Shift in Child Hospice Care Is a Lifeline for Parents Seeking a Measure of Comfort and Hope


POMONA, Calif. — Once you first meet 17-month-old Aaron Martinez, it’s not apparent that one thing is catastrophically flawed.

What you see is a phenomenal little boy with easy, lustrous pores and skin, an abundance of shiny brown hair, and a disarming smile. What you hear are coos and cries that don’t instantly sign something is horribly awry.

However his dad and mom, Adriana Pinedo and Hector Martinez, know the reality painfully nicely.

Though Adriana’s medical doctors and midwife had described the being pregnant as “excellent” for all 9 months, Aaron was born with most of his mind cells useless, the results of two strokes and an enormous bleed he sustained whereas in utero.

Docs aren’t positive what brought about the anomalies that left Aaron with just about no cognitive perform or bodily mobility. His voluminous hair hides a head whose circumference is simply too small for his age. He has epilepsy that triggers a number of seizures every day, and his smile will not be at all times what it appears. “It may very well be a smile; it may very well be a seizure,” his mom stated.

Shortly after Aaron was born, medical doctors instructed Adriana, 34, and Hector, 35, there was no hope and they need to “let nature take its course.” They’d be taught months later that the medical doctors had not anticipated the boy to dwell greater than 5 days. It was on Day 5 that his dad and mom put him in residence hospice care, an association that has continued into his second 12 months of life.

The household will get weekly visits from hospice nurses, therapists, social employees, and a chaplain within the cramped one-bedroom house they lease from the individuals who dwell in the primary home on the identical lot on a quiet residential avenue on this Inland Empire metropolis.

Adriana Pinedo holds her son, Aaron Martinez, throughout a go to with hospice nurses Raul Diaz (left) and Shannon Stiles. Pinedo describes the weekly hospice visits from nurses, therapists, social employees, and a chaplain as “our lifeline.”(Heidi de Marco / KHN)

One of many fundamental standards for hospice care, established by Medicare largely for seniors but in addition utilized to youngsters, is a analysis of six months or much less to dwell. But over the course of 17 months, Aaron’s medical group has repeatedly recertified his hospice eligibility.

Underneath a provision of the 2010 Reasonably priced Care Act, youngsters enrolled in Medicaid or the Youngsters’s Well being Insurance coverage Program are allowed, not like adults, to be in hospice whereas persevering with to obtain healing or life-extending care. Industrial insurers will not be required to cowl this “concurrent care,” however many now do.

Greater than a decade since its inception, concurrent care is extensively credited with enhancing the standard of life for a lot of terminally in poor health youngsters, easing stress on the household and, in some instances, sustaining hope for a treatment. However the association can contribute to a painful dilemma for folks like Adriana and Hector, who’re torn between their fierce dedication to their son and the futility of figuring out that his situation leaves him with no future price hoping for.

“We might lose a life, but when he continues to dwell this fashion, we’ll lose three,” stated Adriana. “There’s no high quality of life for him or for us.”

Aaron’s medical doctors now say he might conceivably dwell for years. His physique hasn’t stopped rising since he was born. He’s within the 96th percentile for top for his age, and his weight is about common.

His dad and mom have talked about “graduating” him from hospice. However he’s by no means steady for lengthy, and so they welcome the visits from their hospice group. The seizures, generally 30 a day, are a persistent assault on his mind and, as he grows, the medicines supposed to regulate them have to be modified or the doses recalibrated. He’s at continuous threat of gastrointestinal issues and probably lethal fluid buildup in his lungs.

Adriana, who works from residence for a nonprofit public well being group, spends a lot of her time with Aaron, whereas Hector works as a landscaper. She has chosen to dwell within the second, she stated, as a result of in any other case her thoughts wanders to a future wherein both “he might die — or he received’t, and I’ll find yourself altering the diapers of a 40-year-old man.” Both of these, she stated, “are going to suck.”

Whereas most cancers is likely one of the main diseases afflicting youngsters in hospice, many others, like Aaron, have uncommon congenital defects, extreme neurological impairments, or unusual metabolic deficiencies. 

“Now we have ailments that households inform us are one in every of 10 instances on the earth,” stated Dr. Glen Komatsu, medical director of Torrance-based TrinityKids Care, which supplies residence hospice providers to Aaron and greater than 70 different children in Los Angeles and Orange counties.

A photo shows Aaron Martinez sleeping in a crib.
Aaron Martinez sleeps within the bed room he shares along with his mom and father in Pomona, California.(Heidi de Marco / KHN)

Within the years main as much as the ACA’s implementation, pediatric well being advocates lobbied onerous for the concurrent care provision. With out the potential for life-extending care or hope for a treatment, many dad and mom refused to place their terminally in poor health children in hospice, considering it was tantamount to giving up on them. That meant the entire household missed out on the assist hospice can present, not simply ache reduction and luxury for the dying youngster, however emotional and non secular care for folks and siblings underneath excessive duress.

TrinityKids Care, run by the massive nationwide Catholic well being system Windfall, doesn’t simply ship nurses, social employees, and chaplains into properties. For sufferers capable of take part, and their siblings, it additionally affords artwork and science initiatives, train lessons, films, and music. Throughout the pandemic, these actions have been performed by way of Zoom, and volunteers ship wanted provides to the kids’s properties.

The flexibility to get remedies that lengthen their lives is a serious cause youngsters in concurrent care are extra doubtless than adults to survive the six-months-to-live analysis required for hospice.

“Concurrent care, by its very intention, very clearly goes to increase their lives, and by extending their lives they’re now not going to be hospice-eligible should you use the six-month life expectancy standards,” stated Dr. David Steinhorn, a pediatric intensive care doctor in Virginia, who has helped develop quite a few youngsters’s hospice packages throughout the U.S.

