document_title: North American Union

question_text: joined mexico and the united states to form nafta

text: North American Union

text: History[edit]

text: Since at least the mid-19th century, numerous concepts for a union among Canada, Mexico and the United States of America, some including the Caribbean, the Central American and the South American countries, have been proposed, such as the North American Technate. Following the North American Free Trade Agreement (NAFTA) and the Maastricht Treaty going into effect there was speculation about the formation of a North American Union, similar to the European Union created by Maastricht, being a possible future step for the region.[12][13][14] Several proposals for continental integration of North America advocated the creation of a union styled after the European Union, though many academic and business groups advocated less dramatic changes involving the formation of a customs union or common market.[15][16]

text: While serving as a policy adviser to the presidential campaign of Vicente Fox during the 2000 general election in Mexico, Jorge Castañeda, influenced by academic Robert Pastor's ideas on deepening integration of NAFTA, encouraged Fox to include policies on integration as part of his campaign.[17] Before and after the election Fox made appearances on several U.S. news programs advocating greater integration including a plan to open up the U.S.-Mexico border within ten years.[18][19] Some in the United States saw this proposal for open borders as a call for or inevitable step towards a "North American Union" and received it with a mixture of praise and criticism, with critics like Pat Buchanan suggesting it would mean an end to U.S. sovereignty.[20][21][22]

text: During an interview for Commanding Heights: The Battle for the World Economy in 2001, after he was elected president, Fox said that he sought with the United States a "convergence of our two economies, convergence on the basic and fundamental variables of the economy, convergence on rates of interest, convergence on income of people, convergence on salaries." He suggested this might take as long as 20 years to be realized, but the ultimate "convergence" he saw between the United States and Mexico would allow them to "erase that border, open up that border for [the] free flow of products, merchandises, [and] capital as well as people". Fox cited the success he claimed countries Republic of Ireland and Spain had in modernizing their economies and raising the standard of living for their citizens by joining what is now the European Union.[18] Vicente Fox also proposed a plan to U.S. President George W. Bush and Canadian Prime Minister Jean Chrétien that he said would move the North American continent towards an economic union based on the example of the European Union. Fox's proposal was rejected by President Bush, with Fox later alleging in his book Revolution of Hope that the White House wanted him to "stop raising hackles" by talking about a North American Union.[23]

text: Later, amid a push for greater integration and concerns about the impact of heightened security on trade relations following the September 11 attacks in 2001, an effort was organized in 2003 by the Canadian Council of Chief Executives, U.S. Council on Foreign Relations, and the Mexican Council on Foreign Relations called the Independent Task Force on North America.[24] Several weeks before a meeting of North American leaders on March 23, 2005 the Task Force issued a press release and a statement from the Task Force's chairmen calling for deeper integration of NAFTA to form a North American Economic and Security Community by 2010.[25]

text: A January 2005 diplomatic cable that was released by Wikileaks in 2011 includes discussion by U.S. government officials about the best approach to North American integration based on an assessment of Canadian views. The cable suggested a new "North American Initiative" that would address goals in the areas of "security" and "prosperity" through incremental measures, saying such a proposal would get the most support from Canadian policymakers. It notes many Canadian economists supported "ambitious" goals like a single market, with some supporting a monetary union, but that they believed the incremental approach was more appropriate at the time. Canada's central bank governor is quoted in the cable as having said that a monetary union is "an issue that should be considered once we have made more progress towards establishing a single market."[4] The National Post's Robert Hiltz described the cable in June 2011 as discussing "the obstacles surrounding the merger of the economies of Canada, the United States and Mexico in a fashion similar to the European Union."[3]

text: Two months later at the March meeting of North American leaders the Security and Prosperity Partnership of North America (SPP) was formed. It was described by the leaders of Canada, Mexico and the United States as a dialogue to provide greater cooperation on security and economic issues.[26] In response to later concerns, a section was put up on the initiative's site clarifying the SPP was not a legal agreement, that the initiative "does not seek to rewrite or renegotiate NAFTA", and that the partnership itself "creates no NAFTA-plus legal status."[27] A number of academics and government officials at the time viewed the SPP as moving North America towards greater integration.[28]

text: In May 2005, the Task Force published a report praising the SPP initiative and pushing for greater economic integration by 2010.[7] They repeated their call for the "establishment by 2010 of a North American economic and security community, the boundaries of which would be defined by a common external tariff and an outer security perimeter."[29] In the report the Task Force said that a North American Community, which would be similar to the European Community which preceded the EU, should not rely on "grand schemes of confederation or union" and did not suggest a supranational government or a common currency. The Task Force’s recommendations included developing a North American common market and security perimeter, among other common goals.

text: The SPP initiative was officially ended on August 2009 though the North American Leaders' Summit and most of the working groups set up under the initiative remain active. Several advocates of integration saw the SPP as being insufficient. One criticism was that the governments lacked a "vision of what North America might become" and as such did not provide the proper context that would allow the initiative to deal with barriers to deeper integration.[30]

text: Claims of implementation[edit]

text: In 2005, claims emerged from critics of North American integration that a "North American Union" was not only being planned, but was being implemented by the governments of Canada, Mexico, and the United States. These critics cited the formation of the Security and Prosperity Partnership of North America and claimed it was an attempt to dramatically alter the economic and political status quo between the countries outside of the scrutiny of the respective national legislatures, a critique heightened by the subsequent publication of the Independent Task Force on North America report which praised the SPP initiative and called for greater economic integration by 2010.[7]

text: While a broad spectrum of observers criticize the secrecy of the SPP and its dominance by business groups,[31] the specific claim that its true aim was to expand NAFTA into a North American Union analogous to the European Union (EU), with open borders and a common currency among other features, was being made by the fall of 2006, when conservative commentators Phyllis Schlafly, Jerome Corsi and Howard Phillips started a website dedicated to quashing what they perceived as the coming North American "Socialist mega-state".[11]

text: The belief that a North American Union was being planned and implemented in secret became widespread, so much so that the NAU was a topic of debate during the 2008 American presidential campaigns and the subject of various U.S. Congressional resolutions[32][33] designed to thwart its implementation. Prominent critics such as Lou Dobbs, then an employee of CNN [34] and Republican presidential candidate Ron Paul[35] denounced the concept, joined by left-wing nationalist groups in Canada,[36] Internet blogs, and widely viewed videos and films such as "Zeitgeist". Corsi’s 2007 book The Late Great USA: The Coming Merger with Mexico and Canada also helped bring the NAU discussion into the mainstream. These beliefs are the latest example of a long line of erroneous conspiracy theories which suggest that the United States’ sovereignty is being eroded by a cabal of foreign and domestic players.[7][11]

