 1% were under 17 years old.
Seventy-seven percent of hospice patients died in their own residences, 19 percent died in institutions, and 4 percent died elsewhere. Of all the patients in the hospice care program, the average survival period was 61.5 days, or about two months.
(2) The Financial State of Hospice Care
Generally speaking, hospice care is a cost-saving and effective method of care because it is provided to the patient in the home by family members, friends, and volunteers, and does not usually require costly technology. In fact, the National Hospice Organization estimates that more than 90 percent of hospice care hours are provided in the patient's home in lieu of high-cost institutional care.A 1995 study showed that every dollar spent on hospice care saved Medicare $1.52 for every dollar spent on Medicare. The sources of savings are the cost of the patient's treatment, medications, hospitalization and nursing care. In the last year of life, hospice patients used $2,737 less in benefits than those who did not use hospice care. In the last month of life, this total***savings were $3,192. Some of the savings from hospice care are not obvious; for example, many endangered patients on Medicare often receive hospice services very late in life, until a few weeks or days before they die.
In the United States, hospice care is included in most private health insurance plans, the federal government's Medicare program for the elderly, and most state health assistance programs for the poor. Many hospices also accept charitable and voluntary forms of donations and community support.
According to the National Hospice Organization, in 1995, the Medicare program paid 65.3 percent of the cost of hospice care for hospice patients, private insurance paid 12 percent, Medicaid paid 7.8 percent, and 4.2 percent of indigent patients were exempt from paying for hospice care.
(3) Hospice Care and the Medicare Program
In the United States, most hospice care is provided by Medicare. in 1994, Medicare spent $1.2 billion of its roughly $200 billion on hospice services. In the Medicare program, hospice teams provide complete case management for Medicare patients, including all services with medications and equipment.
When a patient chooses hospice care, he can wait for Medicare to pay for all therapeutic treatments for the terminal state. Medicare hospice benefits include:
-Nursing services; - Physician services; - Drugs and biology; - Medical, surgical, and speech therapies; - Home health aids and chore services; - Medical support and medical equipment; - Short-term inpatient care; - Medical social services; - Spiritual, dietary, and other counseling; - Professionally trained volunteers; and - Funeral services.
At the end of 1984, only 153 Medicare-identified hospice programs were in operation; by 1995, the number had jumped to 1,857. According to estimates by the U.S. Health Care Finance Administration, Medicare payments increased at an average annual rate of 33.1 percent from fiscal year 1990 through 1996, with hospice services leading the growth rate for all forms of services.
(4) Medicaid Programs
In addition to the Medicare program, Medicaid is a federal and state*** program that provides health care to the needy, with recipients required to contribute their assets to hospice services.In 1999, 43 U.S. states, as well as the District of Columbus, had hospice components in their Medicaid. in 1993, Medicaid spent hospice services amounted to $129 million.
5, BARRIERS TO HOSPICE CARE
In many countries, including some that already have hospice programs, there are some barriers to maximizing the benefits of hospice care. For example, in many developing countries, including some developed countries, reductions in extended family support have made hospice care more difficult for many individuals who receive care at home.
In the United States, a persistent barrier is the difficulty of talking about death. Many individuals are reluctant to recognize a doctor's diagnosis that they have reached a terminal state, and they insist on receiving superfluous treatments that often prove ineffective. Many family members are also hesitant to discuss near-death. The National Hospice Organization found in April 1999 that one in four Americans over the age of 45 said they would be reluctant to raise issues related to their parent's death, even if the father or mother was terminally ill and had less than six months to live. Despite the social taboo against discussing end-of-life issues, the study found that Americans know exactly what they want when faced with an incurable disease. Americans' top preferences are (1) having an option to access services; (2) emotional and spiritual support for the patient and family; (3) pain management according to the patient's wishes; and (4) the option for the patient to die in his or her own home or in the home of one of his or her family members.
In the United States, because hospice conditions are included in Medicare, it is up to the hospital to assess a patient's need for hospice services and notify the patient of the need for hospice services. Many doctors are also hesitant to notify their terminally ill patients of their condition because they do not want to discourage their patients from continuing treatment. On top of that, it is not in fact easy to accurately predict how long a patient will have left to live.
6, American hospice care for China
In recent years, hospice care in China has also begun to attract the attention of the society. in August 1988, China's first institution for the study of death, Tianjin Hospice Research Center was established, followed by the establishment of the Hospice Committee of the China Mental Health Association and the Hospice Fund. in 1988, the first hospice care organization was established in Shanghai. in 1992, the first hospice care organization was set up. In 1988, the first hospice was established in Shanghai, and in 1992, the Songtang Hospital in Beijing, which admits endangered patients, was formally established. Over the past ten years, hospice hospitals have sprung up in many cities, and the cause of hospice care in China is constantly developing.
The current state of hospice care in the United States is the direction of our future development. As a developing country, we can gain a lot of inspiration from hospice care in the United States.
(1) The impact of population aging on society is common in all countries, not only in developed countries, but also in developing countries, there is the same need for end-of-life care. With the development of population aging in China, especially with the emergence of a large number of only children in cities, the social demand for hospice care will become stronger and stronger. The experience of the United States has shown that hospice care is a cost-saving and effective method of care, and an important way of solving the difficulties of caring for families of the terminally ill. In view of the fact that family planning has become a basic national policy in China, society, while advocating eugenics, should also pay attention to end-of-life care, so that the endangered elderly people can try to obtain the conditions for a good death, and bid farewell to life with dignity and peace.
(2) Although there are different types of hospices in the United States, most of them are non-profit organizations with obvious welfare. This is also a revelation to the development of hospices in China: in the process of developing hospices, attention should be paid to both the multi-channel and its welfare nature, and more needs to be organized and developed by the government.
(3) Endangered patients need multifaceted services, hospice care will transfer the work of family members to the community, so that the socialization of care work, in essence, is to transfer the family responsibility to the community to assume. Social commitment is inseparable from the economic conditions, the development of hospice services must start from the national situation and national strength, China's hospice cause can not be a rush, should be gradual, gradual expansion. The task at hand is: society needs to re-conceptualize the need to help individuals facing the end of life to die with dignity and comfort, and to emphasize the compassionate help that family members or caregivers can provide to the dying.
(4) Hospice care in the United States has embarked on the path of institutionalization, with hospice services mostly included in health insurance, thus expanding the coverage of hospice services and enabling more patients to enjoy this benefit. In the specific operation, the United States and the development of a set of strict rules and regulations, not only through a full range of services to ensure that the benefits of the system's beneficiaries, but also completely from the reality of the financial resources, the services provided will be limited to the scope of the economic conditions allow, to ensure that hospice services in a healthy, orderly and lasting operation.
(5) Although hospice care requires society to pay more for its services, receiving hospice services can reduce a large number of, even huge, medical expenses for those patients who are suffering from incurable diseases. Medicare costs can be maximized if the high and ineffective costs of a few are shifted to productive treatments for the majority of others. From this we realize that the moderate development of hospice care is of great practical significance to the current reform of China's health insurance system.