In 1990 the World Health Organization adopted the following definition of palliative care: "it is the active, total care of patients whose disease is not responding to curative treatments." The goal is achievement of the best possible quality of life for patients and their families by providing relief from pain and other distressing symptoms, while integrating the psychosocial and spiritual aspects that influence patient care outcomes. With the inclusion of hospice services, palliative medicine greatly enhances the opportunity for successful end-of-life care for patients and their families.

As a hospice referral is deemed appropriate, framing the referral is an important component of acceptance. In the Education for Physicians on End-of-Life Care Project (EPEC), supported by the American Medical Association (AMA) and the Robert Wood Johnson Foundation, "Module 2: Communicating Bad News," a 6 step protocol was given that can be used to introduce the hospice discussion.

Step 1: Getting Started
Establish an environment conducive to interruption free communication. Include key family members, friends, or health care providers that the patient chooses.

Step 2: Finding Out What the Patient Knows
Questions such as "what do you understand about your illness? and "how would you describe your medical situation?" are good door openers. Frequently, such questions offer insight and lead the discussion.

Step 3: Finding Out How Much the Patient Wants to Know
Individuals absorb information differently. "Would you like to know the full detail of your medical condition? or "do you need clarification of test results or treatment?" offer a gage to the information needs of the individual(s).

Steps 1 - 3 ideally occur in advance of a discussion of hospice. Compassionate communication facilitates the anticipatory grief associated with impending role and functional status changes.

Step 4: Sharing Information
Present the information in sensitive language easily understood by your audience. Use of euphemisms or other avoidance terms frequently diminishes the gravity of the circumstances.

Step 5: Responding to Feelings
Individuals demonstrate a myriad of responses to "bad" news. End-of-life concern is emotionally driven by multiple losses for all people involved. While patients and their attendant families resist discussion, the physician has enormous opportunities to impact the outcome by acknowledging the emotions and gently guiding the process with questions like "I wish the news were different" or "what worries you the most?"

Step 6: Planning and Follow-Up
Identify a plan for the next step. People frequently require time to integrate information. Introduce hospice as a life- and quality- affirming opportunity to surround patients and families as circumstances change.

Hospice eligibility, as defined by the Center for Medicare and Medicaid Services (CMS), asserts a six month or less prognosis. However, CMS recognizes the challenges associated with prognostication, and as a result hospices routinely assess eligibility. By properly communicating the benefits of palliative or hospice care, we, as providers, can do our part to improve end-of-life care and ultimately improve the quality of care for the patients and their families.

Written by: Angus Baker, MD
November 2002

Dr. Baker is a hematologist/oncologist with CareAlliance Health Services in Charleston, South Carolina and medical director of Hospice of Charleston.