text: Phyllis Schlafly claimed the actual goals of the SPP were confirmed by the Task Force,[37][38] and by the Task Force’s co-chair American University professor Robert Pastor.[39] Critics often cite Pastor as being the “father”[40] of the NAU[11][41] and his 2001 book "Towards a North American Community: Lessons from the Old World for the New" has been called a blueprint[42] for the plan, and includes a suggestion to adopt a common North American currency called the amero.[11][43][44][45]

text: Various positive comments about a North American Union concept and an eventual common currency for the Americas by Vicente Fox, in particular some made during a promotional tour for a book in 2007, have been cited by critics as evidence that the body is in fact being enacted or planned.[46]

text: Features[edit]

text: Concepts of a North American Union share a number of common elements between them. NASCO and the SPP have both denied that there are any plans to establish a common currency, a "NAFTA Superhighway", or a North American Union in "Myths vs Facts" pages on their websites.[27][47]

text: Amero[edit]

text: The "amero" is the appellation given to what would be the North American Union's counterpart to the euro. It was first proposed in 1999 by Canadian economist Herbert G. Grubel.[11] A senior fellow of the Fraser Institute think-tank, he published a book entitled The Case for the Amero[43][44] in September 1999, the year that the euro became a virtual currency. Robert Pastor, vice-chairman of the Independent Task Force on North America, supported Grubel's conclusions in his 2001 book Toward a North American Community, stating that: "In the long term, the amero is in the best interests of all three countries."[48] Another Canadian think-tank, the conservative C.D. Howe Institute, advocates the creation of a shared currency between Canada and the United States.[49] Although then-Mexican President Vicente Fox had expressed support for the idea, when Grubel brought up the idea to American officials, they said they were not interested, citing lack of benefits for the U.S.[11]

text: Cross border trade costs are likened to that of a tariff roughly equivalent to 170%. Forty-four percent of that "tariff" is attributed to "border related trade barriers" which breaks down as follows, "a 8% policy barrier, a 7% language barrier, a 14% currency barrier (from the use of different currencies), a 6% information cost barrier, and a 3% security barrier."[50] On August 31, 2007, Internet broadcaster and conspiracy theorists Hal Turner and Ace Sabau claimed to have arranged for a United States government minted Amero coin to be smuggled out of the U.S. Treasury Department by an employee of that organization. Snopes has assessed both Turner's story and the existence of the amero as false.[51]

text: NAFTA superhighway[edit]

text: The Trans-Texas Corridor was first proposed by Texas Governor Rick Perry in 2002. It consists of a 1,200 foot (366 m) wide highway that also carries utilities such as electricity, petroleum, and water, as well as railway track and fiber-optic cables.[10] In July 2007, U.S. Representative and candidate for the Republican nomination in the 2008 presidential election Duncan Hunter successfully offered an amendment to H.R. 3074, the Department of Transportation Appropriations Act, 2008, prohibiting the use of federal funds for U.S. Department of Transportation participation in the activities of the Security and Prosperity Partnership of North America (SPP). Hunter stated that:

text: Unfortunately, very little is known about the NAFTA Super Highway. This amendment will provide Congress the opportunity to exercise oversight of the highway, which remains a subject of question and uncertainty, and ensure that our safety and security will not be compromised in order to promote the business interests of our neighbors[52]

text: The Ministry of Transportation for the province of Alberta displays a diagram on their website that labels I-29 and I-35 as "NAFTA superhighway".[53]

text: In 2011, the Texas Legislature repealed its authorization for the establishment and operation of the Trans-Texas Corridor.[54][55]

text: Official statements[edit]

text: In 2001, President of Mexico Vicente Fox said in an interview for Commanding Heights: The Battle for the World Economy that in the long term he sought with the United States a "convergence of our two economies, convergence on the basic and fundamental variables of the economy, convergence on rates of interest, convergence on income of people, convergence on salaries." He suggested this might take as long as 20 years to be realized, but the ultimate "convergence" he saw between the United States and Mexico would allow them to "erase that border, open up that border for [the] free flow of products, merchandises, [and] capital as well as people".[18] After leaving office, he continued to support the concept, while expressing his disappointment with the changed American political situation which made it seem more difficult to come to fruition.[56] In an online discussion of his book Revolution of Hope: The Life, Faith, and Dreams of A Mexican President Fox cited the process of European integration and asked a question, "Why can't we be not only partners in the long term, but a North American Union?"[57]

text: In September 2006, U.S. Representative Virgil Goode proposed with six co-sponsors non-binding House Concurrent Resolution 487, which specifically outlined opposition to a North American Union or a NAFTA Superhighway as a threat to U.S. sovereignty. The bill never left committee.[58] The same resolution was reintroduced by Goode in January 2007 for the 110th Congress as House Concurrent Resolution 40, this time with forty-three cosponsors,[59] including 2008 Republican presidential candidates Duncan Hunter, Ron Paul and Tom Tancredo, who have all expressed opposition to a North American Union during their campaigns.[60][61][62]

text: U.S. Commerce Secretary Carlos Gutierrez stated in 2007: "There is no secret plan to create a North American union, or a common currency, or to intrude on the sovereignty of any of the partner nations".[63][64]

text: Regarding the NAFTA superhighway, officials from the Federal Highway Administration have denied such a scheme.[8] Also, the NASCO denies a new proposal for a "NAFTA superhighway" saying, "it exists today as I-35."[47]

text: In an August 2007 press conference in Montebello, Quebec, Canadian Prime Minister Stephen Harper stated that he didn't believe that the NAU was a "generally expressed concern", while U.S. President George W. Bush called concerns of a North American Union "political scare tactics" and described as "comical" the "difference between reality and what some people are talking on TV about."[65]


document_title: Ranjit Sagar Dam

question_text: ranjit sagar dam has builded over which river

root

text: Ranjit Sagar Dam

text:
Ranjit Sagar Dam

Location of Ranjit Sagar Dam in Punjab

Ranjit Sagar Dam (India)

Show map of PunjabShow map of IndiaShow all

Country
India

Location
Basholi & Pathankot

Coordinates
32°26′33″N 75°43′43″E / 32.44250°N 75.72861°E / 32.44250; 75.72861Coordinates: 32°26′33″N 75°43′43″E / 32.44250°N 75.72861°E / 32.44250; 75.72861

Status
Operational

Construction began
1981

Opening date
2001

Owner(s)
Punjab State Power Corporation

Dam and spillways

Type of dam
Embankment, earth-fill

Impounds
Ravi River

Height
160 m (525 ft)

Length
617 m (2,024 ft)

Elevation at crest
540 m (1,772 ft)

Width (crest)
14 m (46 ft)

Width (base)
669.2 m (2,196 ft)

