Subinternship Medicine · Year 4 · from Subinternship Medicine
Case 3: Hospice Referral and Family Support
Clinical Image
Source: Wikimedia Commons - Hospice Care - CC BY-SA 4.0
Case Presentation
A 72-year-old man with advanced Parkinson's disease and dementia is admitted for aspiration pneumonia, his third hospitalization in 6 months. He has progressive dysphagia requiring pureed diet and has lost 20 pounds over the past year. His wife has been his primary caregiver but is exhausted. He is non-verbal and cannot participate in decision-making. His wife is his designated healthcare proxy. During a family meeting, the physician explores what the patient would have wanted. His wife recalls him saying, "When I can't recognize you anymore, don't let them keep me alive with tubes and machines." She describes his current quality of life as poor: he no longer recognizes family, requires total care, and seems uncomfortable much of the time. The physician explains that his current trajectory suggests a prognosis of weeks to a few months. She explains hospice services: nursing visits, aide assistance, medications for comfort, equipment like hospital bed and oxygen, 24/7 phone support, and bereavement services. She clarifies that hospice focuses on comfort rather than cure, and that hospitalization is generally avoided unless absolutely necessary for symptom management. She recommends hospice as a way to provide comfort and support at home, honoring what he would have wanted. The wife is initially hesitant, feeling like she's "giving up," but comes to understand hospice as a way of providing the best quality of remaining life. The patient is discharged home with hospice services. A follow-up call from the sub-intern 2 weeks later reveals he is comfortable at home, and his wife is receiving caregiver support. He dies peacefully at home 3 weeks later.
Key Learning Points
- Hospice eligibility requires prognosis of less than 6 months and patient/family agreement to focus on comfort rather than curative treatment
- Hospice provides comprehensive services: nursing, aide, social work, chaplain, bereavement support, medications, and equipment
- Families may perceive hospice as "giving up"; reframe as "choosing comfort" and "honoring what [patient] would have wanted"
- Bereavement follow-up (condolence calls, bereavement services) is part of quality end-of-life care for families