Innovations in End-of-Life Care
an international journal of leaders in end-of-life care

Designing and Sustaining a Palliative Care and Home Hospice Program

An Interview with Charles von Gunten, MD, PhD, FACP

Dr. Charles von Gunten served as Medical Director of the Palliative Care and Home Hospice Program at Northwestern Memorial Hospital located in Chicago, Illinois from 1993 until this past summer. In this interview, Dr. von Gunten reviews the history of this multifaceted program, how it has remained financially viable and his thoughts on key elements for other clinicians and administrators to consider when adapting or designing palliative care and hospice programs in their own institutions. [Citation: von Gunten C, Romer AL. Designing and sustaining a palliative care and home hospice program: An interview with Charles von Gunten. Innovations in End-of-Life Care, 1999;1(5), www.edc.org/lastacts]

How do you define palliative care?

Palliative care is interdisciplinary care which focuses on the relief of suffering and improving quality of life. I like that simple definition because it leads to a host of manifestations of how you actually operationalize that. You notice in that definition it doesn't say anything about how long you have left to live, or whether you're terminally ill, whatever that means. It's simply focusing on relief of suffering and improving quality of life.

We know from the work of the last 25 years, of Dame Cicely Saunders and Eric Cassell, among others, that people don't suffer in isolation. They suffer in a constellation with their families, so when you define "palliative care" as relieving suffering, patients and families have to be the unit of care. Now of course that's what hospice is all about, and in Dame Cicely Saunders' words, "palliative care grew out of and includes hospice care." But palliative care extends beyond hospice.

Dame Saunders defines suffering as having four components: physical, psychological, social, and spiritual. So if palliative care is about relieving suffering, and improving quality of life, it means we have to look at people and their families in those four dimensions, and we know that in order to meet patients' and families' needs in those four dimensions, it is best to have a team approach. No one person--one doctor, one nurse, social worker--can meet someone's needs in those four dimensions. That short definition, "relieving suffering and improving quality of life," sums up in a neat, tight way, those other aspects.

Further conceptual development - and this idea was first advocated by the Canadian Health System and now has been taken up by WHO - is the idea that relieving suffering and improving quality of life is not something that just should happen at the end of life. The relief of suffering and attention to quality of life need to be appropriately integrated across a spectrum of illness and the lifespan. So that's the intellectual, conceptual framework that I think needs to drive the development of palliative care, which in the United States includes hospice care.

Can you say a little more about your choice of the term "palliative care" over "hospice"?

The word "hospice" has different meanings in different countries. In French-speaking countries, it's a public house for the destitute ill. In England, it's primarily a place. In the US, it's a Medicare-funding benefit with a set of regulations that determine who has access to it. Each of these definitions gives somewhat perverse distortions, and that's what I think was so nice about coining the term "palliative care," as it gave us another term to be able to talk about the fundamental conceptual framework. Then we can develop service models and reimbursement mechanisms. But we strongly need to look at what we're doing and why we're doing those activities, without thinking about those service models first. And then turn to, 'how are we going to be able to make this kind of care available to people?'

Can you talk about your experience with Northwestern Memorial Hospital (NMH) in Chicago? Were you there during the whole design implementation of the three distinct elements of its hospice and palliative care program?

No, I wasn't there at the beginning. I was introduced to the service in 1989, when I did a rotation as a resident, and then I worked in the program as a fellow. I think that's a key message: This innovative program didn't "just happen." Charles von Gunten didn't just sit down and say, "Well, we're just going to do this." It really began in 1980, and developed slowly over the intervening nearly 20 years. I became medical director in 1993.

The Palliative Care Program developed first as a home hospice program before the Medicare benefit was created to reimburse hospice in 1982. So it started as a home-support team. The reason they didn't use the word "hospice" is because the medical staff wouldn't permit it. They didn't want to have a service for the dying. So it was called "supportive care" and was modeled after what we now recognize as home hospice, with nurses, social work chaplains, physicians making home visits. It was a service for terminally-ill people.

How did the inpatient acute palliative care unit evolve?

There was a recognized need that there are people at home, cared for by the home hospice-like program, who needed to be admitted to the hospital for a variety of reasons. And in the beginning, they were just admitted to the general wards of the hospital. But as most people have recognized, the skills needed to take care of a very sick population at the end of their life are not available on general wards.

So in part thanks to a gift, and in part because there was no licensed hospice, clinicians at NMH began using a ward of the hospital to admit patients from this supportive care home program. In 1987, NMH started a ten bed in-patient unit in order to provide consistency and continuity of care from the home setting into an in-patient setting.

