One Question our team at Halcyon Hospice hears almost every day from patients and families is, “Why didn’t we know about hospice sooner?” It’s a great question. One answer is that primary care physicians (PCPs) are often the gatekeepers to hospice referrals because Medicare requires a physician to certify that a patient needing hospice has a prognosis of 6 months or less. As a result, many PCPs are reluctant to refer to hospice.
At the same time, physicians will usually say that they believe hospice helps improve the quality of life for those with a life-limiting diagnosis. So why are they so reluctant to refer to hospice? Dr. Christopher Watts says, “There is a general reluctance among PCPs to make that leap to the resolution to take end-of-life measures and use that support that is there. They just don’t want to accept that their patient will die.” According to Myra Christopher, a bioethicist, “Most [people] avoid doing things that they don’t do well. Most of our doctors in practice have now been socialized that death is a failure.”
The most commonly cited issues primary care physicians struggle with before making a referral to hospice include:
Most physicians believe their job is to “cure” every patient and some think that referring to hospice may cause the patient to lose hope or give up and hasten death. However, studies show that hospice actually extends life by 29 days compared to more aggressive treatments. False hope is offered when aggressive treatments that aren’t working are continued and increase pain and suffering. Hospice provides real hope to patients and their families by providing pain and symptom management as well as emotional and spiritual support to minimize suffering at the end-of-life.
Primary care physicians often treat several members of the same family and have a long-term relationship with each of them. Talking about their death or the death of their loved one may make the physician uncomfortable. Judging the timing of having the conversation about end-of-life wishes can be difficult for physicians given the delicate inferences of these conversations.
Physicians may believe some of the many misconceptions that are out there about hospice. The most common myth is that the physician will have to give up their patient and that hospice will withhold services from their patient. In fact, most hospice providers actually encourage the primary care physician to remain involved with their patient. Physicians are still in charge of the patient’s care plan should they choose to be. The quality and goals of treatment won’t change. And the myth about giving up services usually stems from how well hospice manages pain and symptoms. That leads to lower hospitalization rates and lower utilization of health care resources.
Some physicians are uncomfortable with the idea that they will be called on to make decisions that are outside their area of expertise. While there is more support and training available to physicians regarding hospice care these days, according to Dr. Binu George, Pulmonologist, “[physicians] are not equipped to deal with it because in a primary care setting, end of life issues aren’t encountered as much as they are in the acute care setting.” For instance, some PCPs don’t realize that hospice doctors can help by making recommendations on pain medications.
For expert advice on how to counsel patients on hospice, download End-of-Life: The Most Difficult of Conversations from PhysiciansPractice.com written by Charlotte Huff.
Why do you think primary care physicians are reluctant to refer patients to hospice? Please join the conversation by commenting below. We would love to hear your insights.