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20 March 2007 | Volume 146 Issue 6 | Pages 443-449
Hospice programs offer unique benefits for patients who are near the end of life and their families, and growing evidence indicates that hospice can provide high-quality care. Despite these benefits, many patients do not enroll in hospice, and those who enroll generally do so very late in the course of their illness. Some barriers to hospice referral arise from the requirements of hospice eligibility, which will be difficult to eliminate without major changes to hospice organization and financing. However, the challenges of discussing hospice create other barriers that are more easily remedied. The biggest communication barrier is that physicians are often unsure of how to talk with patients clearly and directly about their poor prognosis and limited treatment options (both requirements of hospice referral) without depriving them of hope. This article describes a structured strategy for discussing hospice, based on techniques of effective communication that physicians use in other "bad news" situations. This strategy can make hospice discussions both more compassionate and more effective.
Author and Article Information
From the Center for Health Equity Research and Promotion at the Philadelphia Veterans Affairs Medical Center and the University of Pennsylvania, Philadelphia, Pennsylvania, and the Center for Ethics, Humanities, and Palliative Care, University of Rochester Medical Center, Rochester, New York.
Acknowledgments: The authors thank Gretchen Brown, True Ryndes, and Drs. Barry Kinzbrunner and Perry Fine for their comments and suggestions.
Grant Support: Dr. Casarett is the recipient of an Advanced Research Career Development Award from the Department of Veterans Affairs, a Paul Beeson Faculty Scholars Award in Aging Research, and a Presidential Early Career Award for Scientists and Engineers.
Potential Financial Conflicts of Interest: Grants received: D.J. Casarett, T.E. Quill (Aetna Foundation); Other: D.J. Casarett is the Director of Research for Penn Home Care and Hospice Services, University of Pennsylvania Health System, Philadelphia, Pennsylvania, and T.E. Quill is the Director of the Center for Ethics, Humanities and Palliative Care at the University of Rochester Medical Center, Rochester, New York.
Requests for Single Reprints: David Casarett, MD, MA, 3615 Chestnut Street, Philadelphia, PA 19104; e-mail, casarett{at}mail.med.upenn.edu.
Current Author Addresses: Dr. Casarett: 3615 Chestnut Street, Philadelphia, PA 19104.
Dr. Quill: University of Rochester School of Medicine, PO Box 601, 601 Elmwood Ave, Rochester, NY 14642. ACADEMIA AND CLINIC
"I'm Not Ready for Hospice": Strategies for Timely and Effective Hospice Discussions
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  S. E. Harrington and T. J. Smith The Role of Chemotherapy at the End of Life: "When Is Enough, Enough?" JAMA, June 11, 2008; 299(22): 2667 - 2678. [Abstract] [Full Text] [PDF]
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 M. J. Germain, L. M. Cohen, and A. H. Moss Strategies for Timely and Effective Hospice Discussions: End-Stage Renal Disease Ann Intern Med, December 4, 2007; 147(11): 816 - 816. [Full Text] [PDF]
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