With the development of the inpatient palliative care unit, patients cared for at home could come in and out of the hospital, as needed. The other thing that strongly influenced the development of the inpatient unit was AIDS. Patients suffering from AIDS, young people with a devastating illness that at that time was characterized by needing frequent admissions, formed 25 percent of the patients we were caring for at that time. And I think that led the leaders of the program to think about questions like, "What do these patients and their families need, in terms of support, including medical support?" And this population challenged some of the rigid ideas that had developed within standard hospice about what you would and wouldn't do in a care program at the end of life: transfusions, antibiotics, antiviral, operations, procedures, that kind of thing.

I think it is very important that we consider what will relieve suffering and improve quality of life for this particular individual and his or her family. And the family is not just biological, the family is whoever the patient says it is. These patients and families unsettled old assumptions and definitions about end-of-life care and led to the development of a flexible approach that's really focused on patient and family. But some of the serendipity was that in creating an inpatient acute-care unit, they avoided any reimbursement barriers to running a program like this.

Can you say a little more about the reimbursement?

For a patient covered under commercial insurance, reimbursement to a hospital now is on the order of $1,200 a day. The general in-patient reimbursement for a patient with hospice is $450 a day. That's a huge difference. It permits one to focus only on the patient and family and say, "What is in their best interest?" and "Who needs this care?"

This acute palliative care unit is used by anyone who needs this type of care in an inpatient setting. They don't have to be assigned to the hospice or a hospice benefit, they don't need to have accessed their hospice benefits under their commercial insurance plan. It's simply another ward in the hospital, like any other specialty unit. If you have a heart attack, you go to the coronary care unit. If you have severe pain and suffering and quality of life issues, you go to the palliative care unit.

And the billing codes?

There's no distinction in the billing codes. The billing code is just for standard inpatient care. You need to meet the criteria for being an inpatient in the hospital. The whole reason, since the 1960's, that we've developed specialty units in hospitals is the general recognition that people do well what they do all the time. You assemble a skilled group of professionals, who are highly educated, working around a common goal, and put them in a unit in a hospital and you admit those kind of patients to that unit, and the patients get better care. So that's the case with coronary care units, medical intensive care units, spinal cord units, etc.

It sounds so simple. Were there any barriers? Whose alliance did you have to engage to make this happen?

Remember, we're talking about this retrospectively. No, it's not simple, but this requires persistence. And it's not just me. I stand on the shoulders of other people who were also working on this issue. At Northwestern, I was given a tremendous gift, the gift of a lot of people committed at multiple levels in the organization. Northwestern has a strong commitment to good patient care. There is a strong belief that it is a good thing to take good care of people.

Was there an education or persuasion process that had to occur to make this happen?

I think the most persuasive thing that I can remember is individual cases. What individual people needed. Talking about meeting those needs was more persuasive than talking in generalities. And then the feedback. Remember, the unit opened before managed care had really gotten rolling. We converted an unused ward in the hospital that had previously been closed. Its use has grown over the years, but I think that the feedback we got was one of the key things that permitted it to continue. For example, the number of letters from family members of patients in the palliative care unit to the CEO in praise of the hospital came second in number only to those from the newborn nursery! That registers in the front office because you expect people who are having newborn babies to be really happy with their care, it's a happy event. But second is the place where 60 percent of the people die. That had meaning. Board members of the hospital had their spouses cared for there. Wealthy donors to the hospital were cared for there. So the whole spectrum of people, and all those stimuli that help hospitals make decisions, those were all very, very important. Providing excellent care was the key.

Describe how the palliative care consultation team fit in with these existing pieces.

Well, I think there were two reasons for it. The first was that within hospice and palliative care, we've developed very powerful approaches to care for patients: symptom control, communications skills, planning for the future, helping families cope. Why would you make that only available to people who are in the system, on the unit or in the homecare program? The analogy is, you can find a cardiologist more than in just the coronary care unit, more than in the cath lab. If you have a heart problem and you want a heart specialist to give you advice, you call a heart specialist; he'll come see you. It's the same idea in palliative care. If there are patients for whom there is suffering that is unrelieved, or quality of life is poor and you want to make it better, then you ask people who have expertise in this to come and consult. So that's the idea behind it, and again, I didn't ask the hospital for permission to start it, we just started doing it in the summer of 1993.

