Gail M. Sullivan, MD, MPH

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Common myths about caring for patients with terminal illness: Opportunities to improve care in the hospital setting

Author(s)

Emily Cherlin, MSW

Victor Morris, MD

Jensa Morris, MD

Rosemary Johnson‐Hurzeler, RN, MPH

Gail M. Sullivan, MD, MPH

Elizabeth H. Bradley, PhD

Shortcomings in the quality of care of hospitalized patients at the end of life, especially in the final days, are well documented.1, 2 Recent studies have highlighted inadequate pain and symptom control for hospitalized terminally ill patients,24 poor communication about treatment preferences,57 and limited or delayed referral for hospice care.810 Efforts to improve the quality of end‐of‐life care have been diverse, including increased educational programs,1113 development of palliative care units in hospitals,14, 15 and greater exposure to palliative care for physicians during residency training.16 Despite these efforts, studies assessing the attitudes and knowledge of physicians about hospice and palliative care continue to show deficits in knowledge about managing pain17, 18 as well as hospice policies and services.9

Among the interventions aimed at improving hospital care, the hospitalist movement has emerged as a model of care for improving the quality and cost efficiency of hospital care.1922 Because hospitalists spend substantial time on inpatient services,23 they are often involved in the care of patients with terminal illness, with potential to improve the quality of care that these patients receive while hospitalized. However, little is known about what specific knowledge and perspectives hospitalists and residents have about the care of patients with terminal illness. Although many studies have been conducted among physicians in private practice,9, 10, 2426 they have not focused on the knowledge, reported practices, and attitudes of hospitalists and residents concerning key aspects of end‐of‐life care and hospice. Such information can help to identify potential areas for improving knowledge and addressing common barriers highlighted in linking hospital and posthospital hospice care.

METHODS

Study Design and Sample

During 2006 we surveyed hospitalists and medical residents who were on their oncology rotation at a large academic medical center that did not have a hospital‐based palliative care unit in order to examine their knowledge, attitudes, and practices regarding terminally ill patients and hospice referrals. Hospitalists (n = 23) and medical residents (n = 29) made up a convenience sample of 52 physicians. The medical residents were completing their oncology rotation during the spring of 2006. The Institutional Review Board at Yale University School of Medicine approved the research protocol and verbal consent procedures.

Survey

The brief survey instrument (see Appendix) assessed physicians' knowledge and attitudes about and practices in caring for patients with terminal illness. The survey was adapted from previously published instruments8, 24 that have been shown24 to have good test‐retest reliability and construct validity. The survey contained 5 items pertaining to clinical knowledge about palliative care practices, including common symptoms and drug indications, doses, and side effects.27 An additional 2 items pertained to respondents' knowledge about nonclinical issues concerning eligibility rules for hospice,8 such as how a patient becomes eligible for hospice and whether Medicare benefits can be revoked or reinstated after hospice is elected. The survey also included 10 statements24 assessing physician attitudes about caring for patients with terminal illness. Responses, provided using a 5‐point Likert scale, were collapsed for reporting into a 3‐point scale of agree, neutral, and disagree. The instrument also included an open‐ended question asking physicians to specify what from their perspective was needed to ensure timely referral for hospice and palliative care.

Data Analysis

We used standard frequency analysis to describe the distribution of responses to the survey items. Based on an analysis of common erroneous answers to clinical knowledge questions, we identified several common myths prevalent among hospitalists and medicine residents. We also examined whether knowledge, reported practices, and attitudes differed significantly between the hospitalist and the resident samples using ANOVA or chi‐square statistics as appropriate. We used content analysis to summarize the open‐ended responses about potential ways to overcome what respondents perceived was underutilization of hospice.

RESULTS

Overview

The response rate for the survey was 85.2%. Almost half of the respondents (44.2%) were hospitalists (Table 1). The remaining respondents included first‐year (n = 9) and second‐ or third‐year (n = 16) residents or fellows (n = 4). Approximately 54% of the 52 respondents were female, and the majority (83%) had graduated from medical school between 2000 and 2005. Several common myths were apparent and pertained to essential areas of treating patients with terminal illness: pain control, symptom control, and eligibility for hospice (Table 2). Respondents generally had strong beliefs about caring for patients with terminal illness, and most agreed that many patients who would benefit from hospice either do not receive hospice or receive it only late in the course of their illness (Table 3).

Table 1.Demographic Characteristics of Respondents (n = 52)
Characteristic	n	%
Sex
Female	28	53.9%
Male	24	46.1%
Years since graduation from medical school
1‐2 Years	26	56.5%
3‐5 Years	12	26.1%
>5 Years	8	17.4%
Missing	6
Physician type
Hospitalist	23	44.2%
First‐year resident	9	17.3%
Second‐ or third‐year resident	16	30.8%
Fellow	4	7.7%

Table 2.Knowledge about Hospice and Palliative Care Practices and Eligibility for Hospice Care (n = 52)*
Questions about hospice and palliative care practices	Response (%)
* Correct answers, that is, facts, are in bold.
The incidence of psychological dependence (addiction) to opioids and analgesics when treating pain from cancer or other medical conditions is:
Common (1 in 10 patients)	17.3
Uncommon (1 in 100 patients)	48.1
Very rare (fewer than 1 in 1000 patients)	34.6
When a patient with cancer who is receiving opioids for pain complains of increasing pain, it most likely indicates:
Opioid tolerance	69.2
Increasing pathology of the cancer	26.9
Patient noncompliance	0.0
New onset of a different opioid‐resisting pain	3.9
In the pain patient receiving opioids, 30 mg of oral morphine is equipotent to of IV morphine
1 mg	4.0
5 mg	40.0
10 mg	56.0
20 mg	0.0
The 2 classes of drugs most commonly recommended for treating terminal dyspnea are:
Beta‐blockers and Lasix	7.7
Opioids and benzodiazepines	82.7
Beta‐blockers and corticosteroids	9.6
Beta‐blockers and Singulair (montelukast)	0.0
A hospice patient whose agitation is primarily from anxiety should be treated with:
Chlorpromazine (thorazine)	0.0
Haloperidol	21.6
Lorazepam (Ativan)	76.4
Morphine	2.0
Questions about eligibility for hospice care	Response (%)
Under the Medicare program, a physician must certify that the patient is expected to die within a specified time for the patients to be eligible for hospice services. To the best of your knowledge, patients become eligible for inpatient hospice care when they are expected to die in:
2 Weeks	5.8
6 Weeks	9.6
2 Months	9.6
6 Months	69.2
Other	1.9
Don't know	3.8
To the best of your knowledge, patients become eligible for home hospice care when they are expected to die in:
2 Weeks	0.0
6 Weeks	5.8
2 Months	7.7
6 Months	73.1
Other	0.0
Don't know	13.4

Table 3.Physicians' Beliefs about Caring for Patients with Terminal Illness (n = 52)
Beliefs	Disagree (%)	Neutral (%)	Agree (%)
Most patients want me to tell them their life‐expectancy.	0.0	17.4	82.6
Generally, family caregivers want me to tell them the patient's life expectancy.	4.4	8.7	86.9
Telling the patient and family members that the patient's illness is incurable is difficult for me.	23.0	13.5	63.5
I think it is essential to discuss the prognosis with a patient, even if it is very poor.	0.0	4.4	95.6
Most patients' physical symptoms (eg, pain, shortness of breath, and nausea) are controlled better with hospice than with the care that they would receive in the hospital.	0.0	21.7	78.3
Most patients' emotional symptoms (eg, depression, anxiety) are controlled better with hospice than with the care they would receive in the hospital.	0.0	8.7	91.3
Hospice meets the needs of the family better than conventional care does.	0.0	8.7	91.3
Many patients who should receive hospice care do not receive hospice care.	21.8	13.0	65.2
Many patients would benefit if hospice care were initiated earlier in the course of their illness.	0.0	9.1	90.9
I feel knowledgeable enough to discuss palliative and hospice care with patients and families.	19.2	38.5	42.3

Common Myths in Treating Patients with Terminal Illness

Myth 1. Treating cancer pain with opioids or analgesics causes addiction in 1 in 100 patients. Most physicians thought that addiction in patients treated for cancer pain with opioids or analgesics was much more common than it is. Almost half the respondents (48.1%) thought addiction occurred in 1 in 100 patients, and an additional 17.3% of respondents thought addiction occurred in 1 in 10 patients treated for cancer pain with opioids or analgesics. In contrast, the incidence of addiction in patients treated with opioids or analgesics for cancer pain is fewer than 1 in 1000 patients.28

Myth 2. When patients with cancer already receiving opioids for pain control complain of increasing pain, it most likely indicates opioid tolerance. Nearly 70% of respondents reported that the most likely reason for complaints of increased pain was tolerance to the opioid. However, the most likely reason for increased pain is increasing pathology of the cancer.27

Myth 3. The equipotent to 30 mg of oral morphine is 5 mg intravenous. More than half of respondents were inaccurate in their conversion of oral to intravenous (IV) morphine dosing, a common task of physicians caring for terminally ill patients. Almost half the physicians (44%) erroneously reported that 30 mg of oral morphine was equipotent to 5 mg or less morphine IV. However, in fact, 30 mg of oral morphine is equipotent to 10 mg of morphine IV.27

Myth 4. The most highly recommended drug for treating terminal dyspnea is a beta‐blocker, and the most appropriate drug for agitation due to anxiety is Haldol or morphine. Most respondents were able to identify the correct drugs; however, a sizable proportion of respondents (17.3%) erroneously responded that beta‐blockers and Lasix or beta‐blockers and corticosteroids were the best drugs for treating terminal dyspnea. About one‐fifth of respondents (21.6%) responded that Haldol or morphine was the recommended medication for treating agitation. In fact, opioids and benzodiazepines are the recommended drugs for treating terminal dyspnea,27 and the proper drug for treating agitation is lorazepam (Ativan).27

Myth 5. Patient life expectancy must be 2 months or less to be eligible for hospice. One‐quarter of respondents believed this to be true for inpatient hospice, and nearly 13.5% of respondents believe this to be true for home hospice. In fact, patients are eligible for hospice benefits earlier in the course of their illness. Under Medicare and most insurance policies, patients are eligible for hospice benefits as soon as their life expectancy is 6 months or less, not 2 months or less.27

Physician Beliefs about Caring for Patients with Terminal Illness

The physicians' beliefs about hospice were generally positive; the vast majority of respondents agreed or strongly agreed with the statement that physical and emotional symptoms of patients and family needs are better addressed with hospice than with the hospital care (Table 3). Most respondents also agreed that many patients do not receive hospice as they should and that hospice should be initiated earlier in the course of the illness. In addition, more than 80% of respondents believed patients and their families want their doctors to tell them the patient's life expectancy, and 95.6% of respondents thought it was essential to discuss prognosis, even a poor one, with the patient. Nevertheless, many respondents (65.3%) reported it was difficult to tell patients and their families that an illness was incurable. Furthermore, fewer than half the respondents (42.3%) believed they were knowledgeable enough to discuss hospice and palliative care with patients and their families.

