Some have argued that the only justification for having an in-patient hospice, even in a developed country like the UK, is its role in teaching and in research. It is so much more difficult to do teaching and training on a large scale in the home care setting. There is a limit to how many students one can take on a home visit and how many problems can be shown to each student. In a larger in-patient unit, which the teaching units tend to be, there are many more problems lined up on the wards at any one time. More and more, we see in-patient units as places in which to solve particularly difficult problems. Once these are dealt with, the patient is discharged home to be followed in the home care service. In my own service, I have seen the change of the role of the in-patient service from one in which the patient came in to die, to one which deals with problems which cannot easily be dealt with at home. In the past two and a half years since I have been Medical Director of Assisi Home and Hospice, I have seen our discharge rate rise from 15% in 1994 to 22% in 1995 to 36% in 1996, with a reciprocal drop in the in-patient death rate.
The problems that we deal with are complex. No longer do we admit patients for simple symptom control, which can as easily be done at home. Sometimes, symptoms are difficult to control because of fear, or the inability to accept the illness or death. The home environment may not be amenable to manipulation to eliminate fear or to give the patient enough support. Sometimes, the reason for admission is family anxiety, or family conflict interfering with the patient's care, a major depressive illness or suicidal tendency. Sometimes, the patient needs admission because of the sheer complication of the nursing care required: for unstable spines, or fungating wounds, or fistulae, or rapidly progressive symptoms of disease. No longer at my hospice do we look after relatively stable patients with slowly progressive cancers who need a home to provide them with food and shelter. We pass these patients on to sheltered housing schemes or warden-supervised apartments if they are still able to walk and care for themselves. We follow them on our home care service and take the patients back only when they become too frail to be left in that environment, or when they develop complicated symptoms. We pass on to nursing homes bed-bound patients who require only nursing care, comatose patients who only require tube feeding and turning, unconscious patients who are completely unable to communicate and whose families are more or less accepting their condition. At the hospice, we