The second reason for developing the palliative care consult team was as an educational tool. Doctors at all levels learn best at the bedside. Bringing expertise in palliative care in tandem with education is very powerful. Our residents, fellows and medical students describe some of their best education occurring on the consult service.

The consultation team was also multi-disciplinary?

The core members of the team are doctor and nurse, and they draw on social work and chaplaincy as they're needed.

How did you pay for these additional services?

The physician can bill on a fee-for-service basis for consultation services in this area. The nurse is supported by the budget of the inpatient palliative care unit.

When you did these things, were other hospitals simultaneously doing them?

The Cleveland Clinic had been doing a similar program run by Declan Walsh for a long time.

And how is that model different?

I certainly modeled what I was doing on that work, and then I visited in England and observed what they were doing. They're ahead of us in so much of palliative care.

Where did you go in England?

St. Christopher's Hospice, the Royal Marsden Hospital in London Surrey, and St. Thomas's Hospital in London. The Royal Marsden is a premier cancer institution in England. Each was doing things slightly differently, and it really gave me great ideas. And Declan Walsh at the Cleveland Clinic was very helpful.

The whole financial picture and reimbursement systems in England are different, allowing perhaps for different choices. Were you able to model your reimbursement system on the Cleveland Clinic? Were they using a similar system?

Absolutely. Declan published a paper right around that time.¹ It demonstrated a strong financial picture, shall we say. Declan didn't publish the actual numbers, whereas we did in our paper, because I felt like that was important.time.²

What's different between our systems is, the Cleveland Clinic is a closed staff model system, so that's relatively unique. There are a few others such as the Mayo Clinic, but very few places are like that. Northwestern, by contrast, is a private hospital. Only half the doctors are full-time faculty at Northwestern University Medical School, and the rest are in private practice. When you adapt an integrated system for offering palliative care to patients across settings in a more standard, mainstream setting, it demonstrates that it's possible to offer this kind of care and have it be financially viable in many settings. What it shows is that the concept is robust enough to be developed in multiple places.

This gets to your other point, have others taken this up? The answer is "yes." The same model is being developed again in each hospital in its own way. We've had a lot of people come through in the past few years, expressing a desire to set up a similar program in their own hospitals. And that's sort of springing up all over.

What are some of the key take home messages based on your experience?

Here are some important messages, I think, for anyone getting started:

Each individual program begins in a unique place, with a unique history and a unique set of people that are there, and you start with what you've got.

The second important message is persistence. You have to have this strong vision, and work at it persistently over time. Over time, through some serendipity and a lot of perseverance by a small group of involved, committed people, we built an effective program.

Another key message is, "It's better to beg forgiveness than to ask permission." When you begin, you just start doing it. It's not like there was a giant committee in the hospital that said, "Gee, should we have this in-patient hospice unit in the hospital?"

Other barriers to initiating palliative care across a variety of settings?

The other thing that inhibits people is that the Medicare Hospice Benefit has dominated palliative care in this country. People think, "Well that's the only way that you can fund care for people at the end of life." It's simply not true. It is one way. And the strength of the Northwestern model is to say "This is the care we want to deliver. Now what are the revenue streams we can access in order to fund it?" And there are multiple revenue streams then that are used. The home hospice piece is now Medicare Hospice, but it's important to think more broadly about treatment choices than just what Medicare Hospice Benefit allows.

What's unfortunate is that there are some in the hospice community that perceive this as a threat. When in fact, it represents the triumph of hospice. Hospice has succeeded in convincing the rest of the world that this is good medical care. Good medical care that needs to be rooted in all of the institutions in which patients are cared for. And it's those principles that need to go forward. We can do palliative care in the ICU, we can do palliative care in general medical ward, we can do it in ambulatory outpatient clinic, we can do it in someone's home.

And it's a misreading of me or our work at Northwestern that this is anti-hospice. This is the triumph of hospice, this is an approach to care that hospice pioneered which is being pushed to its logical next steps.

One of the concerns that I've heard from people working in hospice is that some organizations might scrimp on what they would offer if they weren't required to do the full hospice benefit-- that palliative care may just be a way to offer "watered down hospice" and save money. But it sounds like you believe that concern about costs hasn't stood in the way of providing excellent care at Northwestern.

Yes. It's an issue. Everybody needs to be financially responsible so that their program is healthy, but I have trouble understanding the idea of needing to scrimp. The point is to be more generous, not to scrimp. Our goal should be to make this kind of care available to more people.