Dam volume
21,920,000 m3 (28,670,278 cu yd)[1]

Spillway type
Controlled-chute

Spillway capacity
24,637 m3/s (870,047 cu ft/s)

Reservoir

Total capacity
3,280,000,000 m3 (2,659,139 acre⋅ft)

Active capacity
2,344,000,000 m3 (1,900,312 acre⋅ft)

Normal elevation
527.9 m (1,732 ft)

Power Station

Commission date
2000[2]

Hydraulic head
121.9 m (400 ft) (max)[3]

Turbines
4 x 150 MW Francis-type

Installed capacity
600 MW

tag: table

text: The Ranjit Sagar Dam, also known as the Thein Dam, is part of a hydroelectric project constructed by the Government of Punjab on the Ravi River on the Border of two states of India Jammu and Kashmir and Punjab. 60% of the lake is part of J&K. The project is situated near Pathankot city in Pathankot district of the state of Punjab and Kathua city and Basholi tehsil of Kathua district in J&K. The project is the largest hydroelectric dam of the state of Punjab. The township where the site is located is called Shah pur Kandi Township. Feasibility studies for the project began in 1953 and geotechnical studies continued until 1980. Construction began in 1981, the generators were commissioned in 2000 and the project complete in March 2001.[4]

tag: p

text: The project is used for both irrigation purposes and power generation. It has a 600 Megawatt capacity. The dam is one of the highest earth-fill dams in India and has the largest diameter penstock pipes in the country.

text: Several issues and claims were consistently reported by the govt of J&K to govt of Punjab over the usage of water, electricity, employment and compensation to the locals against the land acquisition. Finally on 12 May 2017 govt of J&K has raised this issue in the Northern Zonal Council Meeting held in Chandigarh on this Ministry of Home Affairs, GOI has decided to construct barrage to allow both states to enjoy equal rights over the dam. Barrages will help J&K in irrigation in Samba and Kathua districts in Jammu division of J&K. Punjab govt has also agreed to share electricity produced through the project. But the previous claims of J&K remained unsettled. In 2017 Govt of J&K has claims worth 8000 crores for the loss against govt of Punjab, on which the Punjab govt has never shown any interest to square them off. It is located upstream of the Madhopur Barrage at Madhopur.[3]


document_title: Planet of the Apes (1968 film)

question_text: where was the original planet of the apes filmed at

text: Planet of the Apes (1968 film)

text: Plot[edit]

text: Astronauts Taylor (Charlton Heston), Landon (Robert Gunner) and Dodge (Jeff Burton) are in deep hibernation when their spaceship crashes in a lake on an unknown planet after a long near-light speed voyage, during which they aged 18 months due to time dilation while their fourth crewmate Stewart died and decayed due to a malfunction. The three survivors abandon ship when it immediately starts sinking, Taylor remaining on long enough to see the date is November 25, 3978, approximately two millennia after their departure in 1972. Once ashore, Dodge performs a soil test and pronounces the soil incapable of sustaining life.

text: After abandoning their raft, the astronauts set off through a desolate wasteland in hopes of finding food and water before their provisions run out. They encounter plant life and go swimming at an oasis at the edge of the desert, ignoring eerie scarecrow-like figures around the edge. While they are swimming, their clothes are stolen. The astronauts pursue the thieves, finding their clothes torn to shreds and their supplies pillaged as the perpetrators, a group of mute primitive humans, raid a cornfield. The primitive humans are then set upon by armed gorillas on horseback who capture some of them while killing the rest, Dodge being killed in the chaos while Landon is rendered unconscious. Talyor is shot in the throat and captured alongside the primitive humans, taken to Ape City where his life is saved after a blood transfusion administered by two chimpanzees: animal psychologist Zira (Kim Hunter) and surgeon Galen (Wright King).

text: While unable to speak as his throat wound is healing, called "Bright Eyes" by Zira and placed with one of the captive primitive humans he later names "Nova", Taylor observes the enhanced society of talking apes and in a strict caste system: the gorillas being the military police, hunters and workers; the orangutans overseeing the affairs of government, science, and religion; and intellectual chimpanzees being mostly scientists. While their society is a theocracy similar to the beginnings of the human Industrial Era, the apes consider the primitive humans as vermin that are hunted, either killed outright, enslaved, or used in scientific experiments.

text: Taylor eventually gets Zira's attention, convincing her of his intelligence as she and her fiancé Cornelius (Roddy McDowall), an archaeologist, take an interest in him. But the couple's orangutan superior Dr. Zaius (Maurice Evans) learns of this and arranges for Taylor to be castrated. But Taylor escapes before the castration can occur, passing through a museum during his desperate flight through Ape City where he finds Dodge's stuffed and eyeless corpse on display. When Taylor is recaptured by gorillas, he overcomes his throat injury while roaring: "Take your stinking paws off me, you damn dirty ape!"

text: A hearing to determine Taylor's origins is convened by the president of the Assembly (James Whitmore), Dr. Zaius, and Maximus (Woodrow Parfrey). Dr. Honorious (James Daly) is the prosecutor. Taylor mentions his two comrades at this time, learning that Landon was subjected to a lobotomy that has rendered him catatonic and unable to speak. After the tribunal, believing Taylor to be of a human tribe from beyond their borders, Zaius privately threatens to castrate and lobotomize Taylor for the truth about where he came from. With help from Zira's socially rebellious nephew Lucius (Lou Wagner), Zira and Cornelius free Taylor and Nova and take them to the Forbidden Zone, a taboo region outside Ape City that has been ruled out of bounds for centuries by Ape Law where Taylor's ship crashed. While Cornelius and Zira are intent to gather proof of an earlier non-simian civilization which the former came upon a year prior to be cleared of heresy, Taylor is more focused on the evolution of the ape world and to prove he is not of that world.

text: Arriving at the cave, Cornelius is intercepted by Zaius and his soldiers, with Taylor holding them off while threatening to shoot if he has to. Zaius agrees to enter the cave to disprove their theories and to avoid physical harm to Cornelius and Zira. Inside, Cornelius displays the remnants of a technologically advanced human society pre-dating simian history. Taylor identifies artifacts such as dentures, eyeglasses, a heart valve and, to the apes' astonishment, a talking children's doll. More soldiers appear and Lucius is overpowered, but Taylor holds Zaius hostage so he can arrange his escape. But Zaius admits to Taylor that he always knew of the ancient human civilization, revealing that "the Forbidden Zone was once a paradise, your breed made a desert of it... ages ago!" Taylor nonetheless thinks it best to search for answers, despite being warned that he may not like what he finds. Once Taylor and Nova have ridden off, Dr. Zaius has the gorillas lay explosives to seal off the cave and destroy the evidence while charging Zira, Cornelius and Lucius with heresy.