One other issue is that youngsters, even sick ones, are merely extra strong than many older individuals.

“Sick children are sometimes in any other case wholesome, aside from one organ,” stated Dr. Debra Lotstein, chief of the division of consolation and palliative care at Youngsters’s Hospital Los Angeles. “They could have most cancers of their physique, however their hearts are good and their lungs are good, in comparison with a 90-year-old who at baseline is simply not as resilient.”

All of Aaron Martinez’s important organs, aside from his mind, appear to be working. “There have been instances once we’ve introduced him in, and the nurse seems to be on the chart and appears at him, and she will be able to’t consider it’s that youngster,” stated his father, Hector.

A photo shows a nurse giving 17-month-old Aaron Martinez medicine via an oral syringe.
Hospice nurse Shannon Stiles gently administers Aaron Martinez an oral medicine. Many hospice organizations are reluctant to take youngsters, whose medical and emotional wants are sometimes intense and complicated.(Heidi de Marco / KHN)

When children dwell previous the six-month life expectancy, they have to be recertified to remain in hospice. In lots of instances, Steinhorn stated, he’s prepared to recertify his pediatric sufferers indefinitely.

Even with medical doctors advocating for them, it’s not at all times straightforward for kids to get into hospice care. Most hospices care primarily for adults and are reluctant to take children.

“The hospice will say, ‘We don’t have the capability to deal with youngsters. Our nurses aren’t educated. It’s totally different. We simply can’t do it,’” stated Lori Butterworth, co-founder of the Youngsters’s Hospice and Palliative Care Coalition of California in Watsonville. “The opposite cause will not be eager to, as a result of it’s existentially devastating and unhappy and onerous.”

Funds additionally play a job. Dwelling hospice care is paid at a per diem rate set by Medicare — barely over $200 a day for the primary two months, about $161 a day after that — and it’s usually the identical for youths and adults. Youngsters, significantly these with uncommon circumstances, typically require extra intensive and progressive care, so the per diem doesn’t stretch as far.

The concurrent care provision has made taking pediatric sufferers extra viable for hospice organizations, Steinhorn and others stated. Underneath the ACA, most of the bills for sure medicines and medical providers will be shifted to the affected person’s major insurance coverage, leaving hospices answerable for ache reduction and luxury care.

Even so, the comparatively small variety of children who die annually from protracted illnesses hardly makes pediatric hospice an interesting line of enterprise in an trade craving development, particularly one wherein private equity investors are active and searching for an enormous payday.

In California, solely 21 of 1,336 hospices reported having a specialised pediatric hospice program, and 59 stated they served at the very least one affected person underneath age 21, based on an analysis of 2020 state knowledge by Cordt Kassner, CEO of Hospice Analytics in Colorado Springs, Colorado.

Hospice suppliers that do cater to youngsters typically face a extra fundamental problem: Even with the potential for concurrent care, many dad and mom nonetheless equate hospice with acceptance of dying. That was the case initially for Matt and Reese Sonnen, Los Angeles residents whose daughter, Layla, was born with a seizure dysfunction that had no title: Her mind had merely did not develop within the womb, and an MRI confirmed “fluid taking on house the place the mind wasn’t,” her mom stated.

When Layla’s group first talked about hospice, “I used to be within the automotive on my cellphone, and I nearly crashed the automotive,” Reese recalled. “The primary thought that got here to thoughts was, ‘It’s simply the tip,’ however we felt she was nowhere close to it, as a result of she was sturdy, she was mighty. She was my little woman. She was going to get via this.”

About three months later, as Layla’s nervous system deteriorated, inflicting her to writhe in ache, her dad and mom agreed to enroll her in hospice with TrinityKids Care. She died weeks later, not lengthy after her 2nd birthday. She was in her mom’s arms, with Matt shut by.

“Hastily, Layla breathed out an enormous rush of air. The nurse checked out me and stated, ‘That was her final breath.’ I used to be actually inhaling her final breath,” Reese recounted. “I by no means wished to breathe once more, as a result of now I felt I had her in my lungs. Don’t make me chortle, don’t make me exhale.”

Layla’s dad and mom haven’t any regrets about their resolution to place her in hospice. “It was absolutely the proper resolution, and in hindsight we should always have achieved it sooner,” Matt stated. “She was struggling, and we had blinders on.”

A photo shows Adriana Pinedo sitting at home and feeding her son, Aaron, with a bottle.
Adriana Pinedo spends a lot of her day alone together with her son. She has chosen to dwell within the second, she says, as a result of in any other case her thoughts wanders to a future wherein both “he might die — or he received’t, and I’ll find yourself altering the diapers of a 40-year-old man.”(Heidi de Marco / KHN)

Adriana Pinedo stated she is “infinitely grateful” for hospice, regardless of the heartache of Aaron’s situation. Generally the social employee will cease by, she stated, simply to say hiya and drop off a latte, a small gesture that may really feel very uplifting. “They’ve been our lifeline,” she stated.

Adriana talks a couple of buddy of hers with a wholesome child, additionally named Aaron, who’s pregnant together with her second youngster. “All of the stuff that was on our listing, they’re dwelling. And I like them dearly,” Adriana stated. “Nevertheless it’s nearly onerous to look, as a result of it’s like wanting on the stuff that you just didn’t get. It’s like Christmas Day, staring via the window on the neighbor’s home, and also you’re sitting there within the chilly.”

But she appears palpably torn between that bleak regret and the unconditional love dad and mom really feel towards their youngsters. At one level, Adriana interrupted herself midsentence and turned to her son, who was in Hector’s arms: “Sure, Papi, you’re so stinking cute, and you’re nonetheless my dream come true.”

This story was produced by KHN, which publishes California Healthline, an editorially unbiased service of the California Health Care Foundation.


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