Barriers to Hospice Care and Referrals: Survey of Physicians' Knowledge, Attitudes, and Perceptions in a Health Maintenance Organization

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Abstract
Introduction: Many proponents of hospice care believe that this service is underutilized. Objective: To determine physicians' perceptions of hospice utilization and of their own hospice referral pattern; their perceived and actual knowledge of appropriate hospice referral diagnoses; and perceived barriers to hospice referral. Methods: Surveys for anonymous response were distributed to 125 physicians in 2 internal medicine departments of a large not-for-profit health maintenance organization (HMO). Of these 125 physicians, 89% responded, including 91 staff physicians and 20 residents. Results: Of the 111 physician-respondents, 78% reported their belief that hospice care was underutilized; 84% were unable to identify appropriate hospice diagnoses; and 12% were aware of the "National Hospice Organization Medical Guidelines for Determining Prognosis in Selected Non-Cancer Diseases." Difficulty of predicting death to within 6 months was cited by 37% as the foremost barrier to hospice referral. In addition, 28% expressed concern that patients or families would interpret hospice referral as a costsaving measure; 11% of respondents had been accused of using hospice referral for this purpose. Conclusion: Our study—the first major survey of physician attitudes and practices regarding hospice utilization in an HMO setting—showed that barriers to hospice referral are similar to those in non-HMO settings; physicians have difficulty predicting life expectancy and lack knowledge of patient eligibility guidelines. Physician concern that patients or their family members would construe hospice referral as a cost-saving technique may be a barrier particularly troublesome in an HMO setting.

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