In subgroup analyses comparing responses to knowledge and attitude items reported in Tables 2 and 3, we found no significant differences between hospitalists and any subgroup of residents by year of training or fellows, or between hospitalists and the full sample of residents and fellows. Because of the sample size, the statistical power for evaluating significance was limited in these exploratory subgroup analyses.

Among physicians who provided responses to the open‐ended question (n = 42) about how to enhance hospice referral rates and improve their timeliness, the most commonly reported suggestions were: (1) involve family members, not only patients, in discussions of hospice (38.1%), (2) have discussions about hospice earlier in the course of care with patients (26.2%), and (3) be clear with patients and families about the patient's prognosis (19.0%). Table 4 has a list of all responses provided to this question.

Table 4.Physicians' Suggestions for Improving the Process of Hospice Referral (n = 42)
Response	n	%*
* Percentages add up to more than 100% because some respondents made more than 1 suggestion.
Involving family members as well as patients in discussions of hospice	16	38.1
Having earlier discussion with patients	11	26.2
Being clear with patients and families about patient prognosis	8	19.0
Providing education about hospice to patients and families	6	14.3
Discussions of goals of care with patients and families	6	14.3
Involving social worker in discussions	4	9.5
Providing literature to patients and families about hospice	3	7.1
Having hospice representative available to provide education to patient and families	2	4.8

DISCUSSION

This study demonstrated that, among hospitalists and residents, there are several misconceptions about fundamental aspects of caring for terminally ill patients. Given the potential importance of the role hospitalists play in improving the quality of inpatient care,1922 it is critical to identify and address these misconceptions. Additionally, physicians in this study indicated that more and earlier communication with patients and families about prognosis and about the option of hospice would be beneficial, but they themselves did not feel knowledgeable enough to discuss hospice and palliative care with patients and their families.

The nature of the misconceptions identified in this study shed light on the well‐documented phenomena of inadequate pain control24, 29 and poor symptom management2, 4 at the end of life. Having many of the erroneous beliefs apparent in this study may be consistent with providing less pain medication than needed and appropriate. For instance, many physicians believed that developing addiction to opioids used for cancer pain is more likely to occur than it really is, according to research evidence. It is extremely rare for these patients to become addicted to opioids or other analgesics (fewer than 1 in 1000 patients).28 In addition, most physicians believed that complaints of increased pain among patients receiving opioid therapy for pain control meant tolerance to the medication, a belief consistent with physician reluctance to prescribe more medication because it would lead to tolerance.28 In reality, the increased pain experienced in these situations is typically not a result of tolerance to the pain medication but to the cancer getting worse.27 Additionally, many physicians mistakenly decreased the dose of morphine in converting the route of administration from PO to IV, as is often done in hospitals. Such an error may be a contributing factor to the unintended undertreatment of pain in hospitals. Given the variability of cancer pain4 and the difference in time to peak effect depending on the route of administration,5 it is critical for physicians to understand proper dosing in order to effectively treat cancer pain. Furthermore, many physicians were incorrect about the recommended medications for dyspnea and for agitation, 2 symptoms that are prevalent among patients at the end of life.

The hospitalists and residents reported having very positive views about hospice, as is consistent with the literature.10, 30 However, many respondents indicated that patients who would have benefited from hospice did not receive it at all or only late in their illness. Physicians indicated that better communication with patients and families about hospice, prognosis, and goals of care would enhance appropriate use of hospice. While hospitalists and residents are in a position to initiate such discussions, they reported that these discussions were difficult for them. The challenge is how to promote what is necessary and valuable conversation with patients and families despite their difficulty, so that a realistic plan of care can be designed for all involved. Providing hospitalists and residents with evidence about what approaches are most effective in such discussions would be helpful to better prepare them for their roles in caring for hospitalized patients with terminal illness.

The results of this study have substantiated the need to enhance the education of hospitalists and resident physicians, who can play a vital role in improving the transition from hospital to hospice. Such education could take place as part of the residency experience or be embedded in various continuing medical education requirements that most states now have. The results of a recent national survey of hospitalists31 indicates they consider their palliative care training inadequate and feel ill prepared to care for patients with terminal illness. Our findings are consistent with those of that survey, highlighting information that is poorly understood by both residents and hospitalists. As hospitalists continue to play key roles in linking hospital to posthospital care,21 including hospice, there is greater opportunity to improve end‐of‐life care by expanding hospitalists' understanding of these issues.

Our findings should be interpreted in light of the study's limitations. First, this was an exploratory study, and the sample was modest in size. Nevertheless, the response rate was high: 85.2%. Second, we conducted the study in a single location; results may differ in other geographical areas. Last, we were unable to link reported knowledge and attitudes to patient experiences including quality of care or adequacy of pain control. Inadequate knowledge likely limits the quality of clinical practices, but the magnitude of this effect remains unknown and worthy of future study.

Despite these limitations, this study has contributed to the literature by identifying a set of misunderstandings or myths that may be common among hospitalists and residents who frequently care for hospitalized patients with terminal illness. Many of these misunderstandings were related to pain and symptom management, although some misunderstandings related to logistical issues such as hospice eligibility rules. Previous studies have described interventions to improve physicians' knowledge about palliative and end‐of‐life care practices at the undergraduate, graduate, and postgraduate levels.13 Our findings identified specific gaps in physicians' knowledge. Interventions aimed at closing these gaps might emphasize both specific clinical information about pain management and medication recommendations, and more general information about eligibility for hospice and best practices for communicating early with patients and family is needed to promote more effective care for patients with terminal illness being cared for in acute care settings.

As the use of hospitalists has become a widely accepted model of hospital care,32 ensuring their increased training and education in the care of patients with terminal illness is an important step in improving end‐of‐life care. Larger comparison studies are needed to identify differences in the practices and perspectives of hospitalists and residents and to target educational interventions to meet their particular needs. Further, conducting these studies at additional sites including those with established palliative care programs would be useful for identifying needs among a more diverse set of physicians involved in delivering end‐of‐life care.

APPENDIX

Survey on Hospice and End‐of‐Life Care

Survey ID _________________

Date ______________

I

DEMOGRAPHICS

1

What is your gender?

1
□ Male
2
□ Female
2
What year did you graduate from medical school? ___________

3

What is your primary specialty or area of practice?

1
□ Hospitalist
2
□ Oncology fellow
3
□ Oncology resident
4
□ Physician assistant
5
□ Other: _____________

II

KNOWLEDGE OF HOSPICE AND PALLIATIVE CARE PRACTICES

4

The incidence of psychological dependence (addiction) to opioids and analgesics when treating pain from cancer or other medical conditions is:

a
Common (1 in 10 patients)
b
Uncommon (1 in 100 patients)
c
Very rare (fewer than 1 in 1000 patients)

5

When a patient with cancer who is receiving opioids for pain complains of increasing pain, it most likely indicates:

a
Opioid tolerance
b
Increasing pathology of the cancer
c
Patient noncompliance
d
New onset of a different opioid‐resisting pain

6

In the pain patient receiving opioids, 30 mg of oral morphine is equipotent to _______________ of IV.

a
1mg
b
5 mg
c
10 mg
d
20 mg

7

The 2 classes of drugs most commonly recommended for treating terminal dyspnea are:

a
Beta‐blockers and Lasix
b
Opioids and benzodiazepines
c
Beta‐blockers and corticosteroids
d
Beta‐blockers and Singulair (montelukast)

8

A hospice patient whose agitation is due primarily to anxiety should be treated with:

a
Chlorpromazine
b
Haloperidol
c
Lorazepam
d
Morphine

III

ELIGIBILITY FOR HOSPICE CARE

9

Under the Medicare program, a physician must certify that the patient is expected to die within a specified time for the patients to be eligible for hospice services. To the best of your knowledge, patients become eligible for inpatient hospice care when they are expected to die in:

1
□ 2 Weeks
2
□ 6 Weeks
3
□ 2 Months
4
□ 6 Months
7
□ Other: ________________________
9
□ Don't know

10

To the best of your knowledge, patients are eligible for home hospice care when they are expected to die in:

1
□ 2 Weeks
2
□ 6 Weeks
3
□ 2 Months
4
□ 6 Months
7
□ Other: __________________________
9
□ Don't know
IV
ATTITUDES ABOUT HOSPICE CARE 0

