• Leslea Brickner, Kate Scannell, Stephanie Marquet, and Lynn Ackerson.
• Department of Internal Medicine, Kaiser Permanente Medical Centers, Oakland, California 94611, USA. leslea.brickner@kp.org
• J Palliat Med. 2004 Jun 1;7(3):411-8.

IntroductionMany proponents of hospice care believe that this service is underutilized.ObjectiveTo determine physicians' perceptions of hospice utilization and of their own hospice referral pattern; their perceived and actual knowledge of appropriate hospice referral diagnoses; and perceived barriers to hospice referral.MethodsSurveys for anonymous response were distributed to 125 physicians in 2 internal medicine departments of a large not-for-profit health maintenance organization (HMO). Of these 125 physicians, 89% responded, including 91 staff physicians and 20 residents.ResultsOf the 111 physician-respondents, 78% reported their belief that hospice care was underutilized; 84% were unable to identify appropriate hospice diagnoses; and 12% were aware of the "National Hospice Organization Medical Guidelines for Determining Prognosis in Selected Non-Cancer Diseases." Difficulty of predicting death to within 6 months was cited by 37% as the foremost barrier to hospice referral. In addition, 28% expressed concern that patients or families would interpret hospice referral as a cost saving measure; 11% of respondents had been accused of using hospice referral for this purpose.ConclusionOur study-the first major survey of physician attitudes and practices regarding hospice utilization in an HMO setting-showed that barriers to hospice referral are similar to those in non-HMO settings; physicians have difficulty predicting life expectancy and lack knowledge of patient eligibility guidelines. Physician concern that patients or their family members would construe hospice referral as a cost-saving technique may be a barrier particularly troublesome in an HMO setting.

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