North America Canada

Canadian physician Balfour Mount, who first coined the term "palliative care", was a pioneer in the Canadian hospice movement, which focuses primarily on palliative care in a hospital setting.^[29][30] Having read the work of Kubler-Ross, Mount set out to study the experiences of the terminally ill at Royal Victoria Hospital, Montreal; the "abysmal inadequacy", as he termed it, that he found prompted him to spend a week with Saunders at St. Christopher's.^[31] Inspired, Mount decided to adapt Saunders' model for Canada. Given differences in medical funding in Canada, he determined that a hospital-based approach would be more affordable, creating a specialized ward at Royal Victoria in January, 1975.^[30][31] For Canada, whose official languages include English and French, Mount felt the term "palliative care ward" would be more appropriate, as the word hospice was already used in France to refer to nursing homes.^[30][31] Hundreds of palliative care programs followed throughout Canada through the 1970s and 1980s.^[32]

However, as of 2004, according to the Canadian Hospice Palliative Care Association (CHPCA), hospice palliative care was only available to 5-15% of Canadians, with available services having decreased with reduced government funding.^[33] At that time, Canadians were increasingly expressing a desire to die at home, but only two of Canada's ten provinces were provided medication cost coverage for care provided at home.^[33] Only four of the ten identified palliative care as a core health service.^[33] At that time, palliative care was not widely taught at nursing schools or universally certified at medical colleges; there were only 175 specialized palliative care physicians in all of Canada.^[33]

United States

Main article: Hospice care in the United States

Hospice in the United States has grown from a volunteer-led movement to improve care for people dying alone, isolated, or in hospitals, to a significant part of the health care system. In 2010, an estimated 1.581 million patients received services from hospice. Hospice is the only Medicare benefit that includes pharmaceuticals, medical equipment, twenty-four hour/seven day a week access to care and support for loved ones following a death. Hospice care is also covered by Medicaid and most private insurance plans. Most hospice care is delivered at home. Hospice care is also available to people in home-like hospice residences, nursing homes, assisted living facilities, veterans' facilities, hospitals, and prisons. The first hospice in the US was the Connecticut Hospice.

The first United States hospital-based palliative care programs began in the late 1980s by committed volunteers across the country. A handful of institutions such as the Cleveland Clinic and Medical College of Wisconsin were among the early programs. By 1995, hospices were a $2.8 billion industry in the United States, with $1.9 billion from Medicare alone funding patients in 1,857 hospice programs with Medicare certification.^[34] In that year, 72% of hospice providers were non-profit.^[34] By 1998, there were 3,200 hospices either in operation or under development throughout the United States and Puerto Rico, according to the NHPCO.^[34] According to 2007's Last Rights: Rescuing the End of Life from the Medical System, hospice sites are expanding at a national rate of about 3.5% per year.^[35] As of 2008, approximately 900,000 people in the United States were using hospice every year,^[36] with more than one-third of dying Americans using the service.^[37]