Table 3.

Hospice as a last resort (theme 2)

QuotationNote TitleExemplar Quotation
Subtheme 1: readiness for hospice referral
 20Social Work NoteHe [patient] states that he understands that this option [hospice] is available to him however he would like to place that option on the “back burner” for now.
 21Discharge Plan[Patient’s son] had stated several times “the word hospice really freaked my dad out. I really don’t think he’s ready for that.”
 22Internal Medicine Resident Note[Patient’s wife] said she is not ready to face the fact that he might be dying …she says if patient gets out of the hospital this time, she would consider changing patient’s care to hospice.
 23Social Work Case Manager Note[Patient’s wife] states she would be interested in home hospice, but not until [cancer] work up has been completed. She states she does not want to “give up” on patient…feels that unless patient has a firm diagnosis that she is “cheating him” out of life-prolonging medical treatment.
 24Internal Medicine Attending NoteIf [patient] makes reasonable progress, will need to consider extended care facility placement; if no progress or deteriorates will consider Hospice.
 25Internal Medicine Inpatient NoteOverall prognosis still seems poor… Hospice consulted, staying in “background” for now…while continuing aggressive medical care in [intensive care unit]. May need to revisit w/patient and family in next few days.
 26Hematology and Oncology Outpatient NotePlacement issues (possibly hospice) was not specifically discussed, but wife is aware of this option and the patient will let us know when he is ready.
Subtheme 2: Hospice rarely a proactive choice
 27Internal Medicine Inpatient NotePatient states he would like to leave the hospital and discontinue care, stating “I want that hospice thing.”
 28Hematology and Oncology Outpatient NoteMetastatic [non-small cell lung cancer] to multiple lobes of his right lung: patient declines any active treatment at this time and after a lengthy discussion with the family we have elected to enroll him in hospice.
 29Palliative Care Note[Patient’s] daughter…will consult with…hospice sometime today…She is satisfied with the current plan and that all family members are in agreement and on “one page.” Satisfied that they had attempted hemodialysis.
 30Palliative Care Team ConsultVascular surgery and podiatry have evaluated him. The patient would require possible bilateral [above knee amputations], a surgery that would have a near 100% risk of mortality; therefore, both services recommended hospice. The family is in agreement and has made the patient [do not resuscitate/do not intubate].
 31Internal Medicine Attending Note[Patient] adamantly refuses colonoscopy to gauge severity of his Crohn's with possible option(s) for therapy… patient/family will arrange for hospice services.
 32Internal Medicine NoteRenal discussed possible hemodialysis but patient is now REFUSING…If patient certain to refuse hemodialysis, then will need hospice consult ASAP.
 33Social Work Inpatient ConsultPatient has decided that he no longer wants to take dialysis and states he knows he won't live for long without the dialysis. Patient requested to be referred to [specific hospice agency].
Subtheme 3: tension around hospice referral
 34Internal Medicine Attending NoteVery poor prognosis, patient should be hospice, but he currently refuses hospice care.
 35Medicine History and Physical Examination NoteWill talk to family again today. They should consider hospice again for this patient; otherwise he may die here in the hospital.
 36Social Work NoteVet’s wife was understandably tearful and stated she had decided this morning, before vet’s passing, to pursue hospice
 37Nursing ConsultPatient’s daughter was amendable to meeting with a hospice agency. She has stated that she is not prepared to receive her father back home on [date], she needs time to prepare the space he will be in. However, [physician] called to clarify that the veteran is actively dying and may only have a few days left.
 38Nursing Inpatient NoteConsidering discontinuing hemodialysis and transitioning to hospice…States that he feels like the health care team is “pushing” him to make a decision. States he is not ready to make a decision and will not be until he is able to speak with his sister.
 39Palliative Care Note[Patient’s niece] conveyed patient’s distress about the hospice visit…Patient didn’t understand why the nurse told her to stop taking some of her medication. Patient and niece were also surprised by the “6 months or less” prognosis.
  • Square brackets contain text substituted by the authors to spell out abbreviations, correct misspelling, and remove the names of individuals and institutions.