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One of the hardest things that healthcare providers have to deal with is the moment a patient should start to consider hospice. It is a conversation that many simply avoid. Avoidance is used out of fear because we do not want to upset someone. Sometimes though, it is the most important conversation to start. It is vital to give patients all of their options and educate them so they can make an informed decision. This includes discussing their prognosis.
Mentioning hospice to a patient and their family is often quite upsetting to them. There is an assumption that hospice means choosing to give up on living. Patients/family members may initially be shocked and angered by the word, but continuing this honest discussion is critical. Depending on the patient's situation, sometimes waiting to give further details about hospice until the next visit gives the patient/family time to absorb the idea. Some patients simply do not have this time to wait.
When starting this conversation, the patient/family must first understand the prognosis. This will help with the decision-making. Next, if the patient does not already have a DNR (Do Not Resuscitate) in place for them, this needs to be discussed immediately.
Over the years, I have found that the best way to communicate choosing DNR is by calmly asking the patient how they would like to die. It sounds harsh, but I explain in detail what will happen if they are not a DNR. If they are at home, 911 will be called, paramedics will arrive, CPR will be started (possibility of breaking ribs and a breathing tube being placed down their throat) and they will be whisked away in the ambulance and eventually die in the hospital.
I then discuss the alternative. Due to their prognosis, they choose not to be resuscitated and are able to remain in the quiet and comfort of their home, with their loved ones around them when they take their last breath. There is no chaotic environment like in the hospital setting. Then I ask them how they want to take their last breath and spend their last moments on Earth. 99% of the time, the patient/family chooses a death at home, with the assistance of hospice.
Make sure they understand the prognosis, break down the options at their time of death, explain what hospice or palliative care is and remind the patient that it is their choice. Giving a clear picture of what their choice will look like will help with the decision-making.