Over the past two decades the U.S. hospice industry has struggled to provide holistic palliative care to the terminally ill population and their families. The birth of hospice movement occurred in the United States when it became clear that the traditional medical model did not meet the complex needs of people at the end of life; in this void hospice workers built a system of interdisciplinary care designed to meet the physical, psychological, social, and spiritual needs of terminally ill people and their families. Slowly but surely, hospice care carved its niche in the health care system and finally achieved reimbursement through third-party payers. From the advent of the Medicare hospice benefit, though, and particularly because of the advent of managed care, the health care system, including hospice, has been challenged to contain costs in patient care while improving quality and outcomes (Dinerman, 2002; Rizzo, 2002). Medicare reimbursement has been seen as inadequate to cover hospice costs (Mahoney, 1997; "Seeking Stability," 2003); as a result, administrators have experienced tremendous pressure to make decisions based exclusively on fiscal realities. This has created considerable role conflict as they struggle to maintain the original hospice vision of holistic patient care (Dinerman; Mahoney).