The inpatient hospice unit can do that, because it can bill for the services it provides, it doesn't have a ceiling, right?

There's that, however, having an inpatient palliative care unit is but one element of an effective palliative care program.

What are the areas where you see need for improvement?

I don't see the Northwestern system as complete. The ambulatory outpatient clinic needs to develop more, the consult service could expand-- seeing people who are at home, but who aren't able to be cared for by a home hospice program for a variety of reasons. We're not involved in skilled nursing facilities, we don't see patients in long-term care. All of those are elements that need to be added.

You have written about difficulties that staff working on the acute care unit have had with utilization review boards. You have suggested that national policy changes in palliative care would help. Can you say a bit more?

This is a national issue. Third party payers are interested in limiting cost. In the absence of any national standards for what is appropriate in-patient palliative care, meaning in an acute hospital setting, it's not surprising that insurers make up their own standards. So the reimbursement process ends up being exceedingly individualized. Now again, in the absence of any national standards, utilization review boards and third party payers look to what they do know about.

Well, they do know about what hospice care is, and so if we say, "relieve suffering, improve quality of life," they respond, "Isn't that hospice care? Shouldn't we pay X dollars? In my book here, this is the hospice rate." It's not that these are bad people, it's that in the absence of guidance.... We have not on a national basis described standards for the resource-intense care of patients in acute hospital settings where the primary goal is relief of suffering and improving quality of life. So I think that's what distinguishes the care on that unit from say somewhere else in the hospital. Our major goal, it may not be our only goal, but our major goal may be relieving suffering and that can take a lot of very skilled people, a lot of time, and a lot of medication changes. We may use more resources than other places, but because it's never been described in the current book, then the case manager is scrambling to justify our use of resources to the utilization review person.

So, there are some odd things that have come out of that. I'm aware that there are some insurers that as soon as the patient has a do-not-resuscitate status, take that as evidence that the patient no longer needs to be in the hospital. It's outrageous, outrageous! But that's the kind of policy decisions that emerge when there's no standard. People have to fill it in on their own.

So it sounds like one of the things you're calling for would be something similar to, but even more detailed than the Canadian palliative care standards.

Absolutely. What is appropriate palliative care in a hospital that should be reimbursed as hospital care? We shouldn't have to fight for it. It is good care. What is good palliative care at home? What should hospices be doing, and what should they reasonably be paid for? None of that is being dealt with on that level, in this country, right now.

To illustrate the differences between both costs and care on the general wards and on the inpatient palliative care unit, could you create a hypothetical patient and follow that person in the two settings? Explain how the costs and treatment choices differ.

Let's say there's a patient in the hospital with metastatic breast cancer. And the patient's admitted to the hospital through the emergency department for a decrease in mental status and bone pain. The patient then is admitted to a general hospital ward, where hypercalcemia is diagnosed, and bone metastasis, and pain medication is begun. Traditionally, not much is addressed about advanced directives, or overall goals, The standard operating mode in the emergency department, as it should be, is "life at all costs," rule out everything bad. And so she'll have a head CT, probably a brain MRI, she'll have X-rays of all of her bones, she'll have extensive testing of her bloodwork, because 'Gee, she came to the emergency department, so we're going to do everything." She starts in the emergency department, then she goes to the general hospital ward.

There she will have her blood drawn every day. That's sort of standard in the hospital. You have your blood drawn, complete blood count is drawn every day, she will have an SMA-20 (a chemistry panel) every day. If she coughs, she'll get a chest x-ray.

So what would be different if she moves to the acute palliative care unit?

Let's say that the palliative care team is consulted and we sit down and have a family meeting and the primary goals are to relieve suffering and improve quality of life. But the patient's still groggy, there is still poor pain control, the husband can't cope, the children are in an uproar, and so the patient can't go home safely. So she's moved to the inpatient palliative care unit. The kinds of things that distinguish inpatient palliative care from elsewhere, are that anything is available, you can do any test, but first you ask the question, "Why? Why should we do this test? What will it tell us that will help us relieve this patient's suffering or improve her quality of life?" That's a key question that everyone asks themselves before they do anything on the palliative care unit. That is not a question that is asked in the general hospital setting.

