It’s one of the most difficult decisions a family has to make; what to do when a loved one is terminally ill with only a short time left to live. Should they remain in the hospital? Should they be sent to a nursing facility or should they spend their last remaining days at home?

Hospice is one option and for families living in Clallam County, it’s an option that comes with choice. The county is home to two hospice organizations: Assured Hospice of Clallam and Jefferson Counties and Volunteer Hospice of Clallam County.

At an April 17 public forum hosted by the League of Women Voters of Clallam County, representatives from the two groups met to discuss what hospice is and what the differences are between the two organizations. Representing Volunteer Hospice of Clallam County was executive director Rose Crumb, and from Assured, community education coordinator and liaison Julie Ostling. Both women are registered nurses.

So what is hospice?

Hospice is not just home health care. As both Crumb and Ostling describe it, hospice is a philosophy of keeping patients and their families comfortable, replacing curing treatments with “palliative care” or pain management, and addressing the patient’s and loved ones’ social, spiritual and emotional needs.

“Hospice is a fairly new concept, but it’s really, really old,” Crumb said, adding that the word hospice comes from the Latin root “hospes,” which means guest. “It’s probably the most compassionate level of care,” Ostling said.

Both Assured and Volunteer Hospice require a physician’s recommendation in order to start caring for a patient. Both organizations subscribe to the same care and treatment options, making the agencies in many ways remarkably similar. However, where they differ significantly is in funding.

Although Assured has a small nonprofit foundation as well as a number of volunteers, it is a for-profit, Medicare-certified agency. It’s a licensed business, funded through Medicare, Medicaid and private insurance reimbursements. Assured also is partially employee-owned, with the president and CEO Richard Block owning a majority of the company and 50-75 employees owning the rest.

Volunteer Hospice of Clallam County, although it employs registered nurses, primarily is run and operated by volunteers. It receives funding through memorials, endowments and private donations.

“We’ve never had a billing system, so we don’t bill for anything,” said Crumb. She added that Volunteer Hospice does not bill by choice because it allows the organization more flexibility and does not limit the length of time a patient can receive hospice care.

Ostling countered that, although there are certain regulations that come with being Medicare certified, she believes the restrictions are a good thing because it means there’s always someone checking over your shoulder to ensure you’re providing a top level of care.

Under Medicare, hospice is covered by insurance only if a patient receives a physician’s prognosis of six months or less to live.

“It doesn’t mean we have to kick them off the program,” Ostling said. Patient care is constantly assessed and if after six months a patient still is alive, Ostling noted, the physician just gives another six-month prognosis. “As a nurse, I have to be sure that cost isn’t an issue,” she said.

Under Medicare Part A, Assured is responsible for covering costs related to the patient’s illness, such as medications and equipment. Medicare pays for the treatment of any symptoms not related to the illness. Assured’s costs are reimbursed at a daily rate calculated by Medicare.

Volunteer Hospice of Clallam County is not Medicare certified or licensed and in some ways this has hurt the agency.

In 2006, for example, the agency had planned to build a hospice guesthouse on a donated one-acre parcel on Hendrickson Road in Sequim. The house would have had six private rooms for patients without a caregiver.

It would have been an alternative to a less intimate setting such as a nursing home.

“We were all fired up to have a guesthouse and guess what? It went down the chute,” Crumb said. “We just got tired of pleading our case.”

According to Crumb, while the state Legislature exempts Volunteer Hospice from needing a license, Washington’s Department of Social and Health Services said the agency had to be licensed in order to take care of more than one person within a single facility.

Although Ostling said she admired the concept of a guesthouse, Assured did, during legislative hearings, speak out against the project.

“Our main concern was licensure. We believe in licensure to protect the vulnerable,” Ostling said, adding that Assured was not planning to construct a guesthouse anytime soon.

The two women maintained that there is no competition between the agencies and that they see their coexistence as beneficial to the community.

“I would love to see us work more closely together,” Ostling said.