text: Taylor and Nova, at last free, follow the shoreline and discover the remains of the Statue of Liberty, revealing that this "alien" planet is actually Earth long after a nuclear war. Realizing what Zaius meant earlier, Taylor falls to his knees in despair and anger while condemning humanity for destroying the world.

text: Cast[edit]

text:
Charlton Heston as George Taylor
Roddy McDowall as Cornelius
Kim Hunter as Zira
Maurice Evans as Dr. Zaius
James Whitmore as President of the Assembly
James Daly as Honorious
Linda Harrison as Nova
Robert Gunner as Landon
Lou Wagner as Lucius
Woodrow Parfrey as Maximus
Jeff Burton as Dodge
Buck Kartalian as Julius
Norman Burton as Hunt Leader
Wright King as Dr. Galen
Paul Lambert as Minister

tag: ul

text: Production[edit]

text: Origins[edit]

text: Producer Arthur P. Jacobs bought the rights for the Pierre Boulle novel before its publication in 1963. Jacobs pitched the production to many studios, but was passed over. After Jacobs made a successful debut as a producer doing 1964's What a Way to Go! (1964) for 20th Century Fox and begun pre-production of another movie for the studio, Doctor Dolittle, he managed to convince Fox vice-president Richard D. Zanuck to greenlight Planet of the Apes.[9]

text: One script that came close to being made was written by The Twilight Zone creator Rod Serling, though it was finally rejected for a number of reasons. A prime concern was cost, as the technologically advanced ape society portrayed by Serling's script would have involved expensive sets, props, and special effects. The previously blacklisted screenwriter Michael Wilson was brought in to rewrite Serling's script and, as suggested by director Franklin J. Schaffner, the ape society was made more primitive as a way of reducing costs. Serling's stylized twist ending was retained, and became one of the most famous movie endings of all time. The exact location and state of decay of the Statue of Liberty changed over several storyboards. One version depicted the statue buried up to its nose in the middle of a jungle while another depicted the statue in pieces.[9]

text: To convince the Fox Studio that a Planet of the Apes film could be made, the producers shot a brief test scene from a Rod Serling draft of the script, using early versions of the ape makeup. Charlton Heston appeared as an early version of Taylor (named Thomas, as he was in the Serling-penned drafts), Edward G. Robinson appeared as Zaius, while two then-unknown Fox contract actors, James Brolin and Linda Harrison, played Cornelius and Zira. This test footage is included on several DVD releases of the film, as well as the documentary Behind the Planet of the Apes. Linda Harrison, at the time the girlfriend of studio chief Richard Zanuck, went on to play Nova in the 1968 film and its first sequel, and had a cameo in Tim Burton's Planet of the Apes more than 30 years later, which was also produced by Zanuck. Although Harrison often opined that the producers had always had her in mind for the role of Nova, they had, in fact, considered first Ursula Andress, then Raquel Welch, and Angelique Pettyjohn. When these three women proved unavailable or uninterested, Zanuck gave the part to Harrison. Dr. Zaius was originally to have been played by Robinson, but he backed out due to the heavy makeup and long sessions required to apply it.[10] Robinson later made his final film, Soylent Green (1973), opposite his one-time Ten Commandments (1956) co-star Heston.

text: Michael Wilson's rewrite kept the basic structure of Serling's screenplay but rewrote all the dialogue and set the script in a more primitive society. According to associate producer Mort Abrahams an additional uncredited writer (his only recollection was that the writer's last name was Kelly) polished the script, rewrote some of the dialogue and included some of the more heavy-handed tongue-in-cheek dialogue ("I never met an ape I didn't like") which wasn't in either Serling or Wilson's drafts. According to Abraham some scenes, such as the one where the judges imitate the "See no evil, speak no evil and hear no evil" monkeys, were improvised on the set by director Franklin J. Schaffner and kept in the final film because of the audience reaction during test screenings prior to release.[11][page needed] During filming John Chambers, who designed prosthetic make up in the film,[6] held training sessions at 20th Century-Fox studios, where he mentored other make-up artists of the film.[12]

text: Filming[edit]

text: Filming began on May 21, 1967, and ended on August 10, 1967. Most of the early scenes of a desert-like terrain were shot in northern Arizona near the Grand Canyon, the Colorado River, Lake Powell,[11]:61 Glen Canyon[11]:61 and other locations near Page, Arizona[11]:59 Most scenes of the ape village, interiors and exteriors, were filmed on the Fox Ranch[11]:68 in Malibu Creek State Park, northwest of Los Angeles, essentially the backlot of 20th Century Fox. The concluding beach scenes were filmed on a stretch of California seacoast between Malibu and Oxnard with cliffs that towered 130 feet above the shore. Reaching the beach on foot was virtually impossible, so cast, crew, film equipment, and even horses had to be lowered in by helicopter.[11]:79 The home movies of Roddy McDowall (on YouTube) show makeup, the Ape Village set and the beach site/set - a wooden ramp was built around the point from Westward Beach to Pirates Cove for access to the beach set. The remains of the Statue of Liberty were shot in a secluded cove on the far eastern end of Westward Beach, between Zuma Beach and Point Dume in Malibu.[13] As noted in the documentary Behind the Planet of the Apes,[9] the special effect shot of the half-buried statue was achieved by seamlessly blending a matte painting with existing cliffs. The shot looking down at Taylor was done from a 70-foot scaffold, angled over a 1/2-scale papier-mache model of the Statue. The actors in Planet of the Apes were so affected by their roles and wardrobe that, when not shooting, they automatically segregated themselves with the species they were portraying.[14]

text: Taylor's spacecraft[edit]

text: The spacecraft onscreen is never actually named in the film. But for the 40th anniversary release of the Blu-ray edition of the film, in the short-film created for the release called A Public Service Announcement from ANSA, the ship is called "Liberty 1".[15] The ship had originally been called "Immigrant One" in an early draft of the script, and then called "Air Force One" in a test set of Topps Collectible cards, and dubbed "Icarus" by a fan; that name gained popularity among Ape fandom.[15][16]

text: Reception[edit]

text: Critical response[edit]

text: Planet of the Apes was well received by critics and is widely regarded as a classic film and one of the best films of 1968, applauded for its imagination and its commentary on a possible world gone upside down.[17][18] As of April 2012, the film held a 90% "Certified Fresh" rating on the review aggregate website Rotten Tomatoes, based on 50 reviews.[19] In 2008, the film was selected by Empire magazine as one of The 500 Greatest Movies of All Time.[20]

text: Accolades[edit]

text: The film won an honorary Academy Award for John Chambers for his outstanding make-up achievement. The film was nominated for Best Costume Design (Morton Haack) and Best Original Score for a Motion Picture (not a Musical) (Jerry Goldsmith).[21] The score is known for its avant-garde compositional techniques, as well as the use of unusual percussion instruments and extended performance techniques, as well as his 12-note music (the violin part using all 12 chromatic notes) to give an eerie, unsettled feel to the planet, mirroring the sense of placelessness.