So when this patient suffering from metastatic breast cancer comes onto the acute palliative care unit, there's no reason to draw blood every day. If anything, it makes her quality of life worse. Who wants to be woken up at 5:00 in the morning and have their arm poked for data that really isn't used to change anything? So the routine blood testing stops. Again, if the person has a cough, the patient will be examined. Will a chest x-ray change what we're doing? Will it help us make her feel better, improve her quality of life? If she needs a chest x-ray, she'll get one. But she's not going to get a chest x-ray just because, "Well she had a cough, and of course we have to do a chest x-ray for every cough." It's that change in mind-set which leads to a decrease in the charges, because every time the patient says she's short of breath, we're not going to put on a continuous pulse oximetry. It's not going to help us. And what we found is that on average, charges for patients decrease by 50% when they are on the palliative care unit.

Does that decrease in charges translate into lost revenue for the hospital?

It depends on the reimbursement system. Under Medicare, it doesn't matter how much you spend, you get a set amount. That's the DRG. For commercial payers, some of them pay by a discount, so let's say the hospital charges $100 for a chest x-ray - with the contract, the commercial payer will pay you $50. Well, the more tests you do, the hospital will still get more revenue, though at a discount. In Chicago, a large percentage of the payers pay by a negotiated per diem. So we'll say Blue Cross pays (this is a made-up number) for every patient they'll pay $1200 a day. Because they know on average, that's what it's going to be. So they don't care what you're doing, they care how many days the patient's in the hospital, and you can do what you want. In that case, doing less--fewer tests--saves the hospital money, because they're still getting the same per diem.

So, the point is that decreasing charges per day actually can be in the hospital's best interest. But it somewhat depends because the hospital also has fixed costs associated with doing tests, whether or not a particular test is ordered. You have to have a technician to run the blood samples, you have to have the machines to do the x-rays.

How does staffing on the inpatient palliative care unit compare to other units in the hospital?

This is important - although the charges are lower, the amount of staff time with patients, if anything, is increased. The staffing ratios are a little higher than they are elsewhere in the hospital.

The things that patients report as different in this unit from elsewhere are also revealing. They never remark on the decor. They say the quality of care is either the same or better than it was elsewhere in the hospital. They say, "It's the first place where I feel like I had enough information, people talk to me, and tell me what's going on and help me." And families say, "It's the first place in the hospital where it seemed like we were important." Well, that's not a product of architecture or space or pretty carpets or all that home-like stuff that we get so involved with. It's staff-driven, that is personnel having patient-centered and family-centered care as a clear goal and spending the time they need to spend.

Besides having three settings across which you can care for patients' palliative care needs, do you do anything else to improve continuity of care for patients and families?

Remember, Northwestern's a private hospital, and there's a strong sense of "the patient's doctor is the patient's doctor." The whole point of the staff is to help support that relationship, as well as - because the doctor can't be there all the time - focusing a lot on communication between each other, and being able to give family the information they need, helping draw those connections. So the night nurses know what the plan is; they know what's going on because somebody has told them what's going on. At change of shift, it wasn't just, "Well, blood pressure output and the IVs running," it's "Well, so-and-so's family is expected, and so-and-so's coming in, the doctor was in this morning, and did this and this and this, and described this and this and this, and if they come in tonight, be prepared, this is what's going on." That kind of communication goes a long way toward patients and families feeling there's continuity.

You've mentioned several times that Northwestern Memorial is a private hospital and you've stressed its patient-centered mission. Would you say those are the two main features that allow this kind of care to flourish?

No, it can happen anywhere where there's a commitment to quality care. Northwestern is famous nationally because it has one of the strongest bottom lines anywhere in the country. It's not that they're so mission-driven that they don't spend time looking at the bottom line. They're very financially healthy. What I'm talking about are fundamentals. These are fundamental things that can be present at any hospital in the country. But they have to be valued.

You noted in one of your papers that the effects of opening the inpatient unit in 1987 resulted in almost doubling the number of patients and families who could be served by the program. And that was with just 10 beds initially. Why was that so?

The whole inpatient unit is acute care. Things need to be changing, or patients need to move on. Sixty percent of the patients who were admitted to the unit die on the unit and the average length of stay was six days. Seventy-five percent of the unit patients who come to the unit are transferred from elsewhere in the hospital. So, these are patients who never would have survived to go home to a home-hospice program. They would have been cared for on the general wards of the hospital by staff with no special training in palliative care.

Here's an anecdote: This is a patient who was a young guy with AIDS, that was very advanced, and he came onto the inpatient unit because his insurer only covered one of the for-profit hospices in the city. A member of the hospice staff saw him and his mother at home, and said, "Well, if you come on the hospice program, the only medications you'll get are lorazepam and morphine. That's it. If you don't want that, you don't want hospice."

