• Joan M Teno, David Casarett, Carol Spence, and Stephen Connor.
• Warren Alpert School of Medicine at Brown University, Providence, RI, USA. Joan_Teno@brown.edu
• J Pain Symptom Manage. 2012 Apr 1;43(4):732-8.

ContextMany family members of patients enrolled in hospice for less than seven days state that the hospice referral was made "at the right time."ObjectivesTo examine bereaved family members' perceptions of the timing of hospice referral to identify aspects of the referral process that can be improved.MethodsOpen-ended interviews were conducted in seven hospice programs, interviewing bereaved family members of hospice patients who died within the first week of hospice enrollment.ResultsOf the 100 narrative interviews, 99 respondents stated that their family member was either referred "too late" (n=41) or "at the right time" (n=58) to hospice services. When families stated that referral was "at the right time," their perceptions were based on the patient having refused earlier referral (n=8), a rapid decline in the patient's condition resulting in the late referral (n=20), or a belief in all things coming together as they were meant to (n=11). In contrast, when families stated that referral was "too late," their reasons were centered on concerns with the health care providers' role in decision making (n=24), with the leading concerns being inadequate physician communication (n=7), not recognizing the patient as dying (n=11), or problematic hospice delays in referral from the nursing home or home health agency (n=4). Despite the patient refusing an earlier hospice referral, five family members believed the referral was "too late."ConclusionWhereas family members identified expected concerns with communication, more than one in three stated an earlier hospice referral was not possible.Copyright © 2012 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.

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