text:
AFI's 100 Years...100 Movies—Nominated[22]
AFI's 100 Years...100 Thrills—#59
AFI's 100 Years...100 Heroes and Villains:

Colonel George Taylor—Nominated Hero[23]

AFI's 100 Years...100 Movie Quotes:

"Take your stinking paws off me, you damned dirty ape!"—#66

AFI's 100 Years of Film Scores—#18
AFI's 100 Years...100 Movies (10th Anniversary Edition)—Nominated[24]
AFI's 10 Top 10—Nominated Science Fiction Film[25]

text: Legacy[edit]

text: Original series sequels[edit]

text: Writer Rod Serling was brought back to work on an outline for a sequel. Serling's outline was ultimately discarded in favor of a story by associate producer Mort Abrahams and writer Paul Dehn, which became the basis for Beneath the Planet of the Apes.[11][page needed] The original film series had four sequels:

text:
Beneath the Planet of the Apes (1970)
Escape from the Planet of the Apes (1971)
Conquest of the Planet of the Apes (1972)
Battle for the Planet of the Apes (1973)

text: Television series[edit]

text:
Planet of the Apes (1974)
Return to the Planet of the Apes (animated) (1975)

text: Remake[edit]

text: Planet of the Apes (2001): The film was a re-imagining of the original film, directed by Tim Burton.

text: Reboot series[edit]

text:
Rise of the Planet of the Apes (2011): A series reboot, directed by Rupert Wyatt, was released in August 5, 2011 to critical and commercial success. It is the first installment in the new series of films.[8]
Dawn of the Planet of the Apes (2014): The second entry in the Planet of the Apes reboot series, directed by Matt Reeves, was released in July 11, 2014.[26][27]
War for the Planet of the Apes (2017): The third film in the reboot series, directed by Matt Reeves, was released on July 14, 2017.[28][29][30]

text: Comics[edit]

text: Comic book adaptations of the films were published by Gold Key (1970) and Marvel Comics (b/w magazine 1974-77,[31] color comic book 1975-76[32]). Malibu Comics reprinted the Marvel adaptations when they had the license in the early 1980s. Dark Horse Comics published an adaptation for the 2001 Tim Burton film. Currently Boom! Studios has the licensing rights to Planet of the Apes. Their stories tell the tale of Ape City and its inhabitants before Taylor arrived. However, in July 2014, it was announced that Boom! Studios and IDW Publishing will do a crossover between Planet of the Apes and Star Trek the original series.

text: In popular culture[edit]

text: A parody of the film series titled "The Milking of the Planet That Went Ape" was published in Mad Magazine. It was illustrated by Mort Drucker and written by Arnie Kogen in regular issue #157, March 1973.[33]

text: Numerous parodies and references have appeared in films and other media, including Spaceballs, The Simpsons, Futurama, Family Guy, South Park, Jay and Silent Bob Strike Back, Mad Men, The Big Bang Theory and the Madagascar films.[citation needed]

text: The film is also alluded to in literature, most notably in Junot Díaz's Pulitzer-winning novel The Brief Wondrous Life of Oscar Wao (2007).[citation needed]

text: Gallery[edit]

text:
The crash of the astronauts' spacecraft was partially filmed in and around Lake Powell.

Horseshoe Bend on the Colorado River, near Page, Arizona, was a part of the Forbidden Zone, through which Taylor, Zira, and Cornelius fled Ape City.

Malibu Creek State Park, part of which was formerly the 20th Century Fox Movie Ranch, was the location of the astronauts' initial encounter with primitive humans and superior apes, and of Cornelius, Zira and Taylor's escape from Ape City.

The final scene was filmed at Point Dume's Westward Beach on the Malibu coast.

The cliff face of Point Dume is obscured by the matte painting of the Statue of Liberty.


document_title: Hospice care in the United States

question_text: what is the average time in hospice care

text: Hospice care in the United States

text: History and statistics[edit]

text: The first hospices are believed to have originated in the 11th century, when for the first time the terminally ill were permitted into places dedicated to treatment by Crusaders.[1] In the early 14th century, the order of the Knights Hospitaller of St. John of Jerusalem opened the first hospice in Rhodes, meant to provide refuge for travelers and care for the ill and dying.[2] The hospice practice languished until revived in the 17th century in France by the Daughters of Charity of Saint Vincent de Paul and, later, by the Irish Sisters of Charity, who opened St Joseph's Hospice in London, England in 1902.[2] In the 1950s at St. Joseph's, Cicely Saunders developed many of the foundational principles of modern hospice care. She later founded St Christopher's Hospice in London.[2]

text: In 1971, Hospice, Inc. was founded in the United States, the first organization to introduce the principles of modern hospice care to that country, where medical care had focused on fighting illness through hospital stays.[3] Throughout the 1970s, the philosophies of hospice were being implemented throughout the United States. The hospice movement in the United States became distinguished from that in Britain, according to Stephen Connor's Hospice: Practice, Pitfalls and Promise, by "a greater emphasis on use of volunteers and more focus on psychological preparation for death".[4] In 1982 Medicare, a social insurance program in the United States, added hospice services to its coverage.[3] On September 13, 1982, by request of the senate, US President Ronald Reagan proclaimed the week of November 7 through November 14, 1982, as National Hospice Week.[5]

text: Since then, the hospice industry has rapidly expanded. This growth has accompanied the AIDS epidemic and the aging of the population, with related illnesses. By 1995, hospices were a $2.8 billion industry, with $1.9 billion from Medicare alone funding patients in 1,857 hospice programs with Medicare certification.[6] In that year, 72% of hospice providers were non-profit.[6] By 1998, there were 3,200 hospices either in operation or under development throughout the United States and Puerto Rico, according to the National Hospice and Palliative Care Organization (NHPCO).[6] 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.[7] In 2007, 1.4 million people in the United States used hospice, with more than one-third of dying Americans using the service, approximately 39%.[8][9] In 2008, Medicare alone, which pays for 80% of hospice treatment, paid $10 billion to the 4,000 Medicare-certified providers in the United States.[8][10]

text: As the hospice industry has expanded, so, too, has the concept of hospice care. In 2003 the first US children's hospice facility, the George Mark Children's House Hospice, opened in San Francisco.[11] In February 2009, Buffalo News reported that the balance of non-profit and for-profit hospices was shifting, with the latter as "the fastest-growing slice of the industry."[8]

text: Philosophy and practices[edit]

