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So what happens when a hospital adds a hospice unit and these two worlds combine? Northwest Hospital, part of LifeBridge Health, discovered this in February 2008 when, in partnership with Seasons Hospice and Palliative Care of Maryland, it became the first hospital in the state to open a fully dedicated hospice unit.

Here, Seasons staff and an outside expert from the hospice field explore the various ways a strong hospital/hospice relationship can benefit everyone - from the hospital and hospice, to the patient and his family, and even the community, in this case, in and around Randallstown, MD.

When Hospice Isn't 'Home'

To most people, hospice is synonymous with the word "home." It is thought of as an alternative to hospitals; as a way for patients to die peacefully in the comfort of home.

But at times this is not always best for everyone. Sometimes, a patient's symptoms become so acute he needs more aggressive pain management than can be provided at home.

For him, inpatient hospice is the only way to find comfort and pain relief near the end of life.

All hospice companies must offer access to inpatient services under the Medicare Hospice Conditions of Participation. To do this, some hospices might lease beds at a nearby hospital and transport acute patients there. However this isn't always ideal.

"Patients and families were starting to say, 'I needed inpatient hospice care but I really didn't want to be in a hospital.' Or, 'I really wanted a place that was more home-like,'" explained Judi Lund Person, MPH, vice president of regulatory affairs and state leadership, National Hospice and Palliative Care Organization.

So some hospices, such as Seasons, decided that if more than 300 at-home hospice patients ever needed inpatient care, it would do more than lease a few beds: It would partner with a hospital to build an entire hospice unit - and one that is completely different from the hospital in look, feel and mindset.

Home-Like Atmosphere

When visitors open the frosted-glass doors to Northwest Hospital's 14-bed inpatient hospice unit, they are transported out of a hospital into a warm, home-like atmosphere, explained Michele Parisi, BSN, RN, team director of the unit.

The unit, run by Seasons Hospice staff, offers all-private rooms with flat panel TVs and walls decorated in soft yellows and warm greens. It offers a shared family room, kitchen and eating area for family and friends, who are welcome 24/7.

Herein lays the first benefit an on-site hospice unit offers a hospital: It's the perfect solution for patients who need inpatient care, but would rather spend their final months in a place that looks and feels like home. "The air is different on this unit," Parisi said. "When people come here, they instantly feel a sense of calm."

The Right Expertise

In addition to the right atmosphere, Seasons Hospice also offers the right expertise to Northwest patients who are near the end of life.

"People do well what they do often," said Gary E. Applebaum, MD, executive director of Seasons Hospice. "Hospitals do a great job of taking care of acute patients, in making them healthy and getting them home. Hospitals do not do as well when the goal is comfort rather than cure. Tending to a patient's symptoms is what we do well. We are enormously aggressive about providing high-technology care to make the patient as comfortable as possible."

Easing a patient's pain is more than physical, however. It also requires emotional, psychosocial and spiritual support, said Jane Fisher, social worker. Seasons offers a variety of services a patient would rarely see in an acute care setting. This includes a therapy dog who snuggles with and calms patients, board-certified music therapists who use instruments and song to provide comfort and relieve stress, a chaplain who visits daily to help with all things spiritual, and volunteers who sit with patients and listen to their stories.

This raises an interesting question. If hospitals have separate units for each niche - a unit for surgery (an OR), a unit for traumas and acute illness (an emergency department), and a unit for births (labor/delivery) - why doesn't every hospital have a unit that specializes in end of life, and managing the physical and emotional pain that comes with it?

Northwest Hospital can now say it does, and by having this hospice unit, has "added a needed dimension of care to our hospital that completes the life cycle in a compassionate, caring way," said Candace Hamner, vice president for care management at Northwest.

Support for Grieving Families

Seasons Hospice helps not only Northwest Hospital's patients, but their families, by providing them with the right support to make tough end-of-life decisions.

Imagine a young woman on a busy ICU whose mother just suffered a catastrophic stroke. Her mother is on a ventilator, brain dead. The daughter now has to make the very difficult decision about how and when to let her mother go. But as the noise and busyness of the ICU flows around her, her brain feels scattered; her emotions in chaos.

At Northwest Hospital, this woman can instead be moved - with her mother still on the ventilator - from the busy ICU to the calm, quiet environment of Seasons, where staff can provide as much time and support as the daughter needs.

"I've seen many families in the process of making a hospice decision. And when they step onto our unit, that's often when they make the decision, because the environment is so warm," Fisher said.

The capacity to be there for families at the "transition point" when they decide to move loved ones from hospital to hospice, is unique to being attached to a hospital.

"In outpatient hospice, the family has already made that decision [to accept hospice care] and have come to terms with the fact their loved one isn't going to recover," said Applebaum. "Our staff helps family through very high-stress situations: maybe their loved one has gone into renal failure and decides he doesn't want dialysis. We have the resources to help them through this crisis."

Meeting Community Needs

Looking at Seasons and Northwest from an outsider's perspective, Diane Meier, MD, said the hospice's location alone within the hospital "legitimizes palliative care" and leads to an increased number of appropriate hospice referrals.

"Hospitals and hospices are used to working in very different cultural and professional silos; that's been one of the big problems," said Meier, director of the Center to Advance Palliative Care. "Physicians train in acute care settings, and only really know about acute care. Some have never even seen a hospice patient. They don't know what hospice is or how to refer people to it. Right now more than 30 percent of hospice referrals live less than a week, because they're referred so late.

"Having a unit like this in the midst of an acute care hospital changes the culture," she added. Physicians hear and learn more about hospice; it's in the front of their minds when faced with a patient who can benefit from it.

A hospital, whose physicians are making more appropriate hospice referrals, frees up acute care beds for patients who have a hope of recovery - a dual benefit to the hospital and community.

"If 10 of your 12 ICU beds are filled with people who are not going to leave the hospital alive, your hospital can't take new patients from the ED," Meier said. "That is why you see EDs stacked to the rafters and surgeries that don't take place because the ICU is full. Having a hospice unit on-site opens up acute care beds - and the hospital is now matching the needs of its patients and better serving the community."

Ainsley Maloney Di Duca is a freelance writer for ADVANCE.