Table .Following is a series of statements. Please state whether you strongly agree, agree, neither agree nor disagree, disagree, or strongly disagree with each statement.
	Strongly agree			Strongly disagree
11) Most patients want me to tell them their life expectancy.	1 □	2 □	3 □	4 □	5 □
12) Generally, family caregivers want me to tell them the patient's life expectancy.	1 □	2 □	3 □	4 □	5 □
13) Telling the patient and family members that the patient's illness is incurable is difficult for me.	1 □	2 □	3 □	4 □	5 □
14) I think it is essential to discuss the prognosis with a patient, even if it is very poor.	1 □	2 □	3 □	4 □	5 □
15) Most patients' physical symptoms (eg, pain, shortness of breath, and nausea) are controlled better with hospice than with the care they would receive in the hospital.	1 □	2 □	3 □	4 □	5 □
16) Most patients' emotional symptoms (eg, depression, anxiety) are controlled better with hospice than with the care they would receive in the hospital.	1 □	2 □	3 □	4 □	5 □
17) Hospice care generally meets the needs of the family better than conventional care does.	1 □	2 □	3 □	4 □	5 □
18) Many terminally ill patients who should receive hospice care do not receive hospice care.	1 □	2 □	3 □	4 □	5 □
19) Many patients would benefit if hospice care were initiated earlier in the course of their illness.	1 □	2 □	3 □	4 □	5 □
20) I feel knowledgeable enough to discuss palliative and hospice care with patients and families.	1 □	2 □	3 □	4 □	5 □
21) What do you see as the primary ways to facilitate earlier initiation of hospice care for patients who are eligible? _____________________________________________________________________________________
___________________________________________________________________________________________

References

Institute of Medicine.Approaching Death.Washington, DC:National Academy Press;1997.
SUPPORT Principle Investigators.A controlled trial to improve care for seriously ill hospitalized patients.JAMA.1995;274:1591–1598.
Morrison RS,Meier DE,Fischberg D, et al.Improving the management of pain in hospitalized adults.Arch Intern Med.2006;166:1033–1039.
von Gunten CF.Interventions to manage symptoms at the end of life.J Palliat Med.2005;8(suppl 1):S88–S94.
Bradley EH,Hallemeier AG,Fried TR, et al.Documentation of discussions about prognosis with terminally ill patients.Am J Med.2001;111:218–223.
Chittenden EH,Clark ST,Pantilat SZ.Discussing resuscitation preferences with patients: challenges and rewards.J Hosp Med.2006;1:231–249.
Schulman‐Green D,McCorkle R,Curry L,Cherlin E,Johnson‐Hurzeler R,Bradley E.At the crossroads: making the transition to hospice.Palliat Support Care.2004;2:351–360.
Bradley EH,Fried TR,Kasl SV,Cicchetti DV,Johnson‐Hurzeler R,Horwitz SM.Referral of terminally ill patients for hospice: frequency and correlates.J Palliat Care.2000;16(4):20–26.
Ogle K,Mavis B,Wang T.Hospice and primary care physicians: attitudes, knowledge, and barriers.Am J Hosp Palliat Care.2003;20(1):41–51.
Ogle KS,Mavis B,Wyatt GK.Physicians and hospice care: attitudes, knowledge, and referrals.J Palliat Med.2002;5(1):85–92.
Block SD.Medical education in end‐of‐life care: the status of reform.J Palliat Med.2002;5(2):243–248.
Meier DE,Morrison RS,Cassel CK.Improving palliative care.Ann Intern Med.1997;127(3):225–230.
Weissman DE,Mullan P,Ambuel B,von Gunten CF,Hallenbeck J,Warm E.Improving end‐of‐life care: internal medicine curriculum project—abstracts/progress reports.J Palliat Med.2001;4(1):75–102.
Bailey FA,Burgio KL,Woodby LL, et al.Improving processes of hospital care during the last hours of life.Arch Intern Med.2005;165:1722–1727.
Pan CX,Morrison RS,Meier DE, et al.How prevalent are hospital‐based palliative care programs? Status report and future directions.J Palliat Med.2001;4:315–324.
von Gunten CF,Twaddle M,Preodor M,Neely KJ,Martinez J,Lyons J.Evidence of improved knowledge and skills after an elective rotation in a hospice and palliative care program for internal medicine residents.Am J Hosp Palliat Care.2005;22(3):195–203.
Clark JM,Lurie JD,Claessens MT,Reed VA,Jernstedt GC,Goodlin SG.Factors associated with palliative care knowledge among internal medicine house staff.J Palliat Care.2003;19:253–257.
Fineberg IC,Wenger NS,Brown‐Saltzman K.Unrestricted opiate administration for pain and suffering at the end of life: knowledge and attitudes as barriers to care.J Palliat Med.2006;9:873–883.
Coffman J,Rundall TG.The impact of hospitalists on the cost and quality of inpatient care in the United States: a research synthesis.Med Care Res Rev.2005;62:379–406.
Meltzer D,Manning WG,Morrison J, et al.Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists.Ann Intern Med.2002;137:866–874.
Muir JC,Arnold RM.Palliative care and the hospitalist: an opportunity for cross‐fertilization.Am J Med.2001;111 (9B):10S–14S.
Wachter RM.The evolution of the hospitalist model in the United States.Med Clin North Am.2002;86:687–706.
Wachter RM,Goldman L.The emerging role of “hospitalists” in the American health care system.N Engl J Med.1996;335:514–517.
Bradley EH,Cicchetti DV,Fried TR, et al.Attitudes about care at the end of life among clinicians: a quick, reliable, and valid assessment instrument.J Palliat Care.2000;16(1):6–14.
Bradley EH,Cramer LD,Bogardus ST,Kasl SV,Johnson‐Hurzeler R,Horwitz SM.Physicians' ratings of their knowledge, attitudes, and end‐of‐life‐care practices.Acad Med.2002;77:305–311.
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Rosemary Johnson‐Hurzeler, RN, MPH

Gail M. Sullivan, MD, MPH

Elizabeth H. Bradley, PhD

Author(s)

Emily Cherlin, MSW

Victor Morris, MD

Jensa Morris, MD

Rosemary Johnson‐Hurzeler, RN, MPH

Gail M. Sullivan, MD, MPH

Elizabeth H. Bradley, PhD

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Shortcomings in the quality of care of hospitalized patients at the end of life, especially in the final days, are well documented.1, 2 Recent studies have highlighted inadequate pain and symptom control for hospitalized terminally ill patients,24 poor communication about treatment preferences,57 and limited or delayed referral for hospice care.810 Efforts to improve the quality of end‐of‐life care have been diverse, including increased educational programs,1113 development of palliative care units in hospitals,14, 15 and greater exposure to palliative care for physicians during residency training.16 Despite these efforts, studies assessing the attitudes and knowledge of physicians about hospice and palliative care continue to show deficits in knowledge about managing pain17, 18 as well as hospice policies and services.9

Among the interventions aimed at improving hospital care, the hospitalist movement has emerged as a model of care for improving the quality and cost efficiency of hospital care.1922 Because hospitalists spend substantial time on inpatient services,23 they are often involved in the care of patients with terminal illness, with potential to improve the quality of care that these patients receive while hospitalized. However, little is known about what specific knowledge and perspectives hospitalists and residents have about the care of patients with terminal illness. Although many studies have been conducted among physicians in private practice,9, 10, 2426 they have not focused on the knowledge, reported practices, and attitudes of hospitalists and residents concerning key aspects of end‐of‐life care and hospice. Such information can help to identify potential areas for improving knowledge and addressing common barriers highlighted in linking hospital and posthospital hospice care.

METHODS

Study Design and Sample

During 2006 we surveyed hospitalists and medical residents who were on their oncology rotation at a large academic medical center that did not have a hospital‐based palliative care unit in order to examine their knowledge, attitudes, and practices regarding terminally ill patients and hospice referrals. Hospitalists (n = 23) and medical residents (n = 29) made up a convenience sample of 52 physicians. The medical residents were completing their oncology rotation during the spring of 2006. The Institutional Review Board at Yale University School of Medicine approved the research protocol and verbal consent procedures.

Survey

The brief survey instrument (see Appendix) assessed physicians' knowledge and attitudes about and practices in caring for patients with terminal illness. The survey was adapted from previously published instruments8, 24 that have been shown24 to have good test‐retest reliability and construct validity. The survey contained 5 items pertaining to clinical knowledge about palliative care practices, including common symptoms and drug indications, doses, and side effects.27 An additional 2 items pertained to respondents' knowledge about nonclinical issues concerning eligibility rules for hospice,8 such as how a patient becomes eligible for hospice and whether Medicare benefits can be revoked or reinstated after hospice is elected. The survey also included 10 statements24 assessing physician attitudes about caring for patients with terminal illness. Responses, provided using a 5‐point Likert scale, were collapsed for reporting into a 3‐point scale of agree, neutral, and disagree. The instrument also included an open‐ended question asking physicians to specify what from their perspective was needed to ensure timely referral for hospice and palliative care.

Data Analysis

We used standard frequency analysis to describe the distribution of responses to the survey items. Based on an analysis of common erroneous answers to clinical knowledge questions, we identified several common myths prevalent among hospitalists and medicine residents. We also examined whether knowledge, reported practices, and attitudes differed significantly between the hospitalist and the resident samples using ANOVA or chi‐square statistics as appropriate. We used content analysis to summarize the open‐ended responses about potential ways to overcome what respondents perceived was underutilization of hospice.

RESULTS

Overview

The response rate for the survey was 85.2%. Almost half of the respondents (44.2%) were hospitalists (Table 1). The remaining respondents included first‐year (n = 9) and second‐ or third‐year (n = 16) residents or fellows (n = 4). Approximately 54% of the 52 respondents were female, and the majority (83%) had graduated from medical school between 2000 and 2005. Several common myths were apparent and pertained to essential areas of treating patients with terminal illness: pain control, symptom control, and eligibility for hospice (Table 2). Respondents generally had strong beliefs about caring for patients with terminal illness, and most agreed that many patients who would benefit from hospice either do not receive hospice or receive it only late in the course of their illness (Table 3).

