Home health clinicians may sometimes act as hospice clinicians. Likewise, hospice clinicians usually provide care in home settings. After all, in 2009, about 42% of deaths in the United States occurred while the dying person was receiving hospice services, and 69% of these hospice patients died in their place of residence (National Hospice and Palliative Care Organization, 2010). Thus, with this issue of Home Healthcare Nurse we begin to visit some of the issues of delivering hospice and palliative care at home.

By definition, palliative care is about assessing and treating the various problems associated with a life-threatening illness so as to alleviate the suffering of the patient and family (World Health Organization, 2011). The actual delivery of this care is often provided by hospices, charities, or for-profit healthcare institutions that value holistic and interdisciplinary caregiving. Because palliative care philosophically respects the integral role of the family in providing care and patients' preferences for place of care (and often place of death) as being at home, hospice care often includes home as the setting for that care.

This philosophy of care also appears to produce impressive outcomes. Research findings are beginning to suggest that hospice and palliative care may not just do a good job of ameliorating distressing symptoms, it also saves dollars, extends life, and improves satisfaction with care (e.g., Lin, et al., 2009; Taylor et al., 2007; Temel et al., 2010).

Since modern hospice thinking originated in the United Kingdom in the late 1960s, the United Kingdom has continued to lead the world in endeavors to stretch hospice around the globe. The International Observatory on End of Life Care (IOELC), a leading palliative care research unit in the United Kingdom, began by evaluating the quality of hospice and palliative care around the world. Of all the existent nations, 35, including the United States, were categorized as "approaching integration"-the top ranking showing care that reflects a national policy, education, research, and range of providers and services supporting end-of-life care. Eighty countries were categorized as offering localized provision, whereas 41 countries were viewed as "capacity building," and 78 had no known palliative care efforts (Clark & Wright, 2007). This global view of efforts to provide the dying and their loved ones with palliation for physical, emotional, and spiritual pain indicates that while first world countries are making strides toward providing quality care for the dying, there is much work left-especially in third world countries.

I confess that when I moved to Aotearoa New Zealand 3 years ago, I had a wee bit of an ignorant and arrogant American attitude. I assumed when I began working at a Kiwi hospice that I was entering a less informed and less competent hospice work force. My experience, however, has verified what systematic study has documented: The United States does not provide the best quality of healthcare at the end of life. According to a 2010 report by the Economist Intelligence Unit that used numerous qualitative and quantitative indicators to rank the "quality of death" across 40 OECD countries, the United States and Canada tied for ninth place. (Indeed, New Zealand ranked third-after the United Kingdom and Australia.) As I now prepare to return to my U.S. homeland, it is with strong appreciation for the clever, resourceful alternative approaches to palliative care that clinicians around the globe are using to holistically ease suffering.

Thus, I encourage you not only to read this issue's articles on hospice and palliative care (including one by a group of Australians), but also to look for additional international contributions from hospice professionals to come in near future HHN issues. Contributions to this issue inform us about topics and concerns we must address in home health: How is it that the number of certified and mostly for-profit hospices in the United States nearly doubled between 2001 and 2008? VNAA President and CEO Andy Carter explains and identifies measures that can prevent the MediCare fraud and abuse that may accompany this exponential growth. The column Research Briefs includes findings that indicate family members giving care for dying loved ones at home often cannot participate in external educational interventions, yet are often identified by oncology nurses as "obstacles" to providing end-of-life care. The work of Rawlings and colleagues describes a very successful national system for monitoring and assisting palliative care services in Australia to improve quality. Evdokimoff sheds further light on care transitions-a major transition involving the acceptance of palliative care and/or transitioning to hospice care.

I trust that your reading of this HHN issue will not only encourage you to reflect on the palliative care you give, but also help you to consider the issues from the larger, global perspective. Not only can American clinicians aid and teach those in other countries about how to deliver home health and hospice care, but they will do well if they also learn from those of other cultures and countries about how to deliver palliative care.

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