Curbside Consultation

The Hospice Referral



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Am Fam Physician. 2014 May 1;89(9):745-747.

  Related article: Diagnosis and Management of Pancreatic Cancer

Case Scenario

A 70-year-old patient was recently diagnosed with metastatic pancreatic cancer. We determined that hospice care is an appropriate treatment option. What are some tips for discussing hospice with him?

Commentary

Hospice is a program of care and support for persons facing life-limiting illnesses. Hospice care involves a team-oriented approach to medical care, pain management, and emotional and spiritual support expressly tailored to the patient's needs and wishes.1 Most caregivers and families of patients who have received hospice care report that they would have welcomed more information about hospice from their primary care physician at the time the diagnosis was labeled terminal.2 One significant barrier to hospice referral is physician discomfort in communicating a terminal diagnosis and prognosis.2

Although discussing hospice can be more complex than delivering bad news, the tools developed for communicating serious news can be adapted to aid clinicians in this process. One such tool is the SPIKES protocol for delivering bad news (Table 1).3 The protocol is comprised of six communication steps summarized by the mnemonic SPIKES: set up, perception, invitation, knowledge, emotion, and summary.

Table 1.

Summary of the SPIKES Steps for Delivering Bad News

SPIKES stepSpecific actions or phrases

Set up

Choose appropriate environment for the discussion

Review information to be presented

Consult with other health care professionals regarding prognosis to ensure consensus

Perception

Medical condition

Can you tell me what you know about your illness?

Has anyone talked to you about what to expect with this disease? What did they say?

Goals and values

What is most important to you?

Can you share with me what you are hoping for?

Hospice

Have you heard of hospice? Can you tell me what you know?

Have you had experience with hospice with a loved one?

Invitation

Is it okay if I share some information about hospice with you?

I think hospice is important to talk about; is this a conversation we could have now?

Knowledge

Hospice focuses on providing care and comfort when it becomes very challenging or impossible to cure illness

Hospice could help you meet your goals to:

Remain at home instead of returning to the hospital

Have your pain well managed

Have emotional support for your family

Hospice provides:

Nurse visits to prevent and relieve pain and other uncomfortable symptoms

After-hours nursing staff to answer questions by telephone or make emergency visits if needed

Aides to assist with care needs, such as dressing and bathing

Social work and spiritual care counselors to provide emotional support, guidance, and links to community resources

Medications to relieve pain and other uncomfortable symptoms, such as nausea and constipation

Emotion

I know this is not good news for you

I am sorry to have to tell you this

I understand why you feel that way

See Table 3 for further examples

Summary

To make sure I did a good job explaining this to you, can you tell me what you understood from our conversation?

Based on what I have heard about what is important to you, I think that hospice would be a good option for your care


Information from reference 3.

Table 1.   Summary of the SPIKES Steps for Delivering Bad News

View Table

Table 1.

Summary of the SPIKES Steps for Delivering Bad News

SPIKES stepSpecific actions or phrases

Set up

Choose appropriate environment for the discussion

Review information to be presented

Consult with other health care professionals regarding prognosis to ensure consensus

Perception

Medical condition

Can you tell me what you know about your illness?

Has anyone talked to you about what to expect with this disease? What did they say?

Goals and values

What is most important to you?

Can you share with me what you are hoping for?

Hospice

Have you heard of hospice? Can you tell me what you know?

Have you had experience with hospice with a loved one?

Invitation

Is it okay if I share some information about hospice with you?

I think hospice is important to talk about; is this a conversation we could have now?

Knowledge

Hospice focuses on providing care and comfort when it becomes very challenging or impossible to cure illness

Hospice could help you meet your goals to:

Remain at home instead of returning to the hospital

Have your pain well managed

Have emotional support for your family

Hospice provides:

Nurse visits to prevent and relieve pain and other uncomfortable symptoms

After-hours nursing staff to answer questions by telephone or make emergency visits if needed

Aides to assist with care needs, such as dressing and bathing

Social work and spiritual care counselors to provide emotional

Author disclosure: No relevant financial affiliations.

Address correspondence to Shaida Talebreza, MD, at shaida.talebreza@hsc.utah.edu. Reprints are not available from the authors.

REFERENCES

1. National Hospice and Palliative Care Organization. Hospice care: what is hospice? http://www.nhpco.org/about/hospice-care. Accessed January 13, 2014.

2. Weckmann MT. The role of the family physician in the referral and management of hospice patients. Am Fam Physician. 2008;77(6):807–812.

3. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES—A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5(4):302–311.

4. Back A, Arnold RM, Tulsky JA. Mastering Communication with Seriously Ill Patients: Balancing Honesty with Empathy and Hope. New York, NY: Cambridge University Press; 2009.

A collection of Curbside Consultations published in AFP is available at http://www.aafp.org/afp/curbside.

Please send scenarios to Caroline Wellbery, MD, at afpjournal@aafp.org. Materials are edited to retain confidentiality.


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