After hospice takes over, what happens to the physician?

Today, I hesitated to refer a patient to hospice. The patient is perfect for that model of care.  She has strong family and friend supports, multiple opportunities to maintain quality, independence and dignity, and while she has a disease we cannot fix, she will do very well with personal palliation. Nonetheless, I almost did not recommend hospice, because I realize that hospice is going to completely fail to take care of a key member of this patient’s care team.  They are not going to take care of me.

The hospice concept places the patient and family at the center, surrounded by the hospice team.  The referring doctor is a loose member of that team, but is not involved in the hospice meetings or daily decisions.  The problem with this model is that after taking care of a patient for a long time, the doctor is often close to the patient and more or less, emotionally attached.  Referring a patient to hospice may result in a significant loss to the doctor.

Hospices usually do not maintain a close conversation or bond with the primary doctor. They send the required paperwork and call with the occasional emergency, but often the next significant contact after the original referral, is to notify the physician of the patient’s death.  For those doctors who are not comfortable with end-of-life care, this professional and functional distance may be acceptable.  However, for many doctors who fight fatal diseases month after month or even year after year in each patient, the loss of connection is draining.

I have never had a hospice say, “Hey doc, how are you doing? This must be hard on you.”

My loss, my pain, is not acknowledged. Generally, that is ok.  It is not the job of the health care system to heal my wounds.  However, I wonder if one of the causes of late hospice referral is the abrupt severing of invested patient-physician relationships.  Hospices, who are charged with comfort and bereavement, ignore the pain which comes from loosing patient after patient and having no one say, “Are you alright?”

Thus, as I explained hospice to this patient and her family, I made a point of saying that I would still take care of her, that I would be closely involved and that the hospice was not “taking over.”  I noted that hospices are so motivated to bring comfort and support into that patient’s environment that they often cut out the treating doctor.  My patient’s extraordinarily insightful friend summed up that action, as “militant kindness.”  I could never have said it better.

Those of us who fight battles, which we know we will loose, cope with reality by finding perspective.  We do not invest in false cures or false hope.  We focus on what we can truly achieve.  However, we are just human and, not rarely, we fall in love with the patients and families held gentle in our hands.  Perhaps, sometimes, it might help if someone would hold us as gently.

James C. Salwitz is an oncologist who blogs at Sunrise Rounds.

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  • ninguem

    Once hospice takes over, the physicians job is to sign forms to authorize whatever they feel like doing.

  • buzzkillersmith

    It doesn’t matter all that much what happens to the physician because the physician is not the one who is dying. Get a grip, Dr. S. I expect that when I am agonal my physician will not be foremost in my mind. Perhaps you will feel the same way when it is your time.

    • FEDUP MD

      That’s a bit harsh. For those of us who care for the dying (children in my case) one can become very close to them and their families. I have cried my share of times at funerals and with families.

      Doesn’t everyone say that they want a doctor who cares, who treats them as a person, not an automaton? Is the expectation that we can suddenly turn that humanity on and off like a switch? Because we’re people too and that isn’t realistic to expect out of anyone. Attitudes like yours that the physician’s very real feelings don’t count contributes towards burnout and the doctor who separates themselves emotionally and becomes the “unfeeling” doctor everyone decries.

      It is not the patient’s responsibility, obviously, they have enough on their plate- but that is not what the article is suggesting- it is suggesting that hospice, in caring for the community who is connected emotionally with the patient, consider that the doctor might be one of those people, however peripheral. I personally would at least just like to hear how the family and patient is doing, and not just be treated as a robot who signs forms for meds.

  • ceblen

    I think what you are missing here is that the Hospice Entitlement paid for out of the People’s Medicare Purse by Medicare/Medicaid is designed to save money on expensive end-of-life care for Medicare and Private Insurance and doesn’t allow for any physician’s fee in the per diem Hospice reimbursements other than renewal of prescriptions for pain medication that can be accomplished over the telephone, usually through the RN in the physician’s office.
    The majority of Hospices are for-profit institutions and are not going to share any of their profits for in-home physician’s visits. Even if your patient was well enough to come to your offices, if you tried to bill Medicare/Medicaid for her visit, they wouldn’t reimburse because she has elected Hospice Care. .
    When patients elect to give up their curative care and go on Hospice, they give up their right to Curative Care and the right to see their treating physician for curative care. Under current law, patients can’t be on both curative care and Hospice at the same time.
    This is perhaps why we have had a new specialty “palliative care” and why so many palliative physicians work directly for the hospitals who refer patients to hospice/palliative care when the hospital KNOWS that any further curative treatment will not be reimbursed by Medicare/private insurance.
    I’m surprised, Doctor, that you don’t know it is all about the money!.