| The original hospice concept as it developed in the United States was that hospice care was indicated only when all active therapy was no longer appropriate and had been discontinued. Many of the original hospice programs that sprang up where strongly opposed to active medical intervention and in fact expressed a bias against the medical model. There was a sense that many patients were being over treated with inappropriate chemotherapy or radiation. Some hospice programs bragged that "there are no IV poles" in their hospice. The original hospice Medicare benefit implied that the terminal phase lasted six months prior to death, and yet consistently most patients survive less than two months in hospice. It is clear that most patients do not abandon active therapy until they are convinced that therapy is hopeless and this occurs about two months prior to death. If patients are entered into hospice earlier, they likely will still be interested in some forms of active therapy and it may become an issue within hospice to determine the appropriate use of such therapy. Obviously all intervention need to be individualized for each patient and reflect the values and desires of an informed patient rather than the policy of the hospice or economic considerations. As discussed before there are several key considerations: |