Initiating the Hospice Talk

Before you begin the conversation about hospice or palliative care, several practical details should be carefully considered:

  1. Make time.These conversations should not be rushed.
  2. Make space.Choose a private, quiet place where everyone can be seated.
  3. Turn off your cell phone and pager. Remove any items from the room that might cause a distraction or interruption.
  4. The conversation itself deserves ample forethought. Spend a few minutes imagining how it might unfold. Plan to spend as much time listening as you do talking. You may want to follow an outline like this one:
  5. Find out what the patient knows.Start the conversation by finding out what the patient and family understand about the diagnosis. You could ask, “What is your understanding of your condition?” or “What have you been told about your disease by the other doctors you’ve seen?”
  6. Listen carefully to the patient’s response.If there is a big disparity between what the patient feels his or her prognosis is and what you think it is, the conversation is going to take some time. Speak slowly and clearly, and be sensitive to older patients’ hearing challenges.
  7. Discover the patient’s goals.This is the key to good palliative care, and it requires strong listening skills. Once you know the patient’s goals, there may be numerous ways of helping the patient meet them. If the goals are for palliation, then additional help from a hospice organization can be extremely valuable. It is best to determine the patient’s goals first and then match his or her goals with what hospice can offer, rather than listing what a hospice can do and trying to make the patient’s goals fit into the hospice model.
  8. Identify care/service needs, for the patient and family members. Because many people erroneously associate hospice with “giving up” or imminent death, acceptance of the service can be facilitated by first identifying the patient’s symptoms in need of palliation (pain, constipation, fatigue, sadness, anxiety). Next, looking more at the day-to-day realities of living with a serious condition, identify assistance needs such as weekly home visits to address changing symptoms, emotional or spiritual support, a home health aide to bathe and groom the patient, advice concerning financial or other community programs the patient or family may be eligible for, etc.
  9. Respond to emotions and concerns. Acknowledging feelings and addressing concerns is paramount before eventually making the official recommendation of hospice. Asking about any past experience or concerns about hospice offers an opportunity to dispel myths and reassert the physician’s continued participation in care.
  10. Make a hospice referral. An initial enrollment visit can be scheduled, or an “information only” visit.