Steps for Initiating the Hospice Conversation
(A structured discussion framework inspired by the work of Dr. David Casarett)

1. Establish the medical facts. To avoid mixed messages from medical professionals, coordinate with other care providers to gain consensus about the hospice choice.

2. Set the stage. Choose a comfortable time and setting for an uninterrupted conversation. It is optimal if key decision makers in the family are present.

3. Assess understanding of the prognosis. Begin by asking the patient about his/her understanding of the disease, its severity and what the likely outcome is to be. This is a time to observe any misunderstandings or denial on the part of the patient or family.

4.Help the patient define goals for the foreseeable future. These goals can determine if the focus is curative or palliative. Also ask about the patient’s hopes and fears. Even nonmedical goals, such as seeing a sibling one last time, can provide hope even in the face of an incurable condition. Similarly, ask what the patient/family hopes to avoid (e.g., uncontrolled pain, dying in the hospital). 

5.Reframe those goals, as needed, to align with the realities of the prognosis. Start the process with compassion by using “wish statements” (e.g., “I wish I could say that we will be able to …, but what we can do is …”). Having this conversation sooner rather than later will help the family regroup and come up with achievable goals. It is easier to let go of curative care if there are other hopes to focus on.

6.Identify care/service needs. To help avoid the impression that hospice means giving up or imminent death, first identify the patient’s symptoms in need of palliation (pain, constipation, anxiety, etc). Next, look at the daily realities of living with a serious condition and identify areas where assistance might be needed, such as emotional support, grooming and bathing needs, etc.

7.Introduce hospice as a service that supports goals and addresses care needs. Once the palliative needs and desired services are identified, hospice can be introduced as a program that is free, or very low cost, and designed specifically to address the patient/family’s care and service needs.

8.Respond to emotions and concerns. This is a key step before eventually making the official recommendation of hospice. Asking about any past experience or concerns related to hospice care offers an opportunity to dispel myths and reassert the physician’s continued participation in care.

9.Make a hospice referral. An initial enrollment visit can be scheduled, or an “information only” visit.