text: The goal of hospice agencies in the United States is to provide comfort to the patient and heighten quality of life.[12] How comfort is defined is up to the patient or, if the patient is incapacitated, the patient's family. This can mean freedom from physical, emotional, spiritual and/or social pain. Hospices typically do not perform treatments that are meant to diagnose or cure an illness,[13] and they do not seek to hasten death or, primarily or unduly, to extend life.[14][15][16][17] While it is generally not required that patients sign "Do not resuscitate" (DNR) orders to be on hospice, some hospices require them as a condition of acceptance.[18][19]

text: Many hospice patients, though not all,[20] have made decisions against receiving CPR should their heart or breathing stop. If a patient does decide to request CPR, that service may not be provided by the hospice; the family may need to contact Emergency Medical Services to provide CPR.[21] The principle of not extending life and withdrawing diagnostic or curative treatments is often the greatest barrier for patients in accepting hospice care. In some cases, medical professionals may feel conflict in attempting to provide it.[22]

text: Some confusion still exists as to what treatments a patient may receive in hospice care. Hospices may provide treatments that have been traditionally regarded as curative, including radiation therapy or antibiotics, if these are administered to improve quality of life.[23][24] Determination of appropriate treatment is made by medical personnel on an individual basis.

text: Another aspect of the hospice philosophy is that the care is patient-centered, to treat the whole patient. Many healthcare agencies in the US market themselves as patient-centered; for hospice, this patient-directed care is integral and interwoven throughout the care which is provided.[25] Related Medicare regulations reflect this philosophy.

text: Hospice demographic[edit]

text: In order to qualify for hospice care, a patient must have certification from two physicians that he or she has less than six months to live if his or her disease runs its natural course; usually the patient's primary physician and the Hospice Medical Director will provide this certification.[26] Patients can and do stay on hospice longer than six months, and as long as the hospice team continues to certify with supporting evidence that the patient is terminal, insurance companies will usually continue to pay for hospice care.[27]

text: Many physicians are slow to refer to hospice care, waiting until they are absolutely certain of a terminal prognosis. Some physicians believe that the patient must have a six-month prognosis or less to receive hospice care, while others are overly optimistic in their assessment of prognosis, presuming treatment will be more effective than it is.[27][28] As a result, the majority of patients are referred to hospice in the very end-stages of their diseases, or choose that time to seek hospice care. The average length of stay in hospice before a patient dies was 26 days in 1994 and 19 days in 1998.[29] Although the length of average stays has since increased, the term of care continues to be underused. In 2004 the average stay was 57 days and the median length was 22 days.[30] 33% of hospice patients admitted in 2004 died within seven days of admission.[31]

text: Such late admission is inconsistent with the process of hospice, which is to alleviate patient distress over a period of time, based on time for patients and family members to develop relationships with the hospice team.[32]

text: Some people believe that only individuals suffering from cancer or AIDS can receive hospice care. Hospice in the United States developed around the model of cancer care, with a relatively predictable pattern of deterioration.[33] According to 2002's The Case Against Assisted Suicide: For the Right to End-of-life Care, "60% of hospice patients have cancer."[34] But, patients can be on hospice for numerous other illnesses, such as end-stage heart and lung diseases, stroke, renal failure, Alzheimers, or many other conditions. Any diagnosis that would be an acceptable cause of death on a death certificate is, if expected to be terminal, an acceptable diagnosis for hospice care.[35]

text: Re-certification[edit]

text: In order to qualify for hospice, a patient has to be certified as having a prognosis of less than six months to live. Sometimes patients live longer. Medicare patients who receive the hospice benefit must waive other Medicare benefits that could prolong life.[36] Under the Medicare provisions, the hospice benefit through the first six months is broken up into two 90-day benefit periods. At the end of these two benefit periods, the hospice team will evaluate whether or not the patient continues to have a prognosis of less than six months to live.[37] Following these two 90-day benefit periods, the hospice is required to evaluate more closely and review the case every 60 days. Commercial insurers, managed care program providers, and Medicaid often have their own regulations regarding re-certification. When the hospice re-certifies a six-month or less prognosis, this is based on the patient's current condition.

text: Pediatric hospice care[edit]

text: Patients in hospice have primarily been elderly; according to the 2006 Handbook of Social Work in Health and Aging, more than 80% of hospice patients in the United States are over 65.[38] But hospice care is available to all age groups, including those under 21. Not all hospices are able to serve every population.

text: In 1983, less than 1% of hospice providers offered pediatric care; by 2001, that number had grown to 15%.[39] The first pediatric hospice facility in the United States, the George Mark Children's House Hospice of San Francisco, opened in 2003. While pediatric hospice options are expanding, as of 2006 many adult-oriented hospice programs remained ill-prepared to handle younger populations.[40]

text: The primary diagnosis for children in hospice treatment is cancer, but, like the adult population, children may enter hospice for a variety of conditions, including AIDS, prematurity, congenital disorder, cerebral palsy, cystic fibrosis, or "death-inducing trauma", such as automobile accidents.[40] Hospice care, which is intended to treat the whole family, may also be made available to families expecting a child who is not anticipated to survive long after delivery.[40]

text: The recommended model of hospice for children differs from that of adults. In 2000, the committees on Bioethics and Hospital Care for the American Academy of Pediatrics jointly released a recommendation that palliative care for children should be provided for any life-threatening condition from the point of diagnosis, whether death is the prognosis or not, as the benefits of palliative care can be offered concurrently with curative treatment.[41] The Virginia-based Children's Hospice International also recommends hospice services for all children with life-threatening conditions, even if seeking "hopeful" treatment, "to enhance the quality of life for the child and family".[42] However, the federal standards set by Medicaid require the six-months terminal prognosis. Insurance providers may restrict access to hospice care to pediatric patients undergoing life-extending treatment.[43]

text: Expense[edit]

text: The cost of hospice care may be met by health insurance providers, including Medicare or Medicaid for eligible Americans. Hospice is covered 100% with no co-pay or deductible by Medicare Part A except that patients are responsible for a copay for outpatient drugs and respite care, if needed.[44] (Respite care may be necessary, for instance, if a family member who is providing home hospice care is briefly unable to perform his or her duties and an alternative care provider becomes necessary.)[44] As of 2008, Medicare was responsible for around 80% of hospice payments, reimbursing providers differently from county to county with a higher rate for inpatient hospice care. A lower rate is paid for home care, with a higher rate paid for round-the-clock nursing care in order to get a patient's symptoms under control.[8][45]

text: Most commercial health insurances and Medicaid have a hospice benefit as well.[46] These typically are similar to the Medicare benefit. There may be a co-pay required by commercial health insurance providers depending on individual plans.[47] According to a 2008 article by Lauren Tara LaCapra on TheStreet.com, Medicare and Medicaid paid 78% of home-based hospice charges in 2008, with 12% being supplied by private insurance providers and 10% "out of pocket", paid by the patient.[48] Most non-profit hospice agencies have contingencies for patients who lack insurance coverage and will provide care to the patient free of charge or at reduced rates.[46] LaCapra said that out-of-pocket expenses for home-based hospice services were $758 a year in 2008 for the average hospice patient.[48]

text: Once a patient is enrolled in hospice, the hospice becomes the insurance payor for that patient for any hospice-related illnesses.[47] In other words, if a patient is on hospice for end-stage congestive heart failure, the hospice is responsible for all care related to the heart failure. However, if the patient were to see a podiatrist, this would be billed through their regular insurance.

