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Drawing the line
Herndon et al.1 raise a critical issue that has long plagued hospice, i.e., when to stop active treatment. Even the definition of "active treatment" remains fuzzy, although the World Health Organization does try, as noted by Herndon et al.1 This delineation is more than just an academic exercise because it is clearly tied to the finan- cial existence of hospice. Unfortuna- tely, this is not new, as reflected in the following 1982 testimony before the House Subcommittee on Health de- bating the proposed Medicare Hos- pice Benefit:2 First, where do you draw the line between conventional care and hospice care? Hospice care is not just TLC or tender loving care. It is also the management of a per- son's physical pain and comfort. Throughout the initial legisla- tion that you are reviewing and the interpretive congressional handouts, there are a diversity of terms such as "palliative," "cur- ative," and "aggressive acute ther- apies," which are poorly defined and less well understood. For example, a hospice patient with a painful bone metastases not responding to adequate treatment with analgesics can be "palliated" with localized radia- tion therapy. Likewise, a patient with a pain- rendering bowel obstruction due to recurrent
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