Barriers to hospice care: family physicians' perceptions

Physician factors associated with outpatient palliative care referral

Outpatient palliative care can provide significant benefits to seriously ill patients, but several barriers to appropriate referrals remain. No study has examined the physician factors associated with referral to outpatient palliative care. To determine physician factors, with a focus on physician beliefs, associated with referral to palliative care. Cross-sectional study of 170 primary care physicians at Kaiser Permanente (KP), a large non-profit Health Maintenance Organisation (HMO), using a self-administered questionnaire. Of the 145 respondents, 100 (70%) reported referring any patients to the palliative care program in the prior year, with a median of 3 referrals (interquartile range 2, 6). Factors associated with referral included working at KP between 10 and 20 years as compared to <10 years [Odds ratio [OR] 6.29 (95% confidence interval [CI] 1.38, 28.6)] and having personal experience with palliative care [OR 2.13 (95% CI 0.95, 4.976)]. None of the beliefs scales was associated with referral. Physician characteristics other than their beliefs about palliative care played a significant role in determining referral. Palliative care programs should aim to increase their visibility in the outpatient setting to increase referrals by primary care physicians. Tools that help physicians identify seriously ill patients who could benefit from palliative care may also serve to increase appropriate referrals.

Understanding their options: determinants of hospice discussion for older persons with advanced illness

BACKGROUND

Clinicians' discussions about hospice with patients and families are important as a means of communicating end-of-life options.

OBJECTIVE

To identify determinants of clinicians' hospice discussions and the impact of such discussions on hospice use.

DESIGN

We interviewed 215 patients age > or = 60 years with advanced cancer, chronic obstructive pulmonary disease (COPD), or heart failure (HF) at least every 4 months for up to 2 years. Participants provided information about their health status and treatment preferences. Clinicians completed a questionnaire every 6 months about their estimates of patient life expectancy and their communication with the patient and family about hospice.

RESULTS

In their final survey, clinicians reported discussing hospice with 46% of patients with cancer, compared to 10% with COPD and 7% with HF. Apart from diagnosis of cancer, the factors most strongly associated with hospice discussion were clinicians' estimate of and certainty about patient life expectancy (P < 0.001). However, clinicians were unable to anticipate the deaths of a considerable portion of patients (40%). Although patient unwillingness to undergo minor medical interventions was associated with hospice discussion (P < 0.05), a sizeable portion of clinicians (40%) whose patients reported this characteristic did not have the discussion. Clinicians' discussion of hospice independently increased the likelihood of hospice use (OR = 5.3, 95% CI = 2.3-13).

CONCLUSIONS

Clinicians' discussion of hospice for patients with advanced illness, and, ultimately, patients' use of hospice, relies largely on clinician estimates of patient life expectancy and the predictability of disease course. Many clinicians whose patients might benefit from learning about hospice are not having these discussions.