Table 1.Demographic Characteristics of Respondents (n = 52)
Characteristic	n	%
Sex
Female	28	53.9%
Male	24	46.1%
Years since graduation from medical school
1‐2 Years	26	56.5%
3‐5 Years	12	26.1%
>5 Years	8	17.4%
Missing	6
Physician type
Hospitalist	23	44.2%
First‐year resident	9	17.3%
Second‐ or third‐year resident	16	30.8%
Fellow	4	7.7%

Table 2.Knowledge about Hospice and Palliative Care Practices and Eligibility for Hospice Care (n = 52)*
Questions about hospice and palliative care practices	Response (%)
* Correct answers, that is, facts, are in bold.
The incidence of psychological dependence (addiction) to opioids and analgesics when treating pain from cancer or other medical conditions is:
Common (1 in 10 patients)	17.3
Uncommon (1 in 100 patients)	48.1
Very rare (fewer than 1 in 1000 patients)	34.6
When a patient with cancer who is receiving opioids for pain complains of increasing pain, it most likely indicates:
Opioid tolerance	69.2
Increasing pathology of the cancer	26.9
Patient noncompliance	0.0
New onset of a different opioid‐resisting pain	3.9
In the pain patient receiving opioids, 30 mg of oral morphine is equipotent to of IV morphine
1 mg	4.0
5 mg	40.0
10 mg	56.0
20 mg	0.0
The 2 classes of drugs most commonly recommended for treating terminal dyspnea are:
Beta‐blockers and Lasix	7.7
Opioids and benzodiazepines	82.7
Beta‐blockers and corticosteroids	9.6
Beta‐blockers and Singulair (montelukast)	0.0
A hospice patient whose agitation is primarily from anxiety should be treated with:
Chlorpromazine (thorazine)	0.0
Haloperidol	21.6
Lorazepam (Ativan)	76.4
Morphine	2.0
Questions about eligibility for hospice care	Response (%)
Under the Medicare program, a physician must certify that the patient is expected to die within a specified time for the patients to be eligible for hospice services. To the best of your knowledge, patients become eligible for inpatient hospice care when they are expected to die in:
2 Weeks	5.8
6 Weeks	9.6
2 Months	9.6
6 Months	69.2
Other	1.9
Don't know	3.8
To the best of your knowledge, patients become eligible for home hospice care when they are expected to die in:
2 Weeks	0.0
6 Weeks	5.8
2 Months	7.7
6 Months	73.1
Other	0.0
Don't know	13.4

Table 3.Physicians' Beliefs about Caring for Patients with Terminal Illness (n = 52)
Beliefs	Disagree (%)	Neutral (%)	Agree (%)
Most patients want me to tell them their life‐expectancy.	0.0	17.4	82.6
Generally, family caregivers want me to tell them the patient's life expectancy.	4.4	8.7	86.9
Telling the patient and family members that the patient's illness is incurable is difficult for me.	23.0	13.5	63.5
I think it is essential to discuss the prognosis with a patient, even if it is very poor.	0.0	4.4	95.6
Most patients' physical symptoms (eg, pain, shortness of breath, and nausea) are controlled better with hospice than with the care that they would receive in the hospital.	0.0	21.7	78.3
Most patients' emotional symptoms (eg, depression, anxiety) are controlled better with hospice than with the care they would receive in the hospital.	0.0	8.7	91.3
Hospice meets the needs of the family better than conventional care does.	0.0	8.7	91.3
Many patients who should receive hospice care do not receive hospice care.	21.8	13.0	65.2
Many patients would benefit if hospice care were initiated earlier in the course of their illness.	0.0	9.1	90.9
I feel knowledgeable enough to discuss palliative and hospice care with patients and families.	19.2	38.5	42.3

Common Myths in Treating Patients with Terminal Illness

Myth 1. Treating cancer pain with opioids or analgesics causes addiction in 1 in 100 patients. Most physicians thought that addiction in patients treated for cancer pain with opioids or analgesics was much more common than it is. Almost half the respondents (48.1%) thought addiction occurred in 1 in 100 patients, and an additional 17.3% of respondents thought addiction occurred in 1 in 10 patients treated for cancer pain with opioids or analgesics. In contrast, the incidence of addiction in patients treated with opioids or analgesics for cancer pain is fewer than 1 in 1000 patients.28

Myth 2. When patients with cancer already receiving opioids for pain control complain of increasing pain, it most likely indicates opioid tolerance. Nearly 70% of respondents reported that the most likely reason for complaints of increased pain was tolerance to the opioid. However, the most likely reason for increased pain is increasing pathology of the cancer.27

Myth 3. The equipotent to 30 mg of oral morphine is 5 mg intravenous. More than half of respondents were inaccurate in their conversion of oral to intravenous (IV) morphine dosing, a common task of physicians caring for terminally ill patients. Almost half the physicians (44%) erroneously reported that 30 mg of oral morphine was equipotent to 5 mg or less morphine IV. However, in fact, 30 mg of oral morphine is equipotent to 10 mg of morphine IV.27

Myth 4. The most highly recommended drug for treating terminal dyspnea is a beta‐blocker, and the most appropriate drug for agitation due to anxiety is Haldol or morphine. Most respondents were able to identify the correct drugs; however, a sizable proportion of respondents (17.3%) erroneously responded that beta‐blockers and Lasix or beta‐blockers and corticosteroids were the best drugs for treating terminal dyspnea. About one‐fifth of respondents (21.6%) responded that Haldol or morphine was the recommended medication for treating agitation. In fact, opioids and benzodiazepines are the recommended drugs for treating terminal dyspnea,27 and the proper drug for treating agitation is lorazepam (Ativan).27

Myth 5. Patient life expectancy must be 2 months or less to be eligible for hospice. One‐quarter of respondents believed this to be true for inpatient hospice, and nearly 13.5% of respondents believe this to be true for home hospice. In fact, patients are eligible for hospice benefits earlier in the course of their illness. Under Medicare and most insurance policies, patients are eligible for hospice benefits as soon as their life expectancy is 6 months or less, not 2 months or less.27

Physician Beliefs about Caring for Patients with Terminal Illness

The physicians' beliefs about hospice were generally positive; the vast majority of respondents agreed or strongly agreed with the statement that physical and emotional symptoms of patients and family needs are better addressed with hospice than with the hospital care (Table 3). Most respondents also agreed that many patients do not receive hospice as they should and that hospice should be initiated earlier in the course of the illness. In addition, more than 80% of respondents believed patients and their families want their doctors to tell them the patient's life expectancy, and 95.6% of respondents thought it was essential to discuss prognosis, even a poor one, with the patient. Nevertheless, many respondents (65.3%) reported it was difficult to tell patients and their families that an illness was incurable. Furthermore, fewer than half the respondents (42.3%) believed they were knowledgeable enough to discuss hospice and palliative care with patients and their families.

In subgroup analyses comparing responses to knowledge and attitude items reported in Tables 2 and 3, we found no significant differences between hospitalists and any subgroup of residents by year of training or fellows, or between hospitalists and the full sample of residents and fellows. Because of the sample size, the statistical power for evaluating significance was limited in these exploratory subgroup analyses.

Among physicians who provided responses to the open‐ended question (n = 42) about how to enhance hospice referral rates and improve their timeliness, the most commonly reported suggestions were: (1) involve family members, not only patients, in discussions of hospice (38.1%), (2) have discussions about hospice earlier in the course of care with patients (26.2%), and (3) be clear with patients and families about the patient's prognosis (19.0%). Table 4 has a list of all responses provided to this question.

Table 4.Physicians' Suggestions for Improving the Process of Hospice Referral (n = 42)
Response	n	%*
* Percentages add up to more than 100% because some respondents made more than 1 suggestion.
Involving family members as well as patients in discussions of hospice	16	38.1
Having earlier discussion with patients	11	26.2
Being clear with patients and families about patient prognosis	8	19.0
Providing education about hospice to patients and families	6	14.3
Discussions of goals of care with patients and families	6	14.3
Involving social worker in discussions	4	9.5
Providing literature to patients and families about hospice	3	7.1
Having hospice representative available to provide education to patient and families	2	4.8

DISCUSSION

This study demonstrated that, among hospitalists and residents, there are several misconceptions about fundamental aspects of caring for terminally ill patients. Given the potential importance of the role hospitalists play in improving the quality of inpatient care,1922 it is critical to identify and address these misconceptions. Additionally, physicians in this study indicated that more and earlier communication with patients and families about prognosis and about the option of hospice would be beneficial, but they themselves did not feel knowledgeable enough to discuss hospice and palliative care with patients and their families.

The nature of the misconceptions identified in this study shed light on the well‐documented phenomena of inadequate pain control24, 29 and poor symptom management2, 4 at the end of life. Having many of the erroneous beliefs apparent in this study may be consistent with providing less pain medication than needed and appropriate. For instance, many physicians believed that developing addiction to opioids used for cancer pain is more likely to occur than it really is, according to research evidence. It is extremely rare for these patients to become addicted to opioids or other analgesics (fewer than 1 in 1000 patients).28 In addition, most physicians believed that complaints of increased pain among patients receiving opioid therapy for pain control meant tolerance to the medication, a belief consistent with physician reluctance to prescribe more medication because it would lead to tolerance.28 In reality, the increased pain experienced in these situations is typically not a result of tolerance to the pain medication but to the cancer getting worse.27 Additionally, many physicians mistakenly decreased the dose of morphine in converting the route of administration from PO to IV, as is often done in hospitals. Such an error may be a contributing factor to the unintended undertreatment of pain in hospitals. Given the variability of cancer pain4 and the difference in time to peak effect depending on the route of administration,5 it is critical for physicians to understand proper dosing in order to effectively treat cancer pain. Furthermore, many physicians were incorrect about the recommended medications for dyspnea and for agitation, 2 symptoms that are prevalent among patients at the end of life.

