The Physician's Role The decision to enroll in hospice services can be difficult for patients and families, and may reflect a reluctance to accept a terminal diagnosis. The physician pays a central role in helping patients and families make the switch from life-prolonging treatment, when it is no longer appropriate, to an approach focused on end-of-life care goals. Patients need assurance that no matter what treatment option is chosen, the goal of comfort will always be paramount. The topic of "care goals" should be introduced early in the disease course so these goals can be defined well before a crisis occurs. Physicians have expressed their concerns to me regarding having end-of-life discussions with their terminally ill patients. Many fear they will destroy hope if they talk about death. But in interviews with 100 family members of 100 patients who died while under hospice services conducted by the Leonard Davis Institute of Health Economics, families expressed "excellent" ratings of satisfaction with care.1 The findings include: * Only half of family members reported that the physician initiated the discussion of hospice, and often it was the patient who did. * Only 22 stated that their physician provided information about hospice, with most of the information coming from hospice representatives. * Most recalled at least one event that precipitated the hospice discussion, including escalating needs for home care, whether to initiate, withdraw or withhold life-sustaining treatment, and managing pain. * Most were surprised regarding the 24-hour availability of the hospice nurse. * Almost all identified aspects of hospice care they wished they had learned sooner. Most patients are aware that "something is going on" with their bodies, and may not be surprised when given a life-limiting diagnosis. Frequently, it is the patient's family who has difficulty accepting the fact of impending death. Physicians can help by including the family in discussions about the disease trajectory and by allowing them to participate in setting new goals of care. Goals will be different for patients for whom death is not eminent; those with life-limiting illnesses must choose between length of life and quality of life. While these conversations are difficult for both physicians and families, perhaps it is best stated thusly: "prognostic information is often the single most important piece of information that patients need to make informed choices."2 Remember, it is the goals of care which are changing, not the underlying patient-physician relationship. I have found that patients want to follow the advice of their physicians. But when it comes to referring their patients to hospice, physicians remain hesitant to give the six-month prognosis necessary to qualify them for hospice services. The physician's clinical judgment regarding the normal course of the individual's illness is what Medicare is looking for, and it is understood this is not a science. Hospice can help support patients and families and allow them to remain in their own home. By broaching the important subject of end-of-life care, the physician can empower their patients with choices, allowing them to make an informed decision. Physicians should be able to introduce the prospect of hospice care without feeling that they, or the patient, has failed. The Role of Hospice From the hospice standpoint, hospital admissions constitute acute care. When cure is no longer an option, palliative therapies can help alleviate pain and bring hope to patients and families. When treatments are exhausted or ineffective, comfort care (i.e., hospice care) is the natural next level of care to provide pain management, symptom control and support to patients and families. Under the direction of your physician, the levels of care can be seamless-especially when the expertise of the hospice nurse or social worker is included early in the disease course. Americans are living longer than ever before, and dying not from sudden illness and infection, but from disability and chronic illnesses. People 85 and older comprise the fastest-growing segment of the US population. With increased age comes increased frailty. And while most state they want to spend their final months at home, the National Hospice and Palliative Care Organization's 2003 Report indicated that of all people who died in that year, 75% were in institutions and only 25% at home.3 Now more than ever before, it becomes important for health care providers to communicate with each other to assure quality of care for their patients. The hospice I work for encourages its community physicians to partner with us to ensure that all patients facing life-limiting illnesses receive quality care, from diagnosis, possible hospital admission, nursing home placement, and ultimately to hospice referral. Together, we can provide the support and continuity of care our patients deserve. The Roles of Patient & Family All caregivers, both family and professional, must be involved in discussions with physicians regarding care choices as the illness progresses. A recent study in JAMA revealed that caregivers' adjustment after death, related quality of life and grief reactions were all directly related to the patient's ability to discuss care options openly with their physician. When patient or physician opted for more aggressive treatments such as feeding tubes or admission to the ICU, the patient experienced a lesser quality of life. However, when the patient or physician opted for fewer aggressive treatments near death, and hospice care was instituted before the last months of life, greater quality of life was observed. In the study, "a direct relationship existed between patients' quality of life near death and their bereaved caregivers' quality of life at follow-up" 4. Patients who had a close relationship with their physician and trusted their judgment, felt trusted in return and felt respected as a "whole person." These patients were comfortable discussing questions regarding their care. Providing continuity of care for patients approaching end-of-life is the responsibility of all treatment modalities-the hospital, the nursing home, the hospice-and should be under the direction of the physician. Partnering together is a win-win-win proposition regarding patient and caregiver satisfaction, and in providing pain and symptom management.