Reinventing hospice: Justice and dignity in the design of end-of-life care

There is a growing recognition of the ethical dilemmas that high technology medicine has created for critically and terminally ill persons, and a dawning recognition of the staggering social problems that loom in the graying of the baby boom generation. The basic design of the hospice and palliative care system holds implications for clinical practice, to be sure, but this design is fundamentally a public health issue. The population of seniors in the United States is projected to more than double over the next 40 years, rising from 35 million in 2000 to over 88 million by 2050. America's hospice and palliative care systems are nowhere near ready to face the human demands that these demographic trends will create. This presentation will provide a discussion of the design features of the hospice and palliative care system nationally. It will identify barriers to access in hospice Medicare coverage, medical referral and review, and market and cultural factors. And it will discuss design changes with a view toward facilitating timely and effective access to the hospice and palliative care systems, improving the coherence and continuity of those systems, and expanding their boundaries. Ethics by its very nature offers a design for living; a palliative ethical vision also provides a design for dying that affirms human dignity and the human good. Despite the manifold impediments and challenges present in contemporary health care and society, an ethically robust and practically effective new design for dying in America is within our reach.