The hospitalists and residents reported having very positive views about hospice, as is consistent with the literature.10, 30 However, many respondents indicated that patients who would have benefited from hospice did not receive it at all or only late in their illness. Physicians indicated that better communication with patients and families about hospice, prognosis, and goals of care would enhance appropriate use of hospice. While hospitalists and residents are in a position to initiate such discussions, they reported that these discussions were difficult for them. The challenge is how to promote what is necessary and valuable conversation with patients and families despite their difficulty, so that a realistic plan of care can be designed for all involved. Providing hospitalists and residents with evidence about what approaches are most effective in such discussions would be helpful to better prepare them for their roles in caring for hospitalized patients with terminal illness.

The results of this study have substantiated the need to enhance the education of hospitalists and resident physicians, who can play a vital role in improving the transition from hospital to hospice. Such education could take place as part of the residency experience or be embedded in various continuing medical education requirements that most states now have. The results of a recent national survey of hospitalists31 indicates they consider their palliative care training inadequate and feel ill prepared to care for patients with terminal illness. Our findings are consistent with those of that survey, highlighting information that is poorly understood by both residents and hospitalists. As hospitalists continue to play key roles in linking hospital to posthospital care,21 including hospice, there is greater opportunity to improve end‐of‐life care by expanding hospitalists' understanding of these issues.

Our findings should be interpreted in light of the study's limitations. First, this was an exploratory study, and the sample was modest in size. Nevertheless, the response rate was high: 85.2%. Second, we conducted the study in a single location; results may differ in other geographical areas. Last, we were unable to link reported knowledge and attitudes to patient experiences including quality of care or adequacy of pain control. Inadequate knowledge likely limits the quality of clinical practices, but the magnitude of this effect remains unknown and worthy of future study.

Despite these limitations, this study has contributed to the literature by identifying a set of misunderstandings or myths that may be common among hospitalists and residents who frequently care for hospitalized patients with terminal illness. Many of these misunderstandings were related to pain and symptom management, although some misunderstandings related to logistical issues such as hospice eligibility rules. Previous studies have described interventions to improve physicians' knowledge about palliative and end‐of‐life care practices at the undergraduate, graduate, and postgraduate levels.13 Our findings identified specific gaps in physicians' knowledge. Interventions aimed at closing these gaps might emphasize both specific clinical information about pain management and medication recommendations, and more general information about eligibility for hospice and best practices for communicating early with patients and family is needed to promote more effective care for patients with terminal illness being cared for in acute care settings.

As the use of hospitalists has become a widely accepted model of hospital care,32 ensuring their increased training and education in the care of patients with terminal illness is an important step in improving end‐of‐life care. Larger comparison studies are needed to identify differences in the practices and perspectives of hospitalists and residents and to target educational interventions to meet their particular needs. Further, conducting these studies at additional sites including those with established palliative care programs would be useful for identifying needs among a more diverse set of physicians involved in delivering end‐of‐life care.

APPENDIX

Survey on Hospice and End‐of‐Life Care

Survey ID _________________

Date ______________

I

DEMOGRAPHICS

1

What is your gender?

1
□ Male
2
□ Female
2
What year did you graduate from medical school? ___________

3

What is your primary specialty or area of practice?

1
□ Hospitalist
2
□ Oncology fellow
3
□ Oncology resident
4
□ Physician assistant
5
□ Other: _____________

II

KNOWLEDGE OF HOSPICE AND PALLIATIVE CARE PRACTICES

4

The incidence of psychological dependence (addiction) to opioids and analgesics when treating pain from cancer or other medical conditions is:

a
Common (1 in 10 patients)
b
Uncommon (1 in 100 patients)
c
Very rare (fewer than 1 in 1000 patients)

5

When a patient with cancer who is receiving opioids for pain complains of increasing pain, it most likely indicates:

a
Opioid tolerance
b
Increasing pathology of the cancer
c
Patient noncompliance
d
New onset of a different opioid‐resisting pain

6

In the pain patient receiving opioids, 30 mg of oral morphine is equipotent to _______________ of IV.

a
1mg
b
5 mg
c
10 mg
d
20 mg

7

The 2 classes of drugs most commonly recommended for treating terminal dyspnea are:

a
Beta‐blockers and Lasix
b
Opioids and benzodiazepines
c
Beta‐blockers and corticosteroids
d
Beta‐blockers and Singulair (montelukast)

8

A hospice patient whose agitation is due primarily to anxiety should be treated with:

a
Chlorpromazine
b
Haloperidol
c
Lorazepam
d
Morphine

III

ELIGIBILITY FOR HOSPICE CARE

9

Under the Medicare program, a physician must certify that the patient is expected to die within a specified time for the patients to be eligible for hospice services. To the best of your knowledge, patients become eligible for inpatient hospice care when they are expected to die in:

1
□ 2 Weeks
2
□ 6 Weeks
3
□ 2 Months
4
□ 6 Months
7
□ Other: ________________________
9
□ Don't know

10

To the best of your knowledge, patients are eligible for home hospice care when they are expected to die in:

1
□ 2 Weeks
2
□ 6 Weeks
3
□ 2 Months
4
□ 6 Months
7
□ Other: __________________________
9
□ Don't know
IV
ATTITUDES ABOUT HOSPICE CARE 0

Table .Following is a series of statements. Please state whether you strongly agree, agree, neither agree nor disagree, disagree, or strongly disagree with each statement.
	Strongly agree			Strongly disagree
11) Most patients want me to tell them their life expectancy.	1 □	2 □	3 □	4 □	5 □
12) Generally, family caregivers want me to tell them the patient's life expectancy.	1 □	2 □	3 □	4 □	5 □
13) Telling the patient and family members that the patient's illness is incurable is difficult for me.	1 □	2 □	3 □	4 □	5 □
14) I think it is essential to discuss the prognosis with a patient, even if it is very poor.	1 □	2 □	3 □	4 □	5 □
15) Most patients' physical symptoms (eg, pain, shortness of breath, and nausea) are controlled better with hospice than with the care they would receive in the hospital.	1 □	2 □	3 □	4 □	5 □
16) Most patients' emotional symptoms (eg, depression, anxiety) are controlled better with hospice than with the care they would receive in the hospital.	1 □	2 □	3 □	4 □	5 □
17) Hospice care generally meets the needs of the family better than conventional care does.	1 □	2 □	3 □	4 □	5 □
18) Many terminally ill patients who should receive hospice care do not receive hospice care.	1 □	2 □	3 □	4 □	5 □
19) Many patients would benefit if hospice care were initiated earlier in the course of their illness.	1 □	2 □	3 □	4 □	5 □
20) I feel knowledgeable enough to discuss palliative and hospice care with patients and families.	1 □	2 □	3 □	4 □	5 □
21) What do you see as the primary ways to facilitate earlier initiation of hospice care for patients who are eligible? _____________________________________________________________________________________
___________________________________________________________________________________________

Shortcomings in the quality of care of hospitalized patients at the end of life, especially in the final days, are well documented.1, 2 Recent studies have highlighted inadequate pain and symptom control for hospitalized terminally ill patients,24 poor communication about treatment preferences,57 and limited or delayed referral for hospice care.810 Efforts to improve the quality of end‐of‐life care have been diverse, including increased educational programs,1113 development of palliative care units in hospitals,14, 15 and greater exposure to palliative care for physicians during residency training.16 Despite these efforts, studies assessing the attitudes and knowledge of physicians about hospice and palliative care continue to show deficits in knowledge about managing pain17, 18 as well as hospice policies and services.9

Among the interventions aimed at improving hospital care, the hospitalist movement has emerged as a model of care for improving the quality and cost efficiency of hospital care.1922 Because hospitalists spend substantial time on inpatient services,23 they are often involved in the care of patients with terminal illness, with potential to improve the quality of care that these patients receive while hospitalized. However, little is known about what specific knowledge and perspectives hospitalists and residents have about the care of patients with terminal illness. Although many studies have been conducted among physicians in private practice,9, 10, 2426 they have not focused on the knowledge, reported practices, and attitudes of hospitalists and residents concerning key aspects of end‐of‐life care and hospice. Such information can help to identify potential areas for improving knowledge and addressing common barriers highlighted in linking hospital and posthospital hospice care.

METHODS

Study Design and Sample

During 2006 we surveyed hospitalists and medical residents who were on their oncology rotation at a large academic medical center that did not have a hospital‐based palliative care unit in order to examine their knowledge, attitudes, and practices regarding terminally ill patients and hospice referrals. Hospitalists (n = 23) and medical residents (n = 29) made up a convenience sample of 52 physicians. The medical residents were completing their oncology rotation during the spring of 2006. The Institutional Review Board at Yale University School of Medicine approved the research protocol and verbal consent procedures.

Survey

The brief survey instrument (see Appendix) assessed physicians' knowledge and attitudes about and practices in caring for patients with terminal illness. The survey was adapted from previously published instruments8, 24 that have been shown24 to have good test‐retest reliability and construct validity. The survey contained 5 items pertaining to clinical knowledge about palliative care practices, including common symptoms and drug indications, doses, and side effects.27 An additional 2 items pertained to respondents' knowledge about nonclinical issues concerning eligibility rules for hospice,8 such as how a patient becomes eligible for hospice and whether Medicare benefits can be revoked or reinstated after hospice is elected. The survey also included 10 statements24 assessing physician attitudes about caring for patients with terminal illness. Responses, provided using a 5‐point Likert scale, were collapsed for reporting into a 3‐point scale of agree, neutral, and disagree. The instrument also included an open‐ended question asking physicians to specify what from their perspective was needed to ensure timely referral for hospice and palliative care.

Data Analysis

We used standard frequency analysis to describe the distribution of responses to the survey items. Based on an analysis of common erroneous answers to clinical knowledge questions, we identified several common myths prevalent among hospitalists and medicine residents. We also examined whether knowledge, reported practices, and attitudes differed significantly between the hospitalist and the resident samples using ANOVA or chi‐square statistics as appropriate. We used content analysis to summarize the open‐ended responses about potential ways to overcome what respondents perceived was underutilization of hospice.

