Mission House blends in with all the other homes on its quiet, residential street in Redwood City. The only difference is that it houses terminally ill hospice patients.
On a recent Monday afternoon, five residents were staying in the six-bedroom home. Some were behind closed doors, labeled with their first names. Others sat outside on a sunny patio, chatting with visitors. In the kitchen, a staff member baked chocolate chip cookies.
Operated by the San Mateo nonprofit Mission Hospice & Home Care, Mission House is among the local alternatives for those looking for specialized hospice care. The vast majority of hospice patients — defined by Medicare as people expected to live six months or less — receive care in their own homes, in assisted living facilities or nursing homes.
Local caregivers said specialized hospice care isn't about focusing on death.
"The focus can be on living life and understanding the goals you have with the time you have left and how we can help you take advantage of that," said Christine Ritzo, a registered nurse with Mission Hospice & Home Care.
It's a myth that all hospice patients are bed-bound or on morphine drops, Ritzo said, noting that some patients even take the opportunity to travel with "transfer" hospice support, perhaps making last trips to Hawaii or Lake Tahoe.
The demand for hospice services is growing as the senior population and the number of patients with life-threatening conditions increases. Nationally, the number of patients in hospice grew to 1.61 million in 2019 from 1.38 million in 2015, according to the National Hospice and Palliative Care Organization. Medicare spending on hospice increased $5 billion over a five year period: In 2019, spending reached $20.9 billion compared to $15.9 billion in 2015.
Last October, Gov. Gavin Newsom signed legislation to strengthen hospice oversight statewide. The new laws now place the auditing and oversight procedures of hospice providers under the Department of Public Health.
"For a long time, people treated dying as a medical event, but dying is a human event, and hospice brings the humanity back to the dying experience," said Terri Simpson-Tucker, hospice director for Sutter Care at Home.
Hospice patients receive visits by nurses or health aides as needed — Medicare defines and reimburses for four levels of care — and families get help from social workers, physicians, chaplains, bereavement counselors and a host of volunteers.
But the choice to enter hospice — which is up to the patient and revocable at any time — is tough to face because it requires accepting only comfort care for a terminal illness while explicitly forgoing medical efforts to cure the person's disease.
With advances in chemotherapy, radiation and drugs, "people hold onto that hope," said Mission CEO Dolores Miller. "Sometimes people are not ready. ... It's not until they've been hospitalized, five times, six times, seven times or in their last year of life that they start to think about hospice or something different.
"The (doctor) will say, 'We can't do anything more for you. We're out of curative treatment options — there's only symptom management.' But that's what hospice does."
For patients and families accustomed to exhaustive treatments, hospice can feel like giving up, or even hastening death.
But high-quality hospice care may actually extend life, in the view of Palo Alto Medical Foundation physician David Tran, who directs palliative care and support services there.
"With good, early hospice care, people actually live longer and more comfortably than we often expect," Tran said. "I think it has to do with a reduction in medical complications from treatment, a reduction in people being placed in facilities and allowing people to be at home longer in a less stressful environment."
Simpson-Tucker, of Sutter Care at Home, said some patients are "dying when we're admitting them, which is not optimal. Most patients are on our service for four or five months."
Some even get better and go off hospice but can return later if they get worse, she added.
Between 2015 and 2019, the average length of stay for those in hospice went from 86.7 days to 92.6 days, according to the National Hospice and Palliative Care Organization. About 19% of patients were enrolled in hospice for two days or less, 25% were enrolled for five days or less and 50% were enrolled for 18 days or less, the group said. Patients with Alzheimer's, dementia and Parkinson's disease had the longest lengths of stay, while those with kidney failure and cancer had much shorter stays.
Local providers said hospice work is some of the most rewarding of their medical careers.
Tran became a palliative care and hospice physician after the lonely experience of having been, as a teenager, the main caregiver during the four-year, terminal illness of his own father.
"It would have been great, back then, to have the social support and the kind of spiritual support that hospice offers," Tran said. "As I got further along in my career, this kind of work really called out to me."
Simpson-Tucker called hospice "the most gratifying type of nursing I've ever done.
"I have the privilege of doing something not many people can do, sitting down and talking with someone about their life, the connections they've made in life," she said. "I get to see so much grace with which people leave this world."
While the hospice movement in California began with volunteers and nonprofits in the 1970s, the majority of programs in the state are now for-profit.
To help prospective patients select a provider, Medicare posts comparative information — including ratings from families in categories such as "communication with family" and "getting timely help" — at medicare.gov/care-compare.