Recommending Hospice to Patients with Advanced Illness

Research has shown that a great majority of patients desire to know the truth about their condition, (Buckman & Kason, 1992). When patients are not provided with this information they report feeling alone and abandoned. The challenge is for health care providers to take the time to have these important conversations with patients and their families, as well as consistently provide updates to statuses, given that today’s environment often leaves clinicians constrained with regard to their time, (Kinzbrunner & Policzer, 2011). 

Healthcare providers have the opportunity to offer a precious and invaluable gift to patients and their families by discussing the patient’s options near the end-of-life, while still allowing the patient to enjoy quality of life.  A patient who is informed, and has an understanding of the options they have along with what hospice care can provide will have a stronger sense of control in their situation.

Similar to evaluating the health history of a patient or facilitating a physical, introducing pertinent end-of-life conversations with patients is an attainable skill that can be learned.  When done so effectively and thoughtfully, these discussions allow for stronger relationships between physicians and their patients, and improve the chances that patients will decide the most optimal treatment options, including hospice care.

Obstacles Within Talking About Death

• Worry with regard to the patient’s reaction:  Regardless of the fact that patients want to know the truth about their conditions, they might have a strong emotional reaction or physical outburst initially related to the thought of having limited choices, a loss of control, a deteriorating lifestyle, changes in their image of self, and ultimately losing their life, (Kinzbrunner & Policzer, 2011).  Although these more intense reactions might trigger discomfort for the provider, properly preparing for the conversation along with specific consideration, or even empathy for the patient’s perspective will help to deescalate the situation.

• Worry with regard to the provider’s reaction:  The provider may be concerned about appropriately responding to a patient’s anger, anxiety or sorrow.

• Idea that the provider won’t be able to “do enough”:  Providers can even strengthen the relationship with the patient through exhibiting compassion and honesty while recognizing their own thoughts and feelings regarding the decline of a patient notwithstanding all efforts.  Discussing the options for end-of-life care is the next practical step in the continuum of care for the patient.

• Leading such discussions triggers anxiety:  This obstacle is the easiest to conquer when the provider takes the time to become informed on how to effectively conduct end-of-life conversations thoughtfully and with compassion and empathy.  This learned skill will not only assist patients in making informed decisions, but also ease the discomfort of the provider.

 

SPIKES has six pragmatic aspects:

In case a person is diagnosed with a terminal illness, or is approaching death and is unable to communicate for themselves, end-of-life experts recommend that the following steps be taken proactively to ensure that the patient’s wishes are actually acknowledged and executed.

• Setting – Decide on a private setting where you can sit in person with the patient and their loved one.  If the patient does not speak the same language as you, depend on a professional interpreter as opposed to a family member.  
• Perception – Gauge the perception of the patient by asking how much they know, perceive or suspect before commencing the conversation.
• Invitation – Discreetly invite the patient to provide information about their willingness to receive more information, by asking if they want to discuss test outcomes, treatments, etc. If the patient does not respond favorably, recommend that you try having the discussion at another time, possibly later that day or the next, and then make sure to follow up with them at the decided time.
• Knowledge – Provide information directly and concisely, and once you have opened the discussion, stop talking in order to listen to the patient’s responses, thoughts and emotions.
• Empathy – Acknowledge, and identify with the patient’s emotional reaction in a compassionate and kind way that suggests you not only understand, but appreciate their response and are genuinely concerned about their future as well.
• Summation – Summarize the information and recommend they consider hospice care.

“SPIKE” Your Communication Skills and Your Confidence

As you follow the SPIKES system, you can increase your ability to facilitate effective discussions about end-of-life treatments and embracing hospice, (Buckman & Kason, 1992).

This will help you assess:

• A patient’s understanding about their condition
• A patient’s readiness to discuss end-of-life overall
• The optimal way to adjust to a given patient’s response
• The significant value of both silence and observation
• How best to interpret a patient’s reaction, regardless of its appropriateness
• How to inform your patients in a way that exhibits empathy
• The role hospice care can play in maintaining hope, comfort and dignity

The Role Hospice Plays

Hospice plays an essential part with regard to the satisfaction that a patient and their family experiences at the end-of-life. Optimal hospice care is supplied for months, as opposed to weeks or days. Hospice care can assist in managing pain and symptoms, providing comfort, and addressing the spiritual and emotional needs of the patient and their family when intensity and/or side effects of treatment start to surpass any anticipated advantages.

Hospice care provides patients a sort of gift of time, enabling them to visit with loved ones, enjoy time outdoors, experience family milestones and to get affairs organized.

References

Buckman, R. & Kason, Y. (1992). How to break bad news: A guide for health care professionals. The Johns Hopkins University Press.

Kinzbrunner, B. M. & Policzer, J. (2011). End-of-life-care: A practical guide. McGraw Hill Professional.

Baile, W. F., Buckman, R., Lenzi, R., Glober, G., Beale, E. A., & Kudelka, A. P. (2000). SPIKES – A six step protocol for delivering bad news: Application to the patient with cancer. The Oncologist, 5(4), 302-311. https://doi.org/10.1634/theoncologist.5-4-302.