RESULTS

Overview

The response rate for the survey was 85.2%. Almost half of the respondents (44.2%) were hospitalists (Table 1). The remaining respondents included first‐year (n = 9) and second‐ or third‐year (n = 16) residents or fellows (n = 4). Approximately 54% of the 52 respondents were female, and the majority (83%) had graduated from medical school between 2000 and 2005. Several common myths were apparent and pertained to essential areas of treating patients with terminal illness: pain control, symptom control, and eligibility for hospice (Table 2). Respondents generally had strong beliefs about caring for patients with terminal illness, and most agreed that many patients who would benefit from hospice either do not receive hospice or receive it only late in the course of their illness (Table 3).

Table 1.Demographic Characteristics of Respondents (n = 52)
Characteristic	n	%
Sex
Female	28	53.9%
Male	24	46.1%
Years since graduation from medical school
1‐2 Years	26	56.5%
3‐5 Years	12	26.1%
>5 Years	8	17.4%
Missing	6
Physician type
Hospitalist	23	44.2%
First‐year resident	9	17.3%
Second‐ or third‐year resident	16	30.8%
Fellow	4	7.7%

Table 2.Knowledge about Hospice and Palliative Care Practices and Eligibility for Hospice Care (n = 52)*
Questions about hospice and palliative care practices	Response (%)
* Correct answers, that is, facts, are in bold.
The incidence of psychological dependence (addiction) to opioids and analgesics when treating pain from cancer or other medical conditions is:
Common (1 in 10 patients)	17.3
Uncommon (1 in 100 patients)	48.1
Very rare (fewer than 1 in 1000 patients)	34.6
When a patient with cancer who is receiving opioids for pain complains of increasing pain, it most likely indicates:
Opioid tolerance	69.2
Increasing pathology of the cancer	26.9
Patient noncompliance	0.0
New onset of a different opioid‐resisting pain	3.9
In the pain patient receiving opioids, 30 mg of oral morphine is equipotent to of IV morphine
1 mg	4.0
5 mg	40.0
10 mg	56.0
20 mg	0.0
The 2 classes of drugs most commonly recommended for treating terminal dyspnea are:
Beta‐blockers and Lasix	7.7
Opioids and benzodiazepines	82.7
Beta‐blockers and corticosteroids	9.6
Beta‐blockers and Singulair (montelukast)	0.0
A hospice patient whose agitation is primarily from anxiety should be treated with:
Chlorpromazine (thorazine)	0.0
Haloperidol	21.6
Lorazepam (Ativan)	76.4
Morphine	2.0
Questions about eligibility for hospice care	Response (%)
Under the Medicare program, a physician must certify that the patient is expected to die within a specified time for the patients to be eligible for hospice services. To the best of your knowledge, patients become eligible for inpatient hospice care when they are expected to die in:
2 Weeks	5.8
6 Weeks	9.6
2 Months	9.6
6 Months	69.2
Other	1.9
Don't know	3.8
To the best of your knowledge, patients become eligible for home hospice care when they are expected to die in:
2 Weeks	0.0
6 Weeks	5.8
2 Months	7.7
6 Months	73.1
Other	0.0
Don't know	13.4

Table 3.Physicians' Beliefs about Caring for Patients with Terminal Illness (n = 52)
Beliefs	Disagree (%)	Neutral (%)	Agree (%)
Most patients want me to tell them their life‐expectancy.	0.0	17.4	82.6
Generally, family caregivers want me to tell them the patient's life expectancy.	4.4	8.7	86.9
Telling the patient and family members that the patient's illness is incurable is difficult for me.	23.0	13.5	63.5
I think it is essential to discuss the prognosis with a patient, even if it is very poor.	0.0	4.4	95.6
Most patients' physical symptoms (eg, pain, shortness of breath, and nausea) are controlled better with hospice than with the care that they would receive in the hospital.	0.0	21.7	78.3
Most patients' emotional symptoms (eg, depression, anxiety) are controlled better with hospice than with the care they would receive in the hospital.	0.0	8.7	91.3
Hospice meets the needs of the family better than conventional care does.	0.0	8.7	91.3
Many patients who should receive hospice care do not receive hospice care.	21.8	13.0	65.2
Many patients would benefit if hospice care were initiated earlier in the course of their illness.	0.0	9.1	90.9
I feel knowledgeable enough to discuss palliative and hospice care with patients and families.	19.2	38.5	42.3

Common Myths in Treating Patients with Terminal Illness

Myth 1. Treating cancer pain with opioids or analgesics causes addiction in 1 in 100 patients. Most physicians thought that addiction in patients treated for cancer pain with opioids or analgesics was much more common than it is. Almost half the respondents (48.1%) thought addiction occurred in 1 in 100 patients, and an additional 17.3% of respondents thought addiction occurred in 1 in 10 patients treated for cancer pain with opioids or analgesics. In contrast, the incidence of addiction in patients treated with opioids or analgesics for cancer pain is fewer than 1 in 1000 patients.28

Myth 2. When patients with cancer already receiving opioids for pain control complain of increasing pain, it most likely indicates opioid tolerance. Nearly 70% of respondents reported that the most likely reason for complaints of increased pain was tolerance to the opioid. However, the most likely reason for increased pain is increasing pathology of the cancer.27

Myth 3. The equipotent to 30 mg of oral morphine is 5 mg intravenous. More than half of respondents were inaccurate in their conversion of oral to intravenous (IV) morphine dosing, a common task of physicians caring for terminally ill patients. Almost half the physicians (44%) erroneously reported that 30 mg of oral morphine was equipotent to 5 mg or less morphine IV. However, in fact, 30 mg of oral morphine is equipotent to 10 mg of morphine IV.27

Myth 4. The most highly recommended drug for treating terminal dyspnea is a beta‐blocker, and the most appropriate drug for agitation due to anxiety is Haldol or morphine. Most respondents were able to identify the correct drugs; however, a sizable proportion of respondents (17.3%) erroneously responded that beta‐blockers and Lasix or beta‐blockers and corticosteroids were the best drugs for treating terminal dyspnea. About one‐fifth of respondents (21.6%) responded that Haldol or morphine was the recommended medication for treating agitation. In fact, opioids and benzodiazepines are the recommended drugs for treating terminal dyspnea,27 and the proper drug for treating agitation is lorazepam (Ativan).27

Myth 5. Patient life expectancy must be 2 months or less to be eligible for hospice. One‐quarter of respondents believed this to be true for inpatient hospice, and nearly 13.5% of respondents believe this to be true for home hospice. In fact, patients are eligible for hospice benefits earlier in the course of their illness. Under Medicare and most insurance policies, patients are eligible for hospice benefits as soon as their life expectancy is 6 months or less, not 2 months or less.27

Physician Beliefs about Caring for Patients with Terminal Illness

The physicians' beliefs about hospice were generally positive; the vast majority of respondents agreed or strongly agreed with the statement that physical and emotional symptoms of patients and family needs are better addressed with hospice than with the hospital care (Table 3). Most respondents also agreed that many patients do not receive hospice as they should and that hospice should be initiated earlier in the course of the illness. In addition, more than 80% of respondents believed patients and their families want their doctors to tell them the patient's life expectancy, and 95.6% of respondents thought it was essential to discuss prognosis, even a poor one, with the patient. Nevertheless, many respondents (65.3%) reported it was difficult to tell patients and their families that an illness was incurable. Furthermore, fewer than half the respondents (42.3%) believed they were knowledgeable enough to discuss hospice and palliative care with patients and their families.

In subgroup analyses comparing responses to knowledge and attitude items reported in Tables 2 and 3, we found no significant differences between hospitalists and any subgroup of residents by year of training or fellows, or between hospitalists and the full sample of residents and fellows. Because of the sample size, the statistical power for evaluating significance was limited in these exploratory subgroup analyses.

Among physicians who provided responses to the open‐ended question (n = 42) about how to enhance hospice referral rates and improve their timeliness, the most commonly reported suggestions were: (1) involve family members, not only patients, in discussions of hospice (38.1%), (2) have discussions about hospice earlier in the course of care with patients (26.2%), and (3) be clear with patients and families about the patient's prognosis (19.0%). Table 4 has a list of all responses provided to this question.

Table 4.Physicians' Suggestions for Improving the Process of Hospice Referral (n = 42)
Response	n	%*
* Percentages add up to more than 100% because some respondents made more than 1 suggestion.
Involving family members as well as patients in discussions of hospice	16	38.1
Having earlier discussion with patients	11	26.2
Being clear with patients and families about patient prognosis	8	19.0
Providing education about hospice to patients and families	6	14.3
Discussions of goals of care with patients and families	6	14.3
Involving social worker in discussions	4	9.5
Providing literature to patients and families about hospice	3	7.1
Having hospice representative available to provide education to patient and families	2	4.8

DISCUSSION

This study demonstrated that, among hospitalists and residents, there are several misconceptions about fundamental aspects of caring for terminally ill patients. Given the potential importance of the role hospitalists play in improving the quality of inpatient care,1922 it is critical to identify and address these misconceptions. Additionally, physicians in this study indicated that more and earlier communication with patients and families about prognosis and about the option of hospice would be beneficial, but they themselves did not feel knowledgeable enough to discuss hospice and palliative care with patients and their families.