text: Providers[edit]

text: Hospice is a competitive business.[49] In any given service area, there may be hundreds of different non-profit and commercial providers.[50] Hospices can be small community-based operations, part of regional and national corporations, or part of a hospital or other health system. Data from the National Hospice and Palliative Care Organization indicated that in 2008 58.3% of hospice agencies were independent, with 20.8% based in hospitals, 19.7% geared for home health care and 1.3% in conjunction with nursing homes.[51] In 2007, the mean number of patients being treated in hospice facilities on any given day was 90.2.[citation needed] 79.4% of hospice providers admitted fewer than 500 patients per year.[52] The number of for-profit and non-profit providers has become more balanced as the for-profit sector has grown. In 2007, 47.1% of agencies were for-profit, with 48.6% non-profit. The remaining 4.3% were government-owned providers.[52]

text: In order to receive payments for hospice patients under Medicare or Medicaid, a hospice must be certified by the Centers for Medicare and Medicaid Services, and in 2007 93.1% were.[53] Among those that were not certified, some were in the process of seeking certification. However, some agencies do not seek certification or voluntarily relinquish it. For one example, an agency that is entirely supported through donations or relies on volunteer staff might not choose to seek certification. The NHPCO estimated in 2008 that at least 200 "all-volunteer" programs were in operation in the United States.[53]

text: Levels of care[edit]

text: There are four primary levels of care; routine home care, continuous care, general inpatient and respite/respite inpatient.[54] All hospices in the United States certified by Medicare are required to offer each of these levels of care.[55]

text: Routine home care[edit]

text: Routine home care is the most common level of care provided.[55] In spite of its title, routine home care does not indicate a location of care, but a level (or intensity) of care provided. Routine care may be provided at a nursing home or assisted living facility,[54] although the majority of hospice patients are treated at home.[14] Interdisciplinary team members supply a variety of services during routine home care, including offering necessary supplies, such as durable medical equipment, medications related to the hospice diagnosis and incidentals like diapers, bed pads, gloves, and skin protectants.[56] Twenty-four-hour on-call services must be available as needed.[57] Typically this is provided after normal business hours by a registered nurse prepared to address urgent patient concerns.[57]

text: Continuous care[edit]

text: Continuous Care is a service provided in the patient's home.[55] It is for patients who are experiencing severe symptoms and need temporary extra support.[55] Once a patient is on continuous care, the hospice provides services in the home a minimum of eight hours a day.[54] Because the criteria for continuous care is similar to general inpatient care, and due to the challenges a hospice can face with staffing extended day care in the home, continuous care is intended to be used for short periods of time.[58]

text: General inpatient care[edit]

text: General inpatient care is an intensive level of care which may be provided in a nursing home, a specially contracted hospice bed or unit in a hospital, or in a free-standing hospice unit.[59] General inpatient criteria is for patients who are experiencing severe symptoms which require daily interventions from the hospice team to manage.[54] Often, patients on this level of care have begun the "active phase" of dying, when their prognosis is measured in days as opposed to weeks or months. Although there is a limit to how long Medicare will cover this level of care, it is usually provided for brief periods of time, with five to seven days being the average.[45]

text: Respite[edit]

text: Respite Care (sometimes referred to as respite inpatient) is a brief and periodic level of care a patient may receive. Respite is a unique benefit in that the care is provided for the needs of the family, not the patient. Should a family member need a "break" from caregiving, or if a vacation is planned, then this level of care may be provided. During respite, the patient is transferred from the home to an institutional setting; this can be a nursing home, assisted living, hospital or an inpatient hospice unit.[55] Should a patient be transferred to an assisted living facility, nursing home, or hospital, the hospice would continue to provide care to the patient which is on par with the services provided under the routine home care benefit. In this way, the only difference between respite and routine care is that the hospice pays the room and board charges of the facility. Should a patient receive respite in an inpatient hospice unit the care would be similar to what other patients of the hospice unit receive. Respite is provided for a maximum of five days every benefit period.[59]

text: Hospice interdisciplinary team[edit]

text: The hospice interdisciplinary team is the core service which every hospice provides to patients and families.[60] Hospice differs from other forms of care in that the core members of the hospice team function as an interdisciplinary, rather than a multidisciplinary, team.[61] Multidisciplinary teams involve several professionals who independently treat various issues a patient may have. The problems that are being treated may or may not relate to other issues being addressed by individual team members. Interdisciplinary team approach involves all members of the team working together towards the same goal, which in this case is to afford patients a comfortable dying experience and families the support they need in coping with this. In an interdisciplinary team approach, there can often be role blending by members of the core team, who may take on tasks usually filled by other team members.[61]

text: The hospice team is required by Medicare to meet every 14 days. During this team meeting, patient needs are discussed and planned for the next two weeks.[62] Additionally, the team reviews the patient's medical condition to ensure that the patient still meets criteria for hospice care.

text: Team members[edit]

text: Team members include hospice medical directors, physicians, pharmacists, registered nurses, social workers, counselors, home health aides, and volunteers.[63]

