• Patient neglect: Hospices are supposed to be able to provide either "continuous" nursing care at home or inpatient care at a medical facility. However, when some home hospice patients encounter crises--including pain, breathing troubles, seizures-- and need sustained attention, they are sometimes not getting the assistance they need. According to the Post investigation, one in six U.S. hospice agencies, serving more than 50,000 of the terminally ill, did not provide crisis care to any of their patients in 2012. In fact, at 445 hospices, a third or more of patients died without having seen a skilled nurse in the 48 hours before their death. Read more in "Part One: Terminal neglect? How some hospices decline to treat the dying."
• Safety concerns: The typical hospice provider in the U.S. undergoes a full government inspection about once every six years, according to federal figures, making it one of the least-scrutinized areas of U.S. health care. By contrast, nursing homes are inspected about once a year, and home health agencies every three years. According to the Washington Post, "the dispersal of patients makes oversight difficult to begin with, but the infrequency of inspections means shortcomings are even less likely to be detected." So, how can we really know if a hospice is safe? Read more in "Part Two: Is that hospice safe? Infrequent inspections mean it may be impossible to know." 
• Rising discharge rates: Even though hospices aim to care for their patients until they die, at hundreds of U.S. hospices, more than one in three patients were released alive, according to a new study funded by Medicare.  This is a sign that patients may be leaving to seek treatment elsewhere. It is normal for a hospice to release a small portion of patients before death (15%), but when the rate of patients leaving hospice care alive is double that level, it can signify either that agencies are driving the patients away with inadequate care, or enrolling patients in the first place who aren't really dying -- in order to pad their profits. Read more in "Part Three: Rising rates of hospice discharge in U.S. raise questions about quality of care."  
• Lethal doses: With the surge of hospices enrolling patients who aren't close to death, hospice patients who are not actively dying are nevertheless being treated with powerful pain-killers that are routinely used by hospice providers in order to ease suffering and at the same time hasten death. There are no statistics on how often such abuses may be occurring, but complaints  from around the country illustrate the potential dangers of overdosing and drug dependency and addiction caused by enrolling a non-dying relative in hospice care. Read more in "Part Four: As more hospices enroll patients who aren't dying, questions about lethal doses arise."
• Quality of hospices: Though the federal government publishes consumer data about the quality of other health-care companies, including hospitals, nursing homes, and home health agencies, it provides no such information about hospices. State inspections are often unpublished, and when they are, they are often hard to understand. So, again, a family is typically choosing hospice care blindly with no idea if it is safe for their loved one. Read more in "Part Five: Quality of U.S. hospices varies, patients left in dark."
• A warehouse for dying: Nurses and clinicians at hospice facilities feel powerless to change the system. Although they feel frustrated and may disagree with the aggressive treatment and whether it is necessarily warranted, they have to do what they are legally required to do. Read more in "Part Six: Warehouses for the dying': Are we prolonging life or prolonging death?"
• Dying and profits: As for-profit companies transformed the hospice movement, which was once dominated by community and religious organizations, into a $17  billion industry, patient care suffered along the way. According to The Washington Post investigation, patients who need hospice care are typically much better off using a non-profit hospice facility, because the typical for-profit hospice: spends less on nursing per patient; is less likely to have sent a nurse to a patient's home in the last days of life; is less likely to provide more intense levels of care for patients undergoing a crisis in their symptoms; and has a higher percentage of patients who drop out of hospice care before dying. Read more in "Part Seven: Dying and profits: The evolution of hospice."

Critter Corner: Beating the Winter Blues