When Karie Praszek, MD, a hospitalist at the University of Texas Health Center at Tyler (UTHCT) found out this past fall that she was being considered for the position of medical director of the hospital’s planned hospice inpatient unit, she went home after work and cried. These were tears of happiness because she was finally going to be able to combine her two loves as a physician: hospital medicine and hospice care. “It was like coming full circle,” she explains.
The seven-bed hospice unit at UTHCT opened in partnership with Hospice of East Texas in Tyler in November, following renovations to create more comfortable and spacious rooms. It is one of a growing number of collaborations between hospitals and community hospice programs to provide institutional beds for terminally ill, hospice-enrolled patients in need of short-term inpatient care for symptom management.
In many hospitals, hospitalists are well positioned to provide planning, leadership, hospice referrals, or medical management of hospice units in the hospital. But few of them will follow a path like Dr. Praszek’s to the medical leadership of the hospice unit.
The Needs of End-of-Life Patients
Dr. Praszek’s commitment to the needs of patients facing the end of their lives took her from Texas to Oklahoma to Oregon and back to Texas. She has been a practicing hospitalist at UTHCT since 2004, but medicine wasn’t her first career. In the 1980s, as a computer expert for the U.S. Postal Service, she helped to automate postal facilities. She was well paid, she says, but something was missing in her life.
Wanting to make a meaningful contribution, Dr. Praszek became a volunteer candy striper at a hospital in Dallas. She learned about hospice while assigned to the oncology floor.
“When I started doing hospice care, I fell in love with it, and used volunteer work to hone my skills,” she says. She quit her job and moved to Oklahoma to attend a seminary with a specialized curriculum in death, dying, and grief counseling, all the while volunteering with hospice patients.
“They even trained me to be a certified nurse’s aide,” she says. “I just wanted to do whatever they needed—to do what no one else wanted to do.”
As a volunteer nurse’s aide she cleaned bedpans, changed diapers, and gave bed baths to hospice patients. “I didn’t mind it because it meant I could have more time to talk with the patients,” explains Dr. Praszek.
A turning point came while she was on a hospice wing of a nursing home, working with a patient who had metastatic prostate cancer and was in excruciating pain. “You could hear this gentleman moaning when you entered the building,” she recalls.
The nurses on the unit turned to Dr. Praszek and asked her to call the patient’s physician for an order for more pain medications. “I said, ‘I’m just a volunteer,’ but they told me, ‘You’re our last hope,’ ” recounts Dr. Praszek. “So I called the doctor, and he said he wouldn’t order any more pain medications because he didn’t want the terminally ill patient to become an addict. Then he said, ‘I’m the doctor and you’re not,’ and hung up on me. I thought, well, you so-and-so. I’ll go to medical school instead of nursing school, which I had been considering, so that nobody can ever pull this kind of thing on me again.”
Dr. Praszek completed her pre-med courses, but put off applying because she was afraid that she was too old or not smart enough. Finally, with her husband’s encouragement, she applied to Oregon Health Sciences University and, on her 40th birthday in 1996, received notification of acceptance. Looking for students with significant life experience, the medical school offered Dr. Praszek a full scholarship. She graduated at the head of her class.
After completing her internal medicine residency, she couldn’t find a hospice-related position, but she had learned to appreciate the pace and complexity of hospital medicine. After doing locum tenens (temporary assignments), she landed in the hospitalist position at UTHCT. The 100-bed facility began as a tuberculosis hospital housed in a former U.S. Army base in 1949, and in 1977 it became part of the University of Texas health system.
Today Dr. Praszek heads a three-person hospital medicine department, with another physician and a physician’s assistant and the backup of 10 clinic physicians for after-hours coverage. Her job combines both clinical and administrative responsibilities, including risk assessments, protocol development, and the ethics committee. Roughly 10% of her time is devoted to patients on the hospice unit.
