choice or from the forced discharge of hospice patients who stabilize and cannot be certified as continuing to have less than six months to live. Various options could be made available to rearrange payment and coverage to encourage continuity.
With continuity comes a drive for comprehensiveness. Issues such as family support, bereavement counseling, and housing are unavoidable when care providers stay with the patient through whatever comes up. More continuity and comprehensiveness may well encourage innovations such as paying family caregivers (as much of Europe already does), providing respite care, developing supported housing, and ensuring that medications are available.
Modifications to hospice seem to be an obvious target for improving end-of-life care for patients with cancer (President’s Cancer Panel, 1999). Hospice could be made available on the basis of the extent of illness or disability and then be lifelong, rather than requiring a confident prediction of death within six months. Hospice expertise could be made available to patients who are not eligible for direct services by allowing consultation by the hospice team. It makes sense for hospice team members to become known to patients with eventually fatal malignancies during the course of their illness, rather than just at the very end of life. In short, enrollment into hospice should be a less dramatic change and a more expected and integrated transition. Hospice programs could be paid somewhat more for the first day or two and the last day or two (and perhaps less for longer-term stays). Payments for costly treatments should be considered on their own merits. If evidence shows that the costs are worth it in the community’s judgment, then those interventions that cannot generally be provided within the hospice capitation should be paid separately for small programs or should be folded into the overall capitation rate for large programs.
How could society move to make these reforms? We need an era of innovation and evaluation, aiming to learn how to engineer our care system to provide reliably competent, comprehensive services from the time of onset of serious illness through to death.
In doing this, society will need more reliable data on the relevant populations. The available research has usually measured costs in a referral clinic serving a population that is more than a decade younger than the average of those who face the problem. Policymakers need data about the effects and costs of various treatment strategies and approaches to organizing care delivery, in samples that represent the entire population at risk. This information requires developing new methods and substantial commitments.
Until now, society has focused mainly on premature deaths and disability. Having won many of these battles, most people now get the opportunity to live long and die of degenerative conditions such as cancer. As a