Friday, July 25, 2008

How To Choose A Hospice: Why Doctors Matter

Hospice Guy over at Hospice Blog just finished his 2008 update on How To Choose a Hospice, which I highly recommend for his many insights into how hospices operate and how they can best serve patients and families. One area not covered in detail, but I believe is truly important is the role of the medical director.

Now Medicare has stipulated hospice agencies must have a physician to serve in the role of medical director. In many hospice brochures you may see some language such as 'your care with our hospice will be overseen by a hospice medical director.' Well that can mean a whole range of options, so I suggest if you are deciding between different hospice agencies you ask these questions:

How many full time physicians do you have?

If you had to ask one MD/DO-related question this would be it. A full-time physician employed by the hospice means the physician is dedicated to the field, and probably are already board-certified (and have gained wisdom by reading this blog!). It also means they deal with a lot of the difficult situations that hospice agency encounters, because they are more available to the staff for problem solving than a contracted medical director. To clarify what I mean by a contracted medical director, this is the medical director who is paid by the hospice to attend the interdisciplinary team meeting (usually 1-2hrs/week) and sign papers and do some troubleshooting during the meeting. After those 1-2 hours are up, it is often back to their primary practice which keeps them very very busy. Too busy to attend to problem solving with a hospice nurse, unless it is their own patient. These contracted physicians can be great assets to hospice care, don't get me wrong, but when things are really bad they just don't have the flexibility of time or perhaps the breadth of knowledge and experience a full-time hospice physician may have.

A full time physician also likely indicates a positive answer to the next three questions.

Does your physician make home visits?

Hospice nurses are the key eyes and ears for the hospice team and especially the physicians when it comes to working through medication or symptom issues. But when many problems start to crop up and a paper review & discussion in team don't seem to be helping, it may be time for a physician home visit. The medical home visit was once popular but now dwindling except in hospice. It is a great treat to see patients and families amazed that a doctor would 'bother' stopping by to see them. The field of geriatrics pioneered modern medical home visits and with the growth of hospice physicians, more hospice patients have this available to them. This can sometimes be implied in a brochure, but asking at the hospice info visit is the best way to get this question answered. You want to hear, "Oh yes, we have physicians that can see you at home to help with your symptoms and care." If you hear, "Yes we have a medical director," then you are getting the brochure answer and you won't be seeing a doctor in your home unless they are related to you.

Can the hospice medical director be my main physician?

If they are full-time, the answer is probably yes. This is mostly important for those patients without a strong connection to their primary doctors or who have recently moved. This also speaks to the issue when a community physician may be conflicted over which medications to prescribe. A recent commenter asked about what to do if the community doctor doesn't prescribe morphine, but that is potentially a helpful medication for pain or dyspnea. The hospice nurse is left with no advocate for the patient except the medical director, who can hopefully chat with the community doctor and come to a better understanding of the barriers to prescribing opioids or whatever the conflict maybe. Sometimes the conflict may be prescribing medications in a too aggressive nature leaving the hospice nurse conflicted over whether to follow those orders. In very rare situations the family and patient may ask to change physicians. This obviously is done with great concern for the referring community physician who may feel affronted by the change. This is likely the topic for another full post in itself.
So to review, first ask this:

Is your hospice medical director board certified in hospice and palliative medicine*?
*Official board certification starts Fall 2008, but past voluntary certification is a sign of commitment*

A lot of family practitioners, internists and specialists do a fine job managing many end-of-life issues. That is why they are actually the main physicians guiding care with the hospice agency. They may even be hospice medical directors in their spare time (see below). The primary community doctor gives verbal orders for your medications, and the hospice nurse will be talking with the community doctor or his nurse to update them on your condition. Works fine if things are running smoothly, which is often, but what if you are the hospice patient with very difficult symptoms to control and lots of complicating psychosocial issues. Well you might need an expert; thus the role of the hospice medical director. But some medical directors are not board certified in palliative medicine. There is no requirement for board certification in palliative medicine to be a hospice medical director and you may get someone is has the same qualifications as the primary community doctor. Many people would balk at being referred for a cardiology consultation to the other general practitioner in your doctor's office. When it comes to expert symptom control at the end of life, you should not have to compromise in a tough spot.

How many full time physicians do you have?

because any answer of "1 (or more)" likely means yes to the following more detailed questions:
  • Does your physician make home visits?
  • Can the hospice medical director be my main physician?
  • Is your hospice medical director board certified in hospice and palliative medicine?
  • BONUS QUESTION FOR EXTRA CREDIT: Does your medical director (or hospice agency) read Pallimed? If not, they should!
And don't forget to see Hospice Guy's other posts about how to choose a hospice at Hospice Blog.

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