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End Of Life Care

Preface: There is a transition in the role of hospitality industry in the healthcare system, from short term care of surgical patients from western countries to the long-term preventive care for the disabled. There are important workforce and financial issues that need to be addressed.

Issue: We are witnessing major financial issues in healthcare management in the developed countries. With emphasis on curative care the costs have spiraled upwards in the last three decades and it has been realized that most of the spending occurs in the last 5 years of life. With recognition of the fact that curative care for chronic illnesses is the major cost-determining factor, there is a stress on home-based preventive health services. India is also growing older, but not necessarily healthier. There are several lessons that can be learned from the home based health care system in the U.S. and other developed countries, which can help India avoid these issues.

Due to the progress in medical care the average life span has increased from 40 years in 1951 to 64 years today. However, improving treatments has not transformed into a healthier lifestyle. Preventive health care services are primarily restricted to vaccinations for infections and prenatal checkups. The current healthcare system is focused on curative management of chronic debilitating illnesses in the form of advanced surgery like organ transplant and medical interventions. Due to the fast paced lifestyle and stress on curative management instead of prevention, the burden of disease is slowly transitioning from infectious diseases to chronic illnesses like cardiovascular diseases, stroke, diabetes, etc. This focus on curative services has led to increasing healthcare cost with rising incidence of catastrophic healthcare expenditure.

To understand this trend we need to understand the changes in the healthcare system in the last 30 years. In India, the earliest health insurance service on a large scale was the central government health services. A publication in 1998 had put the cost of treatment borne by the CGHS beneficiary at 12 % of the entire amount, the rest (88%) being borne by the tax payers (This was before the advent of corporate hospitals, which changed the face of healthcare delivery in India).

Until this time people were generally dependent upon government hospitals and private clinics for most of the treatment. The major system of financing health care was either through government/ community hospitals or out of pocket. Hence, access depended not only upon the availability of health care services but also what one could afford. People were careful about their lifestyle and health issues. The advent of insurance system meant that you could afford almost everything, and if you were paying for it and not utilizing it, then you were going to lose that money. This lead to an increased demand for health care, as people were not paying directly for it, they wanted a health visit for every reason (Moral hazard. In insurance, the chance that the insured will be more careless and take greater risks because he or she is protected, thus increasing the potential of claims on the provider). Healthcare force also benefited from it as they were providing newer treatments, which had not been available before. A Boom in healthcare technology and pharmaceutical industry followed.

Under pressure from international agencies, to improve the image of India internationally as meeting the millennium development goals set up by the United Nations, the government has been focused on primary health care (improve nutrition, lower maternal mortality, vaccinations). The government took help from international health management institutions to come up with technical solutions to meet the International agenda, which in the lack of infrastructure, workforce, and financing is sometimes in conflict with the local priorities. Government encouraged private players to manage secondary and tertiary healthcare delivery and training by providing public land at nominal rates to private institutions.


Holistic health care does not mean just curative treatment in the form of surgeries, or medications for chronic illnesses such as diabetes, and hypertension, it is also about preventive checkups, home based care, and changing lifestyle. While preventive checkups are still a domain of the medical field and changing the lifestyle is one’s own choice, home based care is increasingly being recognized as a realm for hospitality, especially with aging population and people with chronic illnesses. Further, neglect, physical disabilities and problems of mobility are among the foremost reasons submitted by the country report on Elderly Abuse by the Help Age India for the World Health Organization. The study on elder abuse in India has clearly shown that neglect is the prime suffering that the elderly feel. Countries such as United States and United Kingdom are also facing this problem. The aging baby boomer population is fast outnumbering the young population. Overreliance on health insurance has lead to a situation where health sector spending has outgrown the economic growth of the country. A survey has shown that an average American spends about seven thousand US dollars a year on his healthcare, most of which is in the last 5 years of life. Slowly, the health care delivery system in developed countries is transitioning towards geriatric and other forms of preventive medical care.

The challenge is to create financially viable services for this special section of the population so that hospitality and clinical services merge and nurses, therapists, and aides visit the home to deliver both medically related home health services and more supportive personal care assistance (activities of daily living such as bathing, dressing, and eating, and with instrumental activities of daily living such as cooking, shopping, and housekeeping).

Workforce solution: Bottom up approach versus Top down approach

The hospitality industry can fill in the gap left by the healthcare system. Where healthcare industry has a top down approach to managing the problem, the hospitality industry can be the bottom up solution to the problem. Already, the hospitality industry is involved in the provision of postoperative care to the outstation patients who have been discharged from the hospitals and need to remain in the vicinity for some extra time. Patient welfare team at hospitals believes that there is always a need for a place, which can provide that extra care to the patient. They suggest that hospitals should have trained nursing aids, nurses, physiotherapists on call, physician on call, and patient accessible services.

We also provide preventive and rehabilitative services with assisted living in the community. 
There is a huge population (the chronically ill, elderly, disabled, and the pregnant) which is in need of this extra care. These people can receive customized care rather than the limited medical options that a hospital can provide. The home care agencies can send nurses, therapists, and aides into the home to deliver both medically related home health services and more supportive personal care assistance

(Activities of daily living such as bathing, dressing, and eating, and assist with instrumental activities of daily living such as cooking, shopping, and housekeeping).

While curative management is mostly about highly trained physicians and surgeons using state of the art equipment to treat patients, preventive management is about the foot soldiers in the form of nurses, social workers, and home aides delivering care to the person, provides preventive and rehabilitative services, for physical and mental disabilities, without compromising on the quality, to cover the burden of disabling chronic illnesses like diabetes, chronic renal failure, heart failure, and stroke.


author credits

DR. DEEPAK KAPOOR is one India's highly qualified laparoscopic surgeons currently enrolled with the Escorts Heart Institute, New Delhi. With foresight and diligence, he aims to provide flawless healthcare services for the chronically ill and the elderly.


Image Source: Wilfredo Rodríguez

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