After The Washington Post reported last month about a North Carolina hospice accused of over-medicating a patient, Peter Brunnick, the chief of the largest nonprofit hospice in the state, warned readers in a Charlotte Observer opinion piece that “all hospices are not created equal.” He urged readers to choose a hospice carefully.

In an interview this week, he offered his thoughts on the state of the industry and what consumers can do to shop wisely.

Peter Brunnick, president and CEO of Hospice & Palliative Care Charlotte Region Peter Brunnick is president and CEO of Hospice & Palliative Care Charlotte Region. (Photo by Phil Alt for Hospice & Palliative Care Charlotte Region)

Peter Whoriskey: As the hospice industry grows, there is an ongoing debate about how to maintain the quality of care. What’s at stake here?

Peter Brunnick: My view is that it’s important because of the seriousness of end-of-life.  We’ve always said that, at a minimum, society owes people a good birth and a good death. Hospice care is about managing pain and allowing people to die with dignity and respect. For survivors, the effects of a bad death can linger for the rest of their lives.

What is the most common reason that patients who should enroll for hospice do not?

There’s a lot of misunderstanding – people equate it with giving up and euthanasia. But it’s not. Sometimes people live longer on hospice than they would otherwise. Other times, the resistance comes from the medical community. They think, “Why don’t we just try this medicine or treatment?” Some of them look at turning a patient over to hospice as a failure. We tell them hospice care is about living each day to the fullest until the very end, and their mindset is changing. We think our outcomes are better.

Medicare statistics indicate that the quality of hospice care varies widely from agency to agency, and that at many dying patients may be getting poor treatment. For example, hundreds of hospices regularly fail to have a nurse visit in the last 48 hours of life. Another analysis of Medicare statistics shows that 18 percent of hospices never provide crisis care — that is, inpatient care or continuous nursing care. How much variety do you see out there in terms of the quality of the agencies?

In the counties around Charlotte, I don’t see a lot of these practices that are being seen nationwide. But it is easy to see in other states that some hospices do not offer general inpatient care and don’t provide after-hours care. We hear stories of that. Most of those stories do not come from the community-based, not-for-profit providers.

Currently, a typical U.S. hospice undergoes a full government inspection about once every six years. Are those inspections frequent enough?

No. That has been an issue in the industry for some time. We’ve asked for more inspections. The lack of inspections has contributed to some of the poor practices. To be blunt, some providers see the risk of getting caught providing poor care as pretty low.

The number of for-profit companies offering hospice services has risen steadily over the years, and they now dominate the field. Is this a good or bad trend?

People can make too much of this issue. There are good for-profit hospices just as there are bad nonprofit hospices.

But a lot of investors are now interested in the industry, with investments coming in from hedge funds and private equity firms. Now I’m a CPA and a business guy. I believe in free enterprise. But the end of life is not the time to say we need to maximize returns for the shareholder. There’s too much at stake.

How should consumers go about choosing a hospice and avoiding the bad ones?

Fundamentally, you have to be a well-informed consumer. You have to ask: How long have they been in business? Where is the closest licensed office — that will play a role in how responsive they will be. Is it accredited by an independent organization? Do they have a volunteer program? Can they truly provide 24-hour, 7-day-a-week service?

Read More: 

As more hospices enroll patients who aren’t dying, questions about lethal doses arise

Terminal neglect? How some hospices treat dying patients.

Is that hospice safe? Infrequent inspections mean it may be impossible to know.