The nature of the misconceptions identified in this study shed light on the well‐documented phenomena of inadequate pain control24, 29 and poor symptom management2, 4 at the end of life. Having many of the erroneous beliefs apparent in this study may be consistent with providing less pain medication than needed and appropriate. For instance, many physicians believed that developing addiction to opioids used for cancer pain is more likely to occur than it really is, according to research evidence. It is extremely rare for these patients to become addicted to opioids or other analgesics (fewer than 1 in 1000 patients).28 In addition, most physicians believed that complaints of increased pain among patients receiving opioid therapy for pain control meant tolerance to the medication, a belief consistent with physician reluctance to prescribe more medication because it would lead to tolerance.28 In reality, the increased pain experienced in these situations is typically not a result of tolerance to the pain medication but to the cancer getting worse.27 Additionally, many physicians mistakenly decreased the dose of morphine in converting the route of administration from PO to IV, as is often done in hospitals. Such an error may be a contributing factor to the unintended undertreatment of pain in hospitals. Given the variability of cancer pain4 and the difference in time to peak effect depending on the route of administration,5 it is critical for physicians to understand proper dosing in order to effectively treat cancer pain. Furthermore, many physicians were incorrect about the recommended medications for dyspnea and for agitation, 2 symptoms that are prevalent among patients at the end of life.

The hospitalists and residents reported having very positive views about hospice, as is consistent with the literature.10, 30 However, many respondents indicated that patients who would have benefited from hospice did not receive it at all or only late in their illness. Physicians indicated that better communication with patients and families about hospice, prognosis, and goals of care would enhance appropriate use of hospice. While hospitalists and residents are in a position to initiate such discussions, they reported that these discussions were difficult for them. The challenge is how to promote what is necessary and valuable conversation with patients and families despite their difficulty, so that a realistic plan of care can be designed for all involved. Providing hospitalists and residents with evidence about what approaches are most effective in such discussions would be helpful to better prepare them for their roles in caring for hospitalized patients with terminal illness.

The results of this study have substantiated the need to enhance the education of hospitalists and resident physicians, who can play a vital role in improving the transition from hospital to hospice. Such education could take place as part of the residency experience or be embedded in various continuing medical education requirements that most states now have. The results of a recent national survey of hospitalists31 indicates they consider their palliative care training inadequate and feel ill prepared to care for patients with terminal illness. Our findings are consistent with those of that survey, highlighting information that is poorly understood by both residents and hospitalists. As hospitalists continue to play key roles in linking hospital to posthospital care,21 including hospice, there is greater opportunity to improve end‐of‐life care by expanding hospitalists' understanding of these issues.

Our findings should be interpreted in light of the study's limitations. First, this was an exploratory study, and the sample was modest in size. Nevertheless, the response rate was high: 85.2%. Second, we conducted the study in a single location; results may differ in other geographical areas. Last, we were unable to link reported knowledge and attitudes to patient experiences including quality of care or adequacy of pain control. Inadequate knowledge likely limits the quality of clinical practices, but the magnitude of this effect remains unknown and worthy of future study.

Despite these limitations, this study has contributed to the literature by identifying a set of misunderstandings or myths that may be common among hospitalists and residents who frequently care for hospitalized patients with terminal illness. Many of these misunderstandings were related to pain and symptom management, although some misunderstandings related to logistical issues such as hospice eligibility rules. Previous studies have described interventions to improve physicians' knowledge about palliative and end‐of‐life care practices at the undergraduate, graduate, and postgraduate levels.13 Our findings identified specific gaps in physicians' knowledge. Interventions aimed at closing these gaps might emphasize both specific clinical information about pain management and medication recommendations, and more general information about eligibility for hospice and best practices for communicating early with patients and family is needed to promote more effective care for patients with terminal illness being cared for in acute care settings.

As the use of hospitalists has become a widely accepted model of hospital care,32 ensuring their increased training and education in the care of patients with terminal illness is an important step in improving end‐of‐life care. Larger comparison studies are needed to identify differences in the practices and perspectives of hospitalists and residents and to target educational interventions to meet their particular needs. Further, conducting these studies at additional sites including those with established palliative care programs would be useful for identifying needs among a more diverse set of physicians involved in delivering end‐of‐life care.

APPENDIX

Survey on Hospice and End‐of‐Life Care

Survey ID _________________

Date ______________

I

DEMOGRAPHICS

1

What is your gender?

1
□ Male
2
□ Female
2
What year did you graduate from medical school? ___________

3

What is your primary specialty or area of practice?

1
□ Hospitalist
2
□ Oncology fellow
3
□ Oncology resident
4
□ Physician assistant
5
□ Other: _____________

II

KNOWLEDGE OF HOSPICE AND PALLIATIVE CARE PRACTICES

4

The incidence of psychological dependence (addiction) to opioids and analgesics when treating pain from cancer or other medical conditions is:

a
Common (1 in 10 patients)
b
Uncommon (1 in 100 patients)
c
Very rare (fewer than 1 in 1000 patients)

5

When a patient with cancer who is receiving opioids for pain complains of increasing pain, it most likely indicates:

a
Opioid tolerance
b
Increasing pathology of the cancer
c
Patient noncompliance
d
New onset of a different opioid‐resisting pain

6

In the pain patient receiving opioids, 30 mg of oral morphine is equipotent to _______________ of IV.

a
1mg
b
5 mg
c
10 mg
d
20 mg

7

The 2 classes of drugs most commonly recommended for treating terminal dyspnea are:

a
Beta‐blockers and Lasix
b
Opioids and benzodiazepines
c
Beta‐blockers and corticosteroids
d
Beta‐blockers and Singulair (montelukast)

8

A hospice patient whose agitation is due primarily to anxiety should be treated with:

a
Chlorpromazine
b
Haloperidol
c
Lorazepam
d
Morphine

III

ELIGIBILITY FOR HOSPICE CARE

9

Under the Medicare program, a physician must certify that the patient is expected to die within a specified time for the patients to be eligible for hospice services. To the best of your knowledge, patients become eligible for inpatient hospice care when they are expected to die in:

1
□ 2 Weeks
2
□ 6 Weeks
3
□ 2 Months
4
□ 6 Months
7
□ Other: ________________________
9
□ Don't know

10

To the best of your knowledge, patients are eligible for home hospice care when they are expected to die in:

1
□ 2 Weeks
2
□ 6 Weeks
3
□ 2 Months
4
□ 6 Months
7
□ Other: __________________________
9
□ Don't know
IV
ATTITUDES ABOUT HOSPICE CARE 0

Table .Following is a series of statements. Please state whether you strongly agree, agree, neither agree nor disagree, disagree, or strongly disagree with each statement.
	Strongly agree			Strongly disagree
11) Most patients want me to tell them their life expectancy.	1 □	2 □	3 □	4 □	5 □
12) Generally, family caregivers want me to tell them the patient's life expectancy.	1 □	2 □	3 □	4 □	5 □
13) Telling the patient and family members that the patient's illness is incurable is difficult for me.	1 □	2 □	3 □	4 □	5 □
14) I think it is essential to discuss the prognosis with a patient, even if it is very poor.	1 □	2 □	3 □	4 □	5 □
15) Most patients' physical symptoms (eg, pain, shortness of breath, and nausea) are controlled better with hospice than with the care they would receive in the hospital.	1 □	2 □	3 □	4 □	5 □
16) Most patients' emotional symptoms (eg, depression, anxiety) are controlled better with hospice than with the care they would receive in the hospital.	1 □	2 □	3 □	4 □	5 □
17) Hospice care generally meets the needs of the family better than conventional care does.	1 □	2 □	3 □	4 □	5 □
18) Many terminally ill patients who should receive hospice care do not receive hospice care.	1 □	2 □	3 □	4 □	5 □
19) Many patients would benefit if hospice care were initiated earlier in the course of their illness.	1 □	2 □	3 □	4 □	5 □
20) I feel knowledgeable enough to discuss palliative and hospice care with patients and families.	1 □	2 □	3 □	4 □	5 □
21) What do you see as the primary ways to facilitate earlier initiation of hospice care for patients who are eligible? _____________________________________________________________________________________
___________________________________________________________________________________________

