When I worked at my prior hospice, we were cutting edge. We brought everything we could home. ALS, LVAD’s, decels, intractable-symptom patients. We aimed to manage as much as we could in the home, and I’m proud to say we did a good job.
It seems a crazy thing to say but much of what we do medically - even higher acuity - can be managed in the home. We can run vents, high-flow oxygen, drains, wound VAC‘s, drips, TPN, feeds in the home. We can do labs and imaging. We are simply limited at this point by the mentality around what is home care and how we pay for things (both of which influence the logistics of care).
Right now, we suffer from a mentality that hospitals are for “real” care, rehab/home health is a quasi-continuation of that "real" care, and that hospice in the home is where you go to die - with little to no "real" care. It’s a patently false way of thinking, because home hospice, when decline and death are well-managed (as they should be), constitutes a formidable amount of true dynamic medical care.
What if we shifted to the mentality that a significant amount of higher-level care could be done in the comfort of one’s home, and that when you actively started passing, that would be managed there too? What if you knew that you could get everything you needed at home, that as a tired, terminal patient you didn’t have to make the choice to go back in, just because only the hospital did such-and-such modality? Hospitals could be then the places one went to, to get better, and if not your home (with a superb hospice team) could take you over and meet your level of care.
As I said above, I think the sky's almost the limit for what can be run in the home – a hospital in the home – especially with our terminal patients.
We just need to collectively believe it can be done.