A Qualitative Investigation of Cross-domain Influences on Medical Decision Making and the Importance of Social Context for Understanding Barriers to Hospice Use

Abstract

Hospice utilization has the potential to improve quality of life for patients while also decreasing healthcare costs at end of life. Barriers to hospice utilization have been identified, but less is known about how patient, provider, and system domains influence one another. We use in-depth interviews with physicians to examine the social, cultural, and economic contexts of decision making and how physician and organizational domains influence patient decision making around hospice. We identify sources of delay in physicians advocating for hospice referrals for their late-life patients that show how patient, physician, and system factors interact. Our results reveal incentives to postpone discussion of hospice that are not fully captured in policy perspectives, clinical guidelines, or current research paradigms focused on individual domains of influence. Opportunities to address previously identified barriers to hospice will benefit from consideration of how seemingly separate domains function in an integrated social context.

Determinants and Outcomes of Hospice Utilization Among Patients with Advance-Staged Hepatocellular Carcinoma in a Veteran Affairs Population

“…The demographic determinants of hospice shown in this study are consistent with studies in other cancers that found race and social environment play an important role in choosing hospice care [13, 14]. Further, we suspect that significant barriers to use hospice and other palliative care for HCC still exist among providers of varying specialties [15, 16]. Further studies are needed to better understand obstacles facing providers.…”

Challenges and facilitators of hospice decision-making: a retrospective review of family caregivers of home hospice patients in a rural US–Mexico border region—a qualitative study

“…Factors contributing to hospice related decision-making, have been identified at the individual level (ie, patient and family's lack of knowledge, attitudes and beliefs toward HC), interpersonal level (ie, Open access patient-provider relationship) and structural or macro level (ie, health insurance reimbursement). [8][9][10][11] Mostly, these challenges do not occur one at a time; rather, their interplay results in a web of complex constraints that complicates the decision-making process. 9 Family members are often closely involved in decisionmaking for EOL care for their loved ones.…”

Does Palliative Care Utilization Facilitate Conversion to Hospice Care? A Qualitative Study of the “Soft No”

“…Those giving "soft" refusals do not explicitly refuse hospice, but their actions function to postpone a hospice decision in an uncertain health context that may become more clear over time. 20 In a health policy context wherein concurrent care options are being considered as part of the Medicare Care Choices Model, 21,22 it is critical to understand how palliative care and hospice sectors of health care coexist and shape patient choices. From a clinical perspective, understanding how and why patients resist or embrace hospice conversion is critical; lessons learned from this case study can shed light on this enduring puzzle by providing a deeper understanding of the longitudinal, iterative processes and alternative influences on patients and families-thus extending beyond existing assumptions about providers "recommending" hospice and patients "electing" services.…”