References

Institute of Medicine.Approaching Death.Washington, DC:National Academy Press;1997.
SUPPORT Principle Investigators.A controlled trial to improve care for seriously ill hospitalized patients.JAMA.1995;274:1591–1598.
Morrison RS,Meier DE,Fischberg D, et al.Improving the management of pain in hospitalized adults.Arch Intern Med.2006;166:1033–1039.
von Gunten CF.Interventions to manage symptoms at the end of life.J Palliat Med.2005;8(suppl 1):S88–S94.
Bradley EH,Hallemeier AG,Fried TR, et al.Documentation of discussions about prognosis with terminally ill patients.Am J Med.2001;111:218–223.
Chittenden EH,Clark ST,Pantilat SZ.Discussing resuscitation preferences with patients: challenges and rewards.J Hosp Med.2006;1:231–249.
Schulman‐Green D,McCorkle R,Curry L,Cherlin E,Johnson‐Hurzeler R,Bradley E.At the crossroads: making the transition to hospice.Palliat Support Care.2004;2:351–360.
Bradley EH,Fried TR,Kasl SV,Cicchetti DV,Johnson‐Hurzeler R,Horwitz SM.Referral of terminally ill patients for hospice: frequency and correlates.J Palliat Care.2000;16(4):20–26.
Ogle K,Mavis B,Wang T.Hospice and primary care physicians: attitudes, knowledge, and barriers.Am J Hosp Palliat Care.2003;20(1):41–51.
Ogle KS,Mavis B,Wyatt GK.Physicians and hospice care: attitudes, knowledge, and referrals.J Palliat Med.2002;5(1):85–92.
Block SD.Medical education in end‐of‐life care: the status of reform.J Palliat Med.2002;5(2):243–248.
Meier DE,Morrison RS,Cassel CK.Improving palliative care.Ann Intern Med.1997;127(3):225–230.
Weissman DE,Mullan P,Ambuel B,von Gunten CF,Hallenbeck J,Warm E.Improving end‐of‐life care: internal medicine curriculum project—abstracts/progress reports.J Palliat Med.2001;4(1):75–102.
Bailey FA,Burgio KL,Woodby LL, et al.Improving processes of hospital care during the last hours of life.Arch Intern Med.2005;165:1722–1727.
Pan CX,Morrison RS,Meier DE, et al.How prevalent are hospital‐based palliative care programs? Status report and future directions.J Palliat Med.2001;4:315–324.
von Gunten CF,Twaddle M,Preodor M,Neely KJ,Martinez J,Lyons J.Evidence of improved knowledge and skills after an elective rotation in a hospice and palliative care program for internal medicine residents.Am J Hosp Palliat Care.2005;22(3):195–203.
Clark JM,Lurie JD,Claessens MT,Reed VA,Jernstedt GC,Goodlin SG.Factors associated with palliative care knowledge among internal medicine house staff.J Palliat Care.2003;19:253–257.
Fineberg IC,Wenger NS,Brown‐Saltzman K.Unrestricted opiate administration for pain and suffering at the end of life: knowledge and attitudes as barriers to care.J Palliat Med.2006;9:873–883.
Coffman J,Rundall TG.The impact of hospitalists on the cost and quality of inpatient care in the United States: a research synthesis.Med Care Res Rev.2005;62:379–406.
Meltzer D,Manning WG,Morrison J, et al.Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists.Ann Intern Med.2002;137:866–874.
Muir JC,Arnold RM.Palliative care and the hospitalist: an opportunity for cross‐fertilization.Am J Med.2001;111 (9B):10S–14S.
Wachter RM.The evolution of the hospitalist model in the United States.Med Clin North Am.2002;86:687–706.
Wachter RM,Goldman L.The emerging role of “hospitalists” in the American health care system.N Engl J Med.1996;335:514–517.
Bradley EH,Cicchetti DV,Fried TR, et al.Attitudes about care at the end of life among clinicians: a quick, reliable, and valid assessment instrument.J Palliat Care.2000;16(1):6–14.
Bradley EH,Cramer LD,Bogardus ST,Kasl SV,Johnson‐Hurzeler R,Horwitz SM.Physicians' ratings of their knowledge, attitudes, and end‐of‐life‐care practices.Acad Med.2002;77:305–311.
Weggel JM.Barriers to the physician decision to offer hospice as an option for terminal care.WMJ.1999;98(3):49–53.
Doyle D,Hanks G,Cherny N,Calman K, eds.Oxford Textbook of Palliative Medicine.3rd ed.Oxford, UK:Oxford University Press;2004.
Portenoy RK,Coyle N.Controversies in the long‐term management of analgesic therapy in patients with advanced cancer.J Pain Symptom Manage.1990;5:307–319.
Moynihan TJ.Use of opioids in the treatment of severe pain in terminally ill patients—dying should not be painful.Mayo Clin Proc.2003;78:1397–1401.
Iwashyna TJ,Christakis NA.Attitude and self‐reported practice regarding hospice referral in a national sample of internists.J Palliat Med.1998;1:241–248.
Plauth WH,Pantilat SZ,Wachter RM,Fenton CL.Hospitalists' perceptions of their residency training needs: results of a national survey.Am J Med.2001;111:247–254.
Wachter RM,Goldman L.The hospitalist movement 5 years later.JAMA.2002;287:487–494.

References

Institute of Medicine.Approaching Death.Washington, DC:National Academy Press;1997.
SUPPORT Principle Investigators.A controlled trial to improve care for seriously ill hospitalized patients.JAMA.1995;274:1591–1598.
Morrison RS,Meier DE,Fischberg D, et al.Improving the management of pain in hospitalized adults.Arch Intern Med.2006;166:1033–1039.
von Gunten CF.Interventions to manage symptoms at the end of life.J Palliat Med.2005;8(suppl 1):S88–S94.
Bradley EH,Hallemeier AG,Fried TR, et al.Documentation of discussions about prognosis with terminally ill patients.Am J Med.2001;111:218–223.
Chittenden EH,Clark ST,Pantilat SZ.Discussing resuscitation preferences with patients: challenges and rewards.J Hosp Med.2006;1:231–249.
Schulman‐Green D,McCorkle R,Curry L,Cherlin E,Johnson‐Hurzeler R,Bradley E.At the crossroads: making the transition to hospice.Palliat Support Care.2004;2:351–360.
Bradley EH,Fried TR,Kasl SV,Cicchetti DV,Johnson‐Hurzeler R,Horwitz SM.Referral of terminally ill patients for hospice: frequency and correlates.J Palliat Care.2000;16(4):20–26.
Ogle K,Mavis B,Wang T.Hospice and primary care physicians: attitudes, knowledge, and barriers.Am J Hosp Palliat Care.2003;20(1):41–51.
Ogle KS,Mavis B,Wyatt GK.Physicians and hospice care: attitudes, knowledge, and referrals.J Palliat Med.2002;5(1):85–92.
Block SD.Medical education in end‐of‐life care: the status of reform.J Palliat Med.2002;5(2):243–248.
Meier DE,Morrison RS,Cassel CK.Improving palliative care.Ann Intern Med.1997;127(3):225–230.
Weissman DE,Mullan P,Ambuel B,von Gunten CF,Hallenbeck J,Warm E.Improving end‐of‐life care: internal medicine curriculum project—abstracts/progress reports.J Palliat Med.2001;4(1):75–102.
Bailey FA,Burgio KL,Woodby LL, et al.Improving processes of hospital care during the last hours of life.Arch Intern Med.2005;165:1722–1727.
Pan CX,Morrison RS,Meier DE, et al.How prevalent are hospital‐based palliative care programs? Status report and future directions.J Palliat Med.2001;4:315–324.
von Gunten CF,Twaddle M,Preodor M,Neely KJ,Martinez J,Lyons J.Evidence of improved knowledge and skills after an elective rotation in a hospice and palliative care program for internal medicine residents.Am J Hosp Palliat Care.2005;22(3):195–203.
Clark JM,Lurie JD,Claessens MT,Reed VA,Jernstedt GC,Goodlin SG.Factors associated with palliative care knowledge among internal medicine house staff.J Palliat Care.2003;19:253–257.
Fineberg IC,Wenger NS,Brown‐Saltzman K.Unrestricted opiate administration for pain and suffering at the end of life: knowledge and attitudes as barriers to care.J Palliat Med.2006;9:873–883.
Coffman J,Rundall TG.The impact of hospitalists on the cost and quality of inpatient care in the United States: a research synthesis.Med Care Res Rev.2005;62:379–406.
Meltzer D,Manning WG,Morrison J, et al.Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists.Ann Intern Med.2002;137:866–874.
Muir JC,Arnold RM.Palliative care and the hospitalist: an opportunity for cross‐fertilization.Am J Med.2001;111 (9B):10S–14S.
Wachter RM.The evolution of the hospitalist model in the United States.Med Clin North Am.2002;86:687–706.
Wachter RM,Goldman L.The emerging role of “hospitalists” in the American health care system.N Engl J Med.1996;335:514–517.
Bradley EH,Cicchetti DV,Fried TR, et al.Attitudes about care at the end of life among clinicians: a quick, reliable, and valid assessment instrument.J Palliat Care.2000;16(1):6–14.
Bradley EH,Cramer LD,Bogardus ST,Kasl SV,Johnson‐Hurzeler R,Horwitz SM.Physicians' ratings of their knowledge, attitudes, and end‐of‐life‐care practices.Acad Med.2002;77:305–311.
Weggel JM.Barriers to the physician decision to offer hospice as an option for terminal care.WMJ.1999;98(3):49–53.
Doyle D,Hanks G,Cherny N,Calman K, eds.Oxford Textbook of Palliative Medicine.3rd ed.Oxford, UK:Oxford University Press;2004.
Portenoy RK,Coyle N.Controversies in the long‐term management of analgesic therapy in patients with advanced cancer.J Pain Symptom Manage.1990;5:307–319.
Moynihan TJ.Use of opioids in the treatment of severe pain in terminally ill patients—dying should not be painful.Mayo Clin Proc.2003;78:1397–1401.
Iwashyna TJ,Christakis NA.Attitude and self‐reported practice regarding hospice referral in a national sample of internists.J Palliat Med.1998;1:241–248.
Plauth WH,Pantilat SZ,Wachter RM,Fenton CL.Hospitalists' perceptions of their residency training needs: results of a national survey.Am J Med.2001;111:247–254.
Wachter RM,Goldman L.The hospitalist movement 5 years later.JAMA.2002;287:487–494.

Issue

Journal of Hospital Medicine - 2(6)

Issue

Journal of Hospital Medicine - 2(6)

Page Number

357-365

Page Number

357-365

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Journal of Hospital Medicine

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Journal of Hospital Medicine

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Common myths about caring for patients with terminal illness: Opportunities to improve care in the hospital setting

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Common myths about caring for patients with terminal illness: Opportunities to improve care in the hospital setting

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hospice, hospitalist, end‐of‐life

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hospice, hospitalist, end‐of‐life

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Elizabeth H. Bradley, PhD

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Department of Epidemiology and Public Health, Yale School of Medicine, 60 College Street, New Haven, CT 06520‐8034; Fax: (203) 785‐6287

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Common Myths in Caring for Patients with Terminal Illness

METHODS

Study Design and Sample

Survey

Data Analysis

RESULTS

Overview

Common Myths in Treating Patients with Terminal Illness

Physician Beliefs about Caring for Patients with Terminal Illness

DISCUSSION

APPENDIX

Survey on Hospice and End‐of‐Life Care

METHODS

Study Design and Sample

Survey

Data Analysis

RESULTS

Overview

Common Myths in Treating Patients with Terminal Illness

Physician Beliefs about Caring for Patients with Terminal Illness

DISCUSSION

APPENDIX

Survey on Hospice and End‐of‐Life Care

METHODS

Study Design and Sample

Survey

Data Analysis

RESULTS

Overview

Common Myths in Treating Patients with Terminal Illness

Physician Beliefs about Caring for Patients with Terminal Illness

DISCUSSION

APPENDIX

Survey on Hospice and End‐of‐Life Care