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by: Alex Smith, @alexsmithMD

I’m going to acknowledge up front that this is a rant.

One of the skilled nursing facilities I work with has a hospice unit.  We occasionally have patients on the hospice unit who might benefit from physical therapy.  The physical therapists that see patients in the skilled nursing facility say they will talk with the patient about their goals, and if their goals are to maintain their current level of functioning, they will work with the patient.  If the goals are to improve their physical function, they cannot offer that type of support.

This seems ridiculous!

If someone has pain, we don’t say, “we will keep your level of pain where it is, but we can’t  help you if you want to improve.”

If someone has social or spiritual issues, we don’t say, “we want to maintain your current level of distress, but can’t help you if you want to be less distressed.”

Why is this happening?  It may be that a part of the problem has to do with resource allocation.  The physical therapists don’t have the resources, nor are they reimbursed for their time the same way, for seeing hospice patients as for patients cared for under the Medicare Skilled Nursing Facility benefit, a comparatively high payment.

Another part – and this may be related – is that we don’t prioritize functional improvement as much as symptom/social/spiritual improvement for hospice patients.  I gues the idea is that hospice patients will inexorably decline functionally and die.  It’s as if physical therapy to improve funciton has been lumped in with life-sustaining treatments.  When did that happen?  Did I miss a meeting?

Granted, most patients on hospice will have an inexorable decline in physical function – something we’ve written about both on the blog and in journals.  And many hospice patients do not have the ability or motivation to participate in physical therapy to the extent needed to recover function.  Wanting extensive physical therapy to recover function, when there is no possibility of recovery, is often a red flag that goals of care and prognosis need to be discussed in more depth.

But to me hospice, at it’s core, is about making each day as good as it can be, for the time that remains.  Being as indepent as possible is an important part of quality of life for many people.  And for a very small number of people in hospice, there is a potential for recovery of some function.

I have a patient now who might benefit.  He’s been delirious in the hospital, but is pulling out of it.  He might benefit from physical therapy to recover some of the additional disability he acquired from lying in bed in the hospital confused for days on end.  Though his family is starting to discuss hospice, they want him to have the best opportunity to improve funcitonally.  I think they’re going to say no to hospice.  And that’s unfortunate.  Our system should be flexible enough to accomodate him.

OK, I’m done ranting.  Maybe your hospice is different?  Or maybe you want to rant too?  Let’s hear it.

This Post Has 8 Comments

  1. Ok, Alex, your rant has motivated me to write! I completely agree with you. I wish hospices would offer more physical therapy for patients that can benefit and that it would be part of the care plan. Maintaining or trying to improve function is important to quality of life. We definitely have patients we send under their skilled benefit who are hospice eligible because of the desire for some physical/ occupational/ speech therapy. If only the payment structure would allow for that…I agree that our system should be structured to accomodate the needs and goals of the patients. Feels good to rant…

  2. Thank you for ranting about PT for hospice. (I warn on my blog when it's a rant.)PT has become a luxury for anyone of a certain age even if not hospitalized. I'm still fighting the battle a year and a half after lumbar fusion (and still weak.)
    Fire, flood, whatever – anything anyone can do for himself is vital.

  3. I've always been able to convince hospices I work for to provide at least 2-3 visits to eval and teach the patient/family/staff what needs to be done for the patient. I do think you would have a hard time convincing the hospices to cover long-term PT/OT except in exceptional circumstances (although one combined home health/hospice near me has done so a couple times with their home health PT/OT's. Have you tried talking to the hospice directly? They are the ones who can decide, since they are the ones who will pay.

  4. I appreciate your rant, maybe I should rant myself???
    I say a real hybrid course of care is needed!
    I am NP, now work as hospitalist, but have extensive gero, hospice and palliative care background. When a hospitalized patient needs PT or ST, for example, has had an acute stroke with hemiparesis and severe dysphagia but wants to be DNR and/or have a comfort care approach, it sends the care provider team into a confused state and they are unable to blend–it's either hospice or full court press- from neurologist on down. It's like the concept of individualized care is too difficult, and then the actual patient, who already coping with a lot is left with hard choices, and that is ridiculous.
    Thanks for letting me vent.
    Kathleen Rye, NP

  5. I guess I'm in the minority here, but I am very happy c/ pt's choosing either hospice or rehab. I have worked c/ several hospice pt's that were dual certified and did not really make any significant progress. In my experience working c/ geriatrics we are usually more guilty of over-utilizing our services than underutilizing and if we add hospice pt's to the mix we are going to exacerbate this situation. That's just my 2 cents based on my experience, I know every pt is different and unique and shoud be treated c/ optimum care and respect, but I am not a proponent for dual care c/ PT and hospice.

  6. Completely agree. I am a PT who prefers end of life care but is only able to practice this in the ICU, as the great majority of companies decline to hire or pay PTs for hospice care (trust me–I've been looking). It is the pay structure. There is no reason we cannot increase a person's quality of life just because they are on hospice–fall risk certainly isn't decreasing! PT and hospice are not at odds with one another! For the curious, the philosophy is called rehab in reverse.

  7. From the hospice point of view and as a Director who has authorized PT for patients,regulations and payment schemes are the real culprit here. We have to be so careful, give patients quality of life, but if it looks like they are doing too well… they no.longer meet guidelines. We also have to sit by while patients are "skilled to death" because of the reimbursement and the payment of room and board.

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