Don't you forget about me.

As soon as I read chapter five on “Nonabandonment” in Quill’s Caring for Patients at the End of Life, I knew immediately which underlying value and assumptions to discuss, as an experience I had with Walter left me with several questions about hospice care. In chapter five, Quill argues that nonabandonment should be a central obligation of physicians, as physicians should focus on nurturing a continuous relationship between themselves and patients. Quill explains that the relationship between patient and physician need not end with diagnosis or even the first or last medical procedure. Rather a long-term relationship between the physician/patient, which lasts until the patient dies or recovers, is of utmost importance. Essentially, nonabandonment highlights a relationship which involves an open-ended commitment.

Of course, Quill acknowledges cultural and systemic issues which affect the ability for physicians to engage in such relationships with patients, as he notes the prevalence of managed care systems, and this latter note is one I wish to take up, given my conversation about Walter this week.

I received a phone call on Tuesday morning from the hospice music therapist. She informed me that Walter was being discharged. I had never heard this term used before, so I asked her to elaborate. She explained that Walter was improving and no longer met the Medicare requirement of a prognosis of death in less than six months. I asked her if that meant that Walter had graduated, a term I had heard used in the past. “Yes,” she replied, “we often use those terms interchangeably.” She continued, “So that means you can visit him until the 11th according to Medicare.” “Thank you for letting me know,” I responded.

After I hung up, I continued thinking about what she had said. I would not use the terms ‘discharge’ and ‘graduated’ interchangeably, given the conversations I’ve had with Walter. 'Graduated' implies that all should be happy and joyous, as Walter has escaped death for a while longer. Given the fear of death in this society, being able to avoid death is commended. However, Walter still has prostate cancer. He has not been cured, and although the providers suspect death is not as imminent as it was before, Walter is still dying.

Walter has some psychological and emotional needs and was benefiting from visits with people from hospice. On more than one occasion, he mentioned that he did not know what hospice, or as he calls it ‘hostel’, was actually all about. However, he often accounted that when he needed to talk and was about to call hostel, someone always arrived before he even called. He was beginning to understand that hospice could be there for him, when he needed them most. He could count on hospice and believed that hospice served more than just his medical or physical needs, as they provided listeners for him to talk through his fears with.

Walter often spoke about friends who had committed suicide and admitted his thoughts about such decisions. The only friends he could speak with about these concerns were suicidal themselves, and so I believe Walter began to count on hospice personnel with whom he could engage in these conversations as they were possibly less-biased than his friends.

And now, Walter has graduated – or more accurately, Walter has been discharged.

I understand that I can still visit Walter on my own and be the listening conversant he might need. I also understand that hospices cannot afford to offer services to all individuals unless paid for by Medicare and that Walter does not meet those requirements anymore. However, I am not sure if Walter understands. He has just gotten to a place where he believes he can trust in and count on hospice and I’m not sure if he will understand where his newfound relationships have gone. I also understand that most likely, Walter will be a hospice patient once again, and so these benefits might again be realized in the future; however, I think he would benefit from hospice in the present.

To me, I feel as though Walter has been abandoned. I appreciate that Quill acknowledged the systemic issues with the philosophy of nonabandonment but having seen Walter’s experience, I’m wondering what happens, specifically in hospice, in those moments when patients graduate or are discharged. Does nonabandonment involve switching patients to palliative care, which offers holistic services without the same hospice requirements? Will hospice personnel strive to not abandon Walter and ensure that he receives palliative care? How did they explain this change to Walter? Will Walter’s family feel the strain of losing the extra support?