Table 2.

Hospice and usual care as antithetical care models (theme 1)

QuotationNote TitleExemplar Quotation
Subtheme 1: understanding of hospice eligibility criteria
 1Social Work NoteAsked veteran why he had refused hospice care. Veteran said: “because they won’t let me go to the hospital.”
 2Geriatric Extended Care ConsultGuidelines for hospice suggest that a creatinine be >8 (>6 for patients with diabetes) [and] that there be persistent hyperkalemia. This veteran has neither.
 3Inpatient Treatment Plan Interdisciplinary NoteNot hospice per [physician] because there are many minor issues that could be treated such as pneumonia (for example) and wants option to transfer to acute. Some dysphagia issues.
 4Home Based Primary Care NoteTaken off hospice to receive additional physical therapy; caregiver states good results.
Subtheme 2: barriers to concurrent dialysis and hospice
 5Palliative Care Consult[Patient and wife] did meet with hospice which they refused due to [the] fact that hospice agency told them he needed to stop his hemodialysis treatment to be on hospice.
 6Hematology Oncology ConsultThe patient has declined hospice care, because he heard that this would imply discontinuation of hemodialysis. He is not ready to die.
 7Social Work NoteShe is concerned that veteran will suffer if dialysis is stopped, due to fluid overload. She inquires about hospice with continuing dialysis, which is not possible with hospice at [name of VA facility].
 8Palliative Care NoteToday’s discussion confirmed that the goals are unchanged, and that discussions around bringing the Veteran home include rehospitalization and continued dialysis, goals that are not in line with hospice.
 9Palliative Care ConsultIf patient’s renal condition deteriorates further that [he] requires renal replacement therapy, then reason for hospice should be ESRD. At this time, patient wishes to receive hemodialysis if necessary and to continue with current medical treatment. Thus, this goes against hospice philosophy, and does not qualify him for hospice yet. If his condition were to be end-stage cardiac disease, then dialysis is considered a form of comfort measure to help with respiration and in this type of situation patients may enter hospice while on hemodialysis.
 10Palliative Care ConsultHe is amenable to home hospice…and qualifies in our estimation under diagnosis of prostate cancer. Dialysis could continue with hospice care, as it is not related to the hospice diagnosis.
 11Social Work NoteIn working with family on [discharge] plan, received call back from [name of hospice]. Since veteran’s calciphylaxis is related to renal disease, Medicare will not allow dialysis and hospice care. However, VA contracts with [name of different hospice agency]…spoke with their director…as well as VA…administrator to verify that VA could cover cost of both fee basis hospice and fee basis dialysis, which was cleared.
 12Internal Medicine Inpatient Attending NoteFamily requested home hospice under patient’s Medicare. Wife asked if patient can continue on dialysis for a little while during home hospice…The hospice agency doctor would need to determine if patient can continue on dialysis during home hospice.
Subtheme 3: limited room for individualization
 13Internal Medicine Resident NoteMacrocytic anemia-had plans for [darbopoeitin]-[discontinue darbepoeitin] with hospice plans.
 14Speech Pathology NotePlan: Speech to follow up ×1 meal, however further speech therapy not indicated for dysphagia if patient transfers to hospice.
 15Pain ConsultThe risks for chronic opioid therapy combined with benzodiazepine would DEFINITELY outweigh the benefits of therapy UNLESS he is a hospice care case (renal failure). I would refer patient back to [primary care provider] to be made [do not resuscitate] with hospice referral, otherwise he is at exceedingly high risk for an overdose event or falls event with more compression fractures.
 16Nursing NoteCould hear this resident crying/bellowing from quite a distance down the hallway. Went to her room to check on her only to find her crying and typing with her computer saying “having acute pain in pelvis and in neck”…I explained to her that we could offer more medication with a hospice status… She said via type “call doctor I will do hospice.”
 17Internal Medicine Attending NoteHydromorphone and lorazepam are “hospice only” medications, supplied in a “comfort pack.” Since he is no longer in hospice, he should no longer need those medications, and I really am not willing to prescribe them.
 18Palliative Care NoteWe discussed the fact that it is sometimes difficult to walk the middle ground i.e., that in the units [medical or surgical floors] sometimes teams are reluctant to use opioids for fear of shortening life. She again reiterated that she wanted her dad to be comfortable.
 19Physician Long Term Care NoteHe continues to gain weight…As mentioned before I’m trying to refrain from doing laboratory studies since he is on hospice. However, with progression of his edema consistent with increasing heart failure, we will increase the torsemide to 80 mg each am and add in metolazone 2.5 mg once a week.
  • Square brackets contain text substituted by the authors to spell out abbreviations, correct misspelling, and remove the names of individuals and institutions.