Retinitis Pigmentosa and Ataxia Caused by a Mutation in the Gene for the α-Tocopherol–Transfer Protein

Abstract

The proposal by Miller and Fins (June 27 issue)1 that hospital care be restructured, with more explicit attention to dying patients, highlights an important and unmet need within our health care system. The quality of hospice care has been excellent for patients who qualify for the Medicare hospice benefit, require extensive informal support, and have a fairly predictable prognosis, but the majority of people in the United States still die in hospitals or nursing homes. Although I agree that we need to restructure hospital care for dying patients, I see no particular need to link that care to the intensive care unit (ICU), as the authors suggest. In fact, many patients who should be eligible for high-quality palliative care in the hospital are patients who are not candidates for the ICU. In addition, since palliative services are needed for patients throughout the hospital, a separate unit must collaborate closely with physicians and other clinical staff from all the other clinical departments. It is important that this discussion receive the highest level of attention from both hospital administrators and health care professionals. One recent development that will aid this process enormously is a new code in the International Classification of Diseases, 9th Revision, Clinical Modification, which was announced by the Health Care Financing Administration (HCFA) in the May 31 Federal Register and went into effect on October 1, 1996.2 Designated the V code, it is for patients who receive terminal or palliative care related to their primary diagnoses. Hospital-chart abstracters must link the V code to a principal diagnosis indicated on the hospital coding sheet. The HCFA intends to study the use of this code for one year, then formulate an appropriate diagnosis-related group (DRG) for payment related to terminal care, in conjunction with existing diagnostic codes. This strategy will allow variability in DRGs according to diagnosis but will add important supplemental information. The code can identify a set of resources expended under palliative care regardless of the diagnosis, making it possible to monitor the quality of care and the extent of its use better.