Comfort Care

February 1, 2005

A possible hospice barrier is the requirement that patients forego further curative care.

In 1988, at age 53, Bob had a ruptured aortic aneurysm. About six years later, he was diagnosed with congestive heart failure (CHF). He's been unable to work ever since. Over the next few decades, Bob experienced six more aneurysms and underwent open-heart surgery more times than he cares to remember-and now he's on kidney dialysis.

Today, this once-rugged mill worker doesn't have the strength to open an aluminum soft drink can. "I am getting weaker and weaker," says Bob, who is a member in SecurityBlue, a Highmark Blue Cross Blue Shield Medicare HMO. He participates in an advance-care planning, or end–of–life care, program Highmark has with Heritage Valley Health System, a hospital system in Western Pennsylvania. The program is for people who are in their last six months of life.

"The [Highmark] program has encouraged us to make our treatment wishes known and involve our children in the process," says Judy, age 64.

As a practicing geriatrician, Judith Black, MD, medical director, senior products for Highmark, has first-hand experience of the emotional turmoil that occurs when families are forced to make healthcare decisions for loved ones at end–of–life without knowing that person's wishes. "When I brought these issues to senior management's attention, most were receptive," Dr. Black says. "Many had experienced those issues personally and realize the potential impact to our membership."

Highmark and other managed care organizations believe that end–of–life care is simply good medicine. MCOs are beginning to recognize that end–of–life care needs to accompany the everyday care members receive, and that it is a cultural issue that should involve health systems, payers, providers and the general public.

"[End–of–life] care is the right thing to do from a quality-of-life perspective, which happens to be less costly," says Philip M. Bonaparte, MD, chief medical officer, Horizon NJ Health. "Financial is never discussed. Quality is key."

In this case, according to Pam Persichilli, RNC, CMCN, director of utilization management at Horizon NJ Health, "quality becomes comfort, and independence is important."

Perceptions of quality care differ from a cultural perspective, so achieving quality requires cultural sensitivity when approaching end–of–life issues, according to William C. Popik, MD, Aetna's chief medical officer. "Different cultures perceive death and dying differently," Dr. Popik says "What might be appropriate behavior in one culture-such as speaking directly about care issues with the person who is dying-may not be acceptable in another culture, where these conversations should more appropriately be held with the spouse or eldest child."