text:
Hospice Medical Director: The hospice medical director, a physician, often provides the most support to the clinical staff providing care to the patient and family. The medical director may also provide medical care if the primary physician is unavailable or if the patient does not have a primary care provider. The hospice medical director is also required under Medicare to recertify patients.[64]
Physician: Physicians involved in patient care may include the primary physician, who can provide valuable information about patient medical history, and physicians connected to the hospice team. These primarily provide support to other hospice team members, but may also treat the patient directly.[65] The physician subspecialty of Hospice and Palliative Medicine was established in 2006,[66] to provide expertise in the care of patients with life-limiting, advanced disease and catastrophic injury; the relief of distressing symptoms; the coordination of interdisciplinary patient and family-centered care in diverse settings; the use of specialized care systems including hospice; the management of the imminently dying patient; and legal and ethical decision making in end-of-life care.[67]
Registered Nurses: Registered nurses are responsible for coordinating all aspects of the patient's care and insuring symptoms (physical or otherwise) are being addressed and managed. The primary care nurse visits a minimum of twice weekly, and the content of the visit can vary greatly. When patients are experiencing few symptoms and/or are early in their diseases, the RN visit may just be a short check up. If a patient's symptoms worsen, the nurse will visit more often, make recommendations for increasing or changing the medication intervention and provide support and education regarding the disease/dying process. Many patients on hospice may require complex treatments: respiratory care, wound care or even IV therapy at home. In most cases, the hospice nurse is trained to handle these unique needs as well.[68]
Social Worker: Every patient is assigned a social worker who visits at the time of admission to hospice. The social worker function can vary from providing superficial support to patients and families to intensive crisis-oriented counseling. Additionally, with a terminal illness often comes more complicated financial stressors; the social worker can be instrumental in connecting the patient and family with community resources including services such as Meals on Wheels.[69] Lastly, if a patient is unable to be cared for at home, the social worker will work to find a safer place for the patient to receive hospice care.[70]
Counselor: Counselors are required as part of the core team by Medicare regulations. Typically, the role is filled by a Chaplain or Spiritual Counselor, but social workers or other persons, sometimes specially trained, may also serve.[71] While not every patient will see a Chaplain on hospice, all hospices have to be able to provide regular and consistent Chaplain services. The Chaplain is available to provide spiritually supportive counseling, life review and may connect a patient with clergy they are comfortable with. At times the hospice Chaplain will officiate at a patient's funeral.[72]
Home Health Aide: The home health, or hospice, aide is not a core service for a hospice patient; this means it is not required that every patient on hospice receive an aide. However, most patients do receive this service, and it is often the one most depended on by the patient and family. The hospice aide typically visits anywhere from 3–7 days a week for approximately 1–2 hours at each visit. His or her functions include providing respite to the primary caregiver and physical support to the patient, including bathing, dressing, or feeding. Many times it is the hospice aide who develops the closest relationship with the patient, due to the frequency of visits. The hospice aide is not a licensed nurse and therefore can not administer medications, treat wounds, handle IV's or similar treatments.[73]
Pharmacist: Pharmacists oversee the patient's drug therapy, which includes filling prescriptions, monitoring for drug interactions and adverse effects, anticipating problems, and assessing the appropriateness of drug therapies in the context of patient-oriented goals.[74][75]
Volunteers: Volunteers form a major part of hospice care in the United States and may provide a variety of physical or emotional comforts to patients and family, including providing housework, health care, spiritual counseling and companionship. Hospice volunteers also provide administrative assistance to hospices.[76]

text: Discharge from hospice[edit]

text: The majority of discharges from hospice are due to the death of the patient, although hospice treatment may not end then as care also provides for a period of bereavement counseling for the family afterward.[77] However, there are several other scenarios when a patient may be discharged from hospice.

text: De-certification:

text: If it is determined at the time of review that a patient's prognosis may be greater than six months, the patient is de-certified (discharged) from hospice.[78] The hospice is required by law to give advance notification to the patient, and the patient can appeal the hospice's decision to Medicare.[79] Usually the hospice plans these discharges weeks in advance to make the transition off hospice, which can be traumatic for patients who have been preparing to die, as smooth as possible. Should the patient's condition worsen once discharged from hospice they can be readmitted to hospice.

text: Revocation:

text: A patient may be discharged by revocation if he or she chooses to relinquish the hospice benefit.[80] Revocation could be due to hospitalization, if the patient chooses to pursue some type of curative treatment or experiences dissatisfaction with hospice care. However, not all hospitalizations of patients require revocation; should the admitting diagnosis to the hospital be unrelated to the condition for which they are in hospice, the patient may remain on hospice while undergoing treatment for it.

text: Transfer of hospice:

text: Transfer of hospice does not involve a discharge from hospice in general, but a discharge from the current hospice provider to another one.[81]

text: Discharge for cause:

text: Occasionally a hospice will be unable to provide care to a patient, either due to philosophical differences with the patient or due to a safety issue. Such causes could include disruptive or abusive behavior from the patient or other persons in the patient's home or refusal to cooperate with the hospice program.[82] Patients may, after being discharged from hospice for any reason, re-enroll in hospice at a later date as necessary.

text: Barriers to Access[edit]

text: As indicated, hospice is frequently under-utilized and often not taken advantage of until very late in a patient's illness. The reasons for this have as much to do with financial considerations as with the psycho-social difficulty in choosing hospice. A 2009 study found that with proper case management hospice access could be liberalized without additional costs to insurers.[83]

text: Reimbursement[edit]

text:
Physicians: There are multiple aspects as to why, financially, hospice care may be difficult to access. The first would relate to physician reluctance. As stated previously, when enrolled in hospice, the patient transitions from their primary insurance to having most of their care managed directly by the hospice. As hospices typically have a limited budget, expensive care may not be permitted by the hospice.[84] Additionally, reimbursement for physician visits can be complicated and result in non-payment to physicians.[85][86] Therefore, difficulty in authorizing expensive treatments and lack of payment for visits can be reasons for non-referral from a physician.
Nursing Homes: A second aspect to reimbursement pertains to the nursing home. In many cases, patients who are transferred to a nursing home from a hospital will have a portion of their nursing home stay reimbursed by Medicare. In these cases, Medicare is paying for some kind of rehabilitative care. Medicare will not reimburse any room and board coverage in the nursing home for patients on hospice. Occasionally, patients who would be better served receiving hospice care will be "rehabilitated" in the nursing home so as to defray the costs of the room and board.[87]
Hospices: While late referral to hospice is a much more prevalent problem than early referral, some hospice providers will hesitate to admit patients to hospice (or they may de-certify them from hospice too early) due to scrutiny from Medicare for patients deemed to be on hospice too long. After a patient has been on hospice for six months, Medicare is more aggressive in auditing the hospice for inappropriate payment of services. For some hospices this is simply not worth the trouble, and patients are screened very carefully prior to admission.[88]

text: Stigma[edit]

text:
Physicians: Medical care is traditionally focused on curing and healing the patient. For many, hospice care is not seen as the true practice of medicine.[8] Physicians face a persistent social stigma in that hospice is mistaken as giving up on a patient, rather than committing to palliation.[89] Additionally, and although this perception has been changing, when thinking of hospice the doctor is often focused on patients with cancer and not many of the other terminal diseases which qualify for hospice care.
Patients: Many patients and families simply do not want to receive hospice care. The most common reason is an unwillingness to recognize when comfort rather than cure is a more realistic goal. When hospice is framed as care for when "there is nothing left to do" instead of a different kind of treatment, patients may believe that choosing hospice is the equivalent of doing nothing.[90][91]