Providing Necessary Care
Hospice is an approach to the care of patients with life-limiting illnesses and their families, emphasizing the relief of pain and other symptoms, maximizing quality of life and support for the emotional and spiritual issues that come up at this time of life. Under the Medicare Hospice Benefit (introduced in 1983) Medicare-certified hospice programs are responsible for providing essentially all of the care needed to manage their enrolled patients, who have a life expectancy of six months or less. Medicare pays the hospice a daily packaged rate for its services—all-inclusive except for attending or consulting physicians, who are able to bill separately. Although the hospice benefit is primarily intended as a service in the patient’s home or other place of residence, such as a nursing home, often terminally ill patients require inpatient care for short periods to bring their medical symptoms under control.
To fill this need, hospice programs can open their own freestanding inpatient facilities, as Hospice of East Texas did with its 28-bed HomePlace, or else contract with a hospital for inpatient beds, as the hospice did with UTHCT. Those involved in planning the hospice unit at UTHCT emphasize that at the rate Medicare pays for inpatient hospice care ($562.69 per day, regionally adjusted), neither partner is likely to derive a profit from it. Instead the unit reflects a true commitment by both to meeting the needs of terminally ill patients in the hospital.
“This hospice unit was the right thing to do,” says UTHCT’s Chief Medical Officer Steven Brown, MD. “It’s an opportunity to educate our medical staff about end-of-life care, introduce the concept of hospice into the hospital, and improve utilization,” by changing the focus of treatment for those who choose the hospice approach.
The unit also provides an opportunity to concentrate palliative care training for nurses on the floor, which includes neuro-restorative and tuberculosis beds as well as non-dedicated hospice beds. Many patients are simultaneously referred to the unit and to Hospice of East Texas, while others may receive hospice care at home at the time of their placement on the unit.
Bring Inpatient Care Closer to Families
Marjorie Ream, CEO of Hospice of East Texas, explains that the origins of the hospice unit at UTHCT are in response to her agency’s family satisfaction surveys. Some families in the northeastern corner of the agency’s 13-county service area said they drove too far to visit loved ones at its HomePlace inpatient facility.
“We looked at our mission statement and started to explore how to make inpatient care available closer to the folks we serve,” says Ream. “I started a dialogue with Dr. Kirk Calhoun, the hospital’s president.”
Coincidentally, Dr. Calhoun had attended a hospital conference where he learned about a collaboration between a public charity hospital and a hospice in Atlanta that had received recognition from the American Hospital Association.
Their first meeting to discuss collaborating was in August 2005, and by November 15 the renovated unit was in operation, with two-room suites large enough to allow the patient’s family members to stay overnight on pullout sofas. Dr. Praszek’s name entered the dialogue after she gave a hospital lecture on end-of-life care and code status. “When we talked with her and she shared her career journey, we could see that she was a logical fit,” explains Ream. “And she really wanted to do this.
“My impression is that Dr. Praszek has a true ‘hospice heart.’ She really understands the interdisciplinary team. She’s an expert clinician, and she understands the differences in treating terminally ill patients. She has a real sense of the patient and family as people,” says Ream. “Nurses love her commitment and enthusiasm and are proud to be her colleagues.”
Dr. Praszek’s first concern is keeping people healthy. “To be a hospitalist on a hospice unit, you have to know how to change your focus from cure to caring,” she says. “It takes someone who is not afraid of confronting their patients’—or their own—mortality. When we first opened the unit, there was a sharp learning curve for physicians in the hospital. But it’s been a pretty smooth transition overall, except for one or two who still have a hard time recognizing when their patient is dying. Most physicians at this institution are learning how to look at the entire lifespan of their patients.”
Dr. Praszek tries to see every patient on the hospice unit each day she is on service. She also works closely with the interdisciplinary team at Hospice of East Texas. Routine care on the unit is provided by hospital staff, while the hospice team provides care management and oversight. Hospice care generally involves fewer intensive medical procedures and more intensive nursing care and comfort measures.
A Deeper Commitment
“My life today is the way it is because I really love my work,” says Dr. Praszek. She brings a lot of it home at night. In fact, Dr. Brown says he occasionally worries about the long hours she works. “But we try to make sure she gets the support she needs.”
“My door is always open,” adds Dr. Praszek. “I’m still learning from the nurses, and I’ve had housekeeping staff give me advice. When they find out my background [as a nurse’s aide], they always say, ‘Oh, that’s why we get along so well.’ ” TH
Larry Beresford wrote about hospitalists who work as administrators in the July issue.