Hospice: The business of dying

Although the definition of hospice is to provide compassionate care for the dying, it is still a business that needs to remain solvent. In order to do so, they must strike a balance between providing care and growing their business. Hospice is often a hard sell to begin with, so how are they able to maintain their integrity as well as their census?

Previous experiences color reactions to referrals

Based on my experiences discussing hospice, patients and families tend to fall into one of three categories. First, they may have never heard of hospice. If they have, they have had either a wonderful or negative experience. It seems that those who have had a positive experience were referred to hospice with enough time prior to their loved ones passing. They were able to get to know the staff, become adjusted to the idea of the death of a loved one, and had the time to react accordingly. Those who had negative experiences tend to have only learned of the need hospice within weeks or days of their loved one’s death, leaving families unprepared for what lay ahead. They often feel that the pain medication hastened death. They may also have been given conflicting information regarding their loved one’s medical outlook and may feel that their needs went unmet.

Making the referral

A hospice referral is filtered through these experiences. Even with positive experiences, it is a tough pill to swallow. Approaching patients at the right time is imperative. A good way to assess whether it is the right time is through the use of a Power of Attorney because they can help to determine a patient’s preferences. Even if they would like aggressive treatment, they can still be informed of the services of hospice. In fact, approaching a referral by simply providing information is an excellent way to initiate a conversation about hospice with patients and their families. If resistance comes up, one can simply sidestep it by letting them know you wanted to inform them of all their options. If they are not interested in hospice, you can assure them you will not bring it up again.

Financial motivation

Unfortunately, there are times when resistance does not come from the patients or families, but from physicians themselves. Some feel that by referring patients to hospice they are giving up, some are uncomfortable talking about death, while others have a cultural opposition. One may not be completely off the mark to suspect that a physician does not refer to hospice because they will no longer follow a patient and therefore cannot bill for services. Billing and increasing business is clearly an agenda of hospice agencies, particularly the for-profit ones. However, for non-profits and for-profits alike, if business were not made a priority then hospices would not be able to exist. The priority for increasing an agency’s census is not a malevolent one. But if this agenda supersedes that of providing excellent patient care, then there is a real problem.

Balancing business with the mission of hospice

Marketing is essential to spreading the word about hospice. The marketing liaison may be the first person at the agency that a patient and family meet. A social worker or other professional in the position of referring to agencies may want to observe how the marketing liaison interacts with staff and patients. By doing this and by following up with families to learn about their experiences with different agencies, one is able to build a list of reliable referral sources. Understanding the nuances to this delicate situation and having trusted resources will assist professionals in the field of aging and those they serve when coordinating a hospice referral. Photo courtesy of Seattle Municipal Archives


  • Larry Beresford

    Thank you for contributing to the dialogue that needs to continue on a wider scale about hospice care, what is it, what is it used for, what are its benefits and advantages, what are its problems, when is the right time to access it, etc. As someone who writes about hospice for a living, I hope to see broader understanding of hospice care, so that everyone who might benefit from it at least has the option to choose it and is able to make that choice based on accurate information.

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