Recently, I was at an interdisciplinary team (IDT) meeting as medical director for a hospice. During the meeting, one of the nurses reported that one of her patients had a severe sore throat. She also relayed the information that her primary care physician (PCP) had declined continuing as her PCP once she became enrolled in hospice. By default, then, I was her PCP. Fortunately, I had time between the end of the meeting and my next appointment to stop by her house, which was not particularly out of the way. The patient was an elderly woman on hospice with end-stage chronic obstructive pulmonary disease. One of the hospice nurses happened to be there with me during my visit. It took us each about two seconds to look in her throat and identify thrush as the culprit, probably related to inhaled corticosteroids. We prescribed a treatment, and she was better in short order.
The reason that I am reporting this episode is because I think it highlights something that happens, in my opinion, too often. I have become, by default, the PCP for many of the hospice patients on my team. Many of them I actually never see. It would be impractical for me to go to each of their locations. Therefore, I usually rely on the reporting of the high-quality hospice nurses with my team to treat any primary care type issues.
As a medical director for a hospice, I provide hospice-related medical care. This includes, of course, palliative treatment related to their hospice diagnosis. In ideal circumstances, I feel that the patient’s PCP should be the one providing for the patient’s continued primary care needs. Often, patients have had a long-term relationship with their PCP. As a family doctor myself, I recognize that there are many times when patients come to me for support or problems that are being primarily taken care of by other specialists. They often seek a reassuring confirmation from someone with whom they have established trust. When could this trusting relationship be of more benefit to the patient than in end-of-life circumstances? People who are at the end of their life continue to have primary care problems, such as sore throats, urinary tract infections, rashes, bowel issues and an endless list that can best be addressed by the PCP. Additionally, the knowledge acquired by the PCP during that long-term relationship can be valuable to the hospice team in treating a patient in the best possible manner. This patient is usually totally new to the members of the hospice team at the time of the admission. However, the PCP may have years of experience with the patient, which would be helpful in end-of-life management.
I am not sure why many PCPs decline to continue caring for patients once they’re on hospice. It may be that they don’t fully understand how hospice works. The hospice team will take care of hospice-related problems. Primary care issues are separate.
It may be that a lot of doctors don’t feel comfortable taking care of patient’s pain medication needs, particularly in today’s environment. Hospice nurses and providers are educated in pain management and will prescribe appropriate medications for end-of-life. PCPs may not be involved, but certainly could be if they desire. Another issue is that in our American system of medical training, very little time has traditionally been spent on end-of-life issues. A lot of doctors feel that once a patient is on hospice, there is nothing more they can do for them since they’re not going to be better. We often seem to view death as a failure in our system, although it is inevitable.
It should be noted that any services provided by the patient’s own PCP still can be billed to insurance the same as if they were not in hospice.
I would hope that as physicians become more comfortable with hospice, they will continue to treat their patients at end of life. Ideally, this should be a total team effort, with both the hospice team and the primary care team involved for optimal treatment.