When one considers all the challenges hospice workers face, late referral might not come to mind. But according to Birmingham’s Brannon Wiltse, with Community Hospices of America, late referral is one of the biggest hospice challenges because, in this situation, patients are received when it is too late to help them. Wiltse said too often patients are referred to hospice when they have only 72 hours or less to live. That means some of the industry’s most important services are of little use to them or their families. “I think an emphasis on early referral is a good one,” said David Stone, executive director of the Alabama Hospice Organization, discussing suggested ways physicians can help their hospice partners. That’s because in addition to easing pain and discomfort, hospice is also designed to deal with all end-of-life issues, including financial, spiritual and relational. Social workers and chaplains visit families to help with funeral plans and financial concerns. Patients are encouraged to share their wishes with a facilitator to smooth transitions and allow plans to be made in an environment with fewer stressors. Although Wiltse said more physicians are educated on this relatively new service, others are either unaware of the breadth of services or continue in efforts to prolong life, grieving with their patients over a lack of cure. “It’s okay to let us come in,” Wiltse tells physician clients. “It’s not a failure.” Wiltse refers physicians to an end-stage referral criteria checklist for diseases ranging from cancer to dementia. Hospice programs thoroughly assess patients to ensure they meet admission standards. Stone emphasized that hospice is designed for the terminally ill, not the chronically ill. He said to separate the two, physicians might ask themselves what change in health status has brought the patient to the terminal point. For patients with chronic conditions, “That boundary line might be a little less clear cut,” Stone said. “It is a tightrope.” The tightrope will become more familiar as baby boomers age, said Melanie Hill, of Wiregrass Hospice, a Birmingham-area provider. She said an estimated 20 to 25 percent of Medicare dollars are projected to be spent in the next 10 to 15 years on hospice care, representing only a fraction of what would be spent in a hospital setting. Hospice allows the family to bond with the hospice workers in their home environment, though inpatient hospice units in nursing homes and hospitals are an emerging trend. Hill said about half of their referrals do not understand the role of hospice. Some think they are being referred to a home health agency. That’s why education of both medical professionals and patients is so important. “Medical students are now being taught about hospice alternatives,” Hill said. Physicians can also invite hospice agencies to make presentations to their staff about how to introduce the hospice option, helping everyone from family to medical workers through the denial stage. All hospice personnel emphasize that physicians do not lose contact or control over their patient’s care with the referral. “They can be as involved as they want to be. They don’t lose their patients,” Hill said. Stone said that the hospice alternative should never come as a surprise to a patient. He suggests that physicians with senior populations raise concerns to each patient when they are in relatively good health, asking “Have you thought about end-of-life issues? Have you talked with your family about what you would like to have in the end? Have you named a healthcare proxy?” These kinds of questions should be asked routinely and often, Stone said, emphasizing to the senior that they can have a part in planning for the end of life. “The reality is that we’re all going to die, most likely of some chronic condition,” Stone said. When a patient is diagnosed with a disease like chronic obstructive pulmonary disease (COPD), they should be briefed on the fact that a day will come when medications may become less effective. “What happens then? What kind of care would you like to receive then? Do you see yourself dying in a hospital setting, or in a nursing facility, or at home?” These “deep and meaningful conversations,” Stone said, are necessary so that it becomes easier for the physician to say, “We’ve been talking about this all along, and you’re probably now entering that stage.” Hospice advocates say this philosophy returns some control to patients about their end-of-life choices, preparing them emotionally and spiritually for the future. Hospice, like other referrals, Stone said, should “never come as a shock” and should come early enough to provide all the best services to the terminal patient. September 2007