The term "hospice" (from the same linguistic root as "hospitality") can be traced back to medieval times when it referred to a place of shelter and rest for weary or ill travelers on a long journey. The name was first applied to specialized care for dying patients in 1967 by physician Dame Cicely Saunders, who founded the first modern hospice - St. Christopher's Hospice - in a residential suburb of London.

Saunders introduced the idea of specialized care for the dying to the United States during a 1963 visit with Yale University. Her lecture, given to medical students, nurses, social workers, and chaplains about the concept of holistic hospice care, included photos of terminally ill cancer patients and their families, showing the dramatic differences between before and after symptom control care. This lecture launched the following chain of events, which resulted in the development of hospice care as we know it today:

1965: Florence Wald, then Dean of the Yale School of Nursing, invites Saunders to become a visiting faculty member of the Yale School of Nursing for the spring term.

1968: Wald takes a sabbatical from Yale to work at St. Christopher's and learn everything she can about hospice.

1969: A book based on more than 500 interviews with dying patients is published entitled, On Death and Dying. Written by Dr. Elizabeth Kubler-Ross, it identifies the five stages through which many terminally ill patients progress. The book becomes an internationally known best seller. Within it, Kubler-Ross makes a plea for home care as opposed to treatment in an institutional setting and argues that patients should have a choice and the ability to participate in the decisions that affect their destiny.

1972: Kubler-Ross testifies at the first national hearings on the subject of death with dignity, which is conducted by the US Senate Special Committee on Aging. In her testimony, Kubler-Ross states, "We live in a very particular death-denying society. We isolate both the dying and the old, and it serves a purpose. They are reminders of our own mortality. We should not institutionalize people. We can give families more help with home care and visiting nurses, giving the families and the patients the spiritual, emotional, and financial help in order to facilitate the final care at home."

1974: The first hospice legislation is introduced by Senators Frank Church and Frank E. Moss to provide federal funds for hospice programs. The legislation is not enacted.

1974: America's first hospice, The Connecticut Hospice, Inc., in Branford, Connecticut, begins providing hospice services in the home. The National Cancer Institute funds The Connecticut Hospice for three years to develop a national demonstration center for home care for the terminally ill and their families.

1978: A US Department of Health, Education, and Welfare task force reports that "the hospice movement as a concept for the care of the terminally ill and their families is a viable concept and one which holds out a means of providing more humane care for Americans dying of terminal illness while possibly reducing costs. As such, it is the proper subject of federal support."

1979: The Health Care Financing Administration (HCFA) initiates demonstration programs at 26 hospices across the country to assess the cost effectiveness of hospice care and to help determine what a hospice is and what it should provide.

1980: The W.K. Kellogg Foundation awards a grant to the Joint Commission of Accreditation of Hospitals (JCAHO) to investigate the status of hospice and to develop standards for hospice accreditation.

1982: Congress includes a provision to create a Medicare hospice benefit in the Tax Equity and Fiscal Responsibility Act of 1982, with a 1986 sunset provision.

1984: JCAHO initiates hospice accreditation.

1986: The Medicare hospice benefit is made permanent by Congress and hospices are given a 10% increase in reimbursement rates. States are given the option of including hospice in their Medicaid programs. Hospice care is now available to terminally ill nursing home patients.

1989: The Government Accounting Office releases a study stating that only about 35% of eligible hospices are Medicare certified. There are several reasons listed, one of which is the low payment rates that HCFA had established for hospices.

1989: Congress gives hospices their first increase (20%) in reimbursement since 1986 and ties future increases to the annual increase in the hospital market basket through a provision contained in the Omnibus Budget Reconciliation Act of 1989.

1991: The Commission on the Future Structure of Veterans Health Care (Mission Commission) releases a report recommending inclusion of hospice care in the veteran's benefit package.

1992: Congress passes the Indian Health Care Improvement Act of 1992, calling for a hospice feasibility study.

1993: Hospice is included as a nationally guaranteed benefit under President Clinton's health care reform proposal. Hospice now is an accepted part of the health care continuum.

1994: HCFA sends a memorandum alerting the regions of problems regarding questionable certifications and recertifications of terminal illnesses. This results in the first "focused medical review" for hospices and a wake-up call to the industry to improve its documentation and certification procedures or be denied payments.

1995: HCFA releases an expanded version of the Hospice Interpretive Guidelines, which provides much needed clarification of the Conditions of Participation (CoP). The Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) Hospice Benefit is implemented June 1, 1995. It mirrors the Medicare Hospice Benefit in CoPs and reimbursements.

1995: HCFA convenes a Negotiating Committee on Medicare Hospice Wage Index that recommends a proposed rule to revise the hospice wage index, which has not been updated since 1983. HCFA also initiates a comprehensive review and rewriting of the CoPs.

1995: The Office of the Inspector General (OIG) announces that Operation Restore Trust (ORT), a special program to combat waste, and abuse in Medicare and Medicaid in five targeted states - California, Florida, Illinois, New York, and Texas - would be expanded to include hospice.

1996: The Ninth US Circuit Court of Appeals in San Francisco overrules a Washington state law against physician-assisted suicide. The Second US Circuit Court of Appeals strikes down New York's law against physician-assisted suicide. Both rulings are appealed to the U.S. Supreme Court.

1996: US Congressmen Ben Cardin (D-MD) and Rob Portman (R-OH) introduce the "Medicare Hospice Benefit Amendments of 1996" (HR 3714), a bill that will make technical changes and improvements to the Medicare hospice benefit, to the House of Representatives. US Senator John Breaux (D-LA) introduces a companion bill (S 2034). The hospice industry provides full support for both bills.

1997: ORT is extended and expanded to target 12 new states and additional types of health care providers.

1997: Reps. Cardin and Portman reintroduce their hospice legislation, which is now called "The Hospice Amendments Bill of 1997" (HR 521). Senator Ron Wyden (D-OR) introduces "The Medicare Modernization and Patient Protection Act of 1997." A major goal of the bill, which includes a number of hospice provisions similar to HR 521, is to shore up the Medicare trust fund.

1997: Congress passes legislation barring taxpayer dollars from financing physician-assisted suicide. In addition, the legislation authorizes grants and demonstration projects to promote hospice and home care as alternatives to physician-assisted suicide. The House passed the measure, HR 1003, the "Assisted Suicide Funding Restriction Act of 1997" and an identical measure (S 304) cleared the Senate. End-of-life issues continue to receive national attention, including proposed legislation on "Medicaring," which is intended to extend hospice-like services to patients who have incurable diseases, but do not qualify for hospice care because they have unpredictable conditions or are expected to live longer than Medicare guidelines allow.

1997: In a unanimous decision the Supreme Court rules that terminally ill people do not have a constitutional right to doctor-assisted suicide. The court upheld laws in New York and Washington state that make it a crime for doctors to give life-ending drugs to mentally competent but terminally ill patients who no longer want to live.

1997: The Balanced Budget Act of 1997 provided modification to the Medicare Hospice Benefit which constituted substantial improvements for patients and families. Of greatest significance was the re-definition of the benefit periods; patients are now eligible for 90, 90, and an unlimited number of 60 day renewals. The new model eliminated the provision which rendered a hospice patient forever ineligible if he/she revoked or was discharged under the previous legislation.

2000: The Benefits Improvement and Protection Act of 2000 (BIPA) legislation increases the base Medicare daily payment rates for hospice care in FY 2001 by 5.0 percentage points. In addition, the language in the Act modifies current law to specify that the physician's or hospice medical director's certification regarding terminal illness shall be based on his/her clinical judgment regarding the normal course of an individual's illness.

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