Having the hospice conversation: How to talk to patients about hospice

As a physician, it is your responsibility to ensure patients get the care they want and deserve. This includes knowing when it might be time to start conversations about end-of-life care and how exactly to talk to patients about hospice.

There are many different views about hospice care and someone’s previous experience or cultural background may dictate how they feel. However, the public’s general opinion on end-of-life care could surprise you.

The public’s view on hospice and end-of-life care

End-of-life care is a hard subject to discuss among families and even health care professionals. That’s why studies on public perception, such as this KFF study about end-of-life medical care in the U.S., are important to know and understand. That way, if a patient has reservations or misunderstandings about their choices for end-of-life care, you could help clarify and get them the care they wish for.

According to KFF, 71% of the public believes that end-of-life care should prioritize pain and discomfort relief over prolonging life as long as possible. Knowing this, you will be able to highlight hospice or palliative care as a preferred option over exhaustive curative treatments, if the patient’s view aligns with the public’s.

And while 70% of Americans know at least a little about hospice, their opinion is overwhelmingly positive, according to KFF. American patients and their loved ones have a good starting point for their views about hospice, yet they want to know more. This fact may allow for an easier way to open up the conversation and begin educating.

According to KFF, an overwhelming 71% of Americans would prefer to die in their home. This may help patients understand why hospice could be a good option for them, as hospice care is provided wherever the patient calls home.

And lastly, 88% of the public feels that physicians should be completely honest about their prognosis and chance of recovery, even if the chance is low, according to KFF. This showcases the importance of starting the hospice conversation when the time is right in a patient’s health care journey.

How to know when patients are ready for the hospice conversation

In addition to a terminal illness diagnosis, there are different signs and symptoms that a patient may be ready for hospice care.

Ask yourself, do you have a patient with a terminal illness that has any of the following indicators?

• Functional decline
• Extreme weight loss
• Multiple comorbidities
• Decreasing serum albumin
• Increased infections
• Increased hospitalizations
• Dependence in most activities of daily living (ADL)
• Karnofsky Performance Status or Palliative Performance Scale of less than 50%

Additionally, if a patient has lost hope about treatment or is seeing no improvements, it may be time to consider their values and what matters most to them in their care.

How to talk to your patients about hospice: Determine values and preferred care first

Hospice is reserved for people with a terminal illness and a prognosis of six months or less. However, many patients and their loved ones feel they learned about hospice too late. It is appropriate to start the hospice conversation with any patient diagnosed with a terminal illness and a life expectancy of 6-12 more months.

When speaking to patients with a terminal illness, it is important to understand what matters most to them. Ask questions about their values and what type of care they prefer. This builds the foundation to approach the hospice conversation.

Question examples include:

• Do you want potentially heroic interventions at the end of life? Which ones?
• How do you feel about ventilators or other methods of keeping you alive?
• How do you feel about CPR?
• When near the end, do you want to be at a hospital, a nursing facility or at home?
• Is there anything else that really matters to you that you want me to know?

Having the hospice conversation

If you’ve determined hospice care aligns with your patient’s values and preferred care, it may be time to have the hospice conversation. To help facilitate, the Journal of General Internal Medicine created four steps to having the hospice conversation.

Step 1: Initiate the discussion and appoint a decision maker.

This is the time to gather general thoughts that the patient and their loved ones have about hospice and clarify any misconceptions such as hospice is only for the last few days of life or hospice means giving up hope. Make sure their knowledge about hospice care is current and accurate so that they can consider it as an option.

Be sure to discuss who the decision maker is, if different from the patient, and create an atmosphere of trust and support.

Step 2: Clarify the patient’s prognosis

Remember that the majority of patients want their physicians to be completely honest about their prognosis. Be truthful about the outlook of a patient’s disease.

The best way to achieve this is to use direct, simple language. When receiving heavy information, patients and their loved ones may not be able to process complicated concepts and medical terms.

Step 3: Identify the patient and family’s end-of-life goals

Bring up previously discussed values and preferences and determine the goals of care. Commonly held goals among patients with a terminal illness include: maximizing time with family and friends, avoiding hospitalization, maintaining functionality and minimizing pain.

Step 4: Develop a treatment plan

After laying out the facts and misconceptions about hospice, guide what options are best for your patient and their family. Make sure the patient’s health and needs are a priority. Clarify any important directives and documentation and explain the Medicare hospice benefit, if necessary.

If hospice is the best option, outline what can be expected and the next steps such as connecting the patient and loved ones to their chosen hospice provider.

It’s important to remember to be gentle and understanding. Each person has different views, religious backgrounds and values that may influence their decision. As with most decisions, remind patients that choosing hospice doesn’t have to be a permanent decision; they can always choose to stop hospice and resume curative treatment if they feel the need.

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At Enhabit Home Health & Hospice, our referral process is as streamlined as possible, allowing physicians to refer patients quickly and easily, providing them with a smooth transition of care. If you have a patient in your care who is showing signs they could benefit from hospice care, learn how to refer them to Enhabit today.