Now that gets played out in too many hospices in this country. This guy was overall doing pretty well. He was on his anti-retrovirals, he was on his suppressive medications, but his problem was he had recurrent pneumothorax where both lungs would collapse, and he'd be terribly short of breath. So he was cared for under home-health, but then would occasionally be readmitted to our inpatient unit. Under standard hospice, he couldn't have done that. So that's where the doubling in the number comes from. It's opening this door to people who may not fit the parameters of the Medicare Hospice Benefit, but who need palliative care.

Can you comment on the change in location of deaths within the hospital since the inception of the inpatient palliative care unit?

Since its inception, we've seen a decrease in the number of deaths in the general medical wards. The numbers switched. Initially 40 percent of deaths were in general in-patient wards, and 25 percent in the palliative care unit; now those numbers have just flipped, with about 38 percent of all deaths in the hospital occurring in the palliative care unit.

Is this a sign of better end-of-life care?

You can argue that "Shouldn't this be able to be done anywhere in the hospital?" But talk to anyone who works for the hospital, and they'll tell you it doesn't happen. And that's a potential downside of the unit. You have a lot of people coming through, a lot of people dying, and there are some people on the unit who are there for short periods and go home. You don't want the reputation as the death house, you go there to die. And yet, if you're going to die in the hospital, the kind of care provided on the unit is more closely associated with what most people would like than elsewhere in the hospital.

But there's an interesting outcome of this. Northwestern just built a brand-new hospital. And many of the aspects of the inpatient palliative care unit in the old building, the private rooms, large, places for family to stay overnight, home-like, are now throughout the entire new, 500-bed hospital. All the rooms are private, all the rooms have a sofa that can be pulled out into a bed. All the rooms are large, so that multiple family members can be there. It's taking palliative care principles and making them available in bricks and mortar to everybody who comes into the institution. That's terrific! The hospital's seen a jump--they've advertised, but they've had a 20% increase in admissions since they opened the new building. But again it's a commitment to the whole-patient experience. There's still an acute palliative care unit in the new building.

But it doesn't look as different perhaps?

That's right. It doesn't look as different. So what needs to distinguish it is not the way it's decorated, but the care that's given.

To wrap up, could you say a little bit about what you're currently doing?

Well, I've moved to the Center for Palliative Studies at San Diego Hospice, with a goal of building an educational framework that will produce skilled clinicians for the country. There is a broad need for physicians who have essentially consultant-level skills in this area. Hospitals want someone who really knows how to do good palliative care on a consultant level. So when the usual things don't work, whom do you turn to?

Is this something like the Edmonton Palliative Care Program that Eduardo Bruera was running?

He had a small fellowship program which is similar in some ways. What they put together in Edmonton was a system of palliative care across the city, with home care, several skilled-care units and one acute-care tertiary unit, and they had an educational program attached to that. That's not unlike what San Diego Hospice has here. They have a 24-bed inpatient hospital, and a large home program, and a large program in nursing homes. Over the last 20 years, they've developed a strong clinical program, and have had a commitment to education and research since the beginning. I'm here to bring it to the level of training fellows and physicians who are in practice and who would like additional training, because there's a tremendous need now. St. Christopher's Hospice in England has done this for 20 years. So, I look strongly to St. Christopher's and other models for what we want to do here. There are eight full-time physicians on staff here, a larger faculty than I had at Northwestern.

And is your program just for training physicians, or since you mentioned the importance of the team approach, are you also training nurses and other palliative care team members?

We have nurses and social work and chaplain students, but my main focus is going to be physicians, which is not to diminish the importance of the others. This is a hospice. So the whole team is part of the air you breathe. Everybody participates.

Any wrap up thoughts?

The main message is that palliative care is not a threat to hospice in this country. And I think it's a real disservice to patients and families to even set up that false dichotomy. We are all going for the same thing, which is good care for patients and families, relieving their suffering, improving their quality of life. And for myself, we are working to develop a system that will care for all of us well when we are at the end of our life.

References

1. Walsh D, Gombeski Jr. WR, Goldstein P, Hayes D & Armour M. Managing a palliative oncology program: The role of a business plan. Journal of Pain and Symptom Management. 1994;9:109-118.
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2. von Gunten CF, Martinez J. A program of hospice and palliative care in a private, nonprofit U.S. teaching hospital. Journal of Palliative Medicine. 1998;1:265-276.
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