Hospice Demystified — Dr. Mike Haas Talk Portal

📆Key Dates

📥 Download PowerPoint Presentation Hospice_Demystified_DrMikeHaas_LAFP2026.pptx · Ready to edit in PowerPoint or Google Slides

⚠️ May 22, 2026

Speaker forms due to Ragan LeBlanc (LAFP)

Now → June

Draft slides · gather literature · Dr. Mike Q&A

Week of June 16

Final slide review with Dr. Mike

⚠️ June 23, 2026

PowerPoint due → rleblanc@lafp.org

🎤 July 23, 2026

TALK — 3:30 PM CST, Sandestin

🧭Narrative Arc

"Hospice is not giving up. It's giving more — more comfort, more dignity, more time for what matters. Your referral is what makes that possible."

Frame the problem (underuse + late referral)

Teach identification (who, when, how)

Teach communication (how to have the conversation)

Teach the continuum (palliative care ≠ hospice)

Teach the end-of-life moment (clinical + human)

Demystify the system (what hospice actually IS)

Empower action (you can do this in your practice)

📑Slide Skeleton (Click to Expand)

Section 1 The Problem: Hospice is Underused Slides 1–5 ▶

Slide 1 — Title

"Hospice Demystified"

Dr. Michael Haas, MD | LAFP 79th Annual Assembly | July 2026
Optional: powerful, quiet image — a hand hold, a sunset, something human

Slide 2 — Opening Hook

The Case That Didn't Have to End That Way

Clinical vignette: patient dies in ICU on a vent, family in shock, no one had the conversation
OR stat hook: "Nearly half of Medicare patients who died enrolled in hospice for 7 days or less. Many for just 3."
Question to the room: "How many of you have had a patient you wish you'd referred sooner?"

Slide 3 — The Utilization Problem

The Numbers Don't Lie

~50% of Medicare decedents use hospice (NHPCO 2024)
Median length of stay: ~18 days — many enroll in the final week
~1 in 4 patients dies within 7 days of enrollment
The gap: Patients who could benefit for months are only getting days

Source: NHPCO Facts & Figures 2024; MedPAC 2025 Report to Congress Ch. 9

Slide 4 — Why Does This Happen?

The Barriers Are Real — But Fixable

Physician: prognosis uncertainty, fear of "taking away hope," discomfort with the conversation
System: late referral culture, confusing eligibility, fragmented care
Patient/Family: "hospice = giving up," fear of morphine, cultural factors
Key insight: The #1 reason for late referral is physician hesitation — we are the fix

Slide 5 — What's at Stake

The Counterintuitive Truth

Early hospice → better pain control, better family satisfaction, fewer hospitalizations
Temel et al., NEJM 2010: Early palliative care in metastatic NSCLC → better QoL + longer survival (11.6 vs. 8.9 months)
Patients who get palliative care earlier sometimes live longer

Temel JS et al. N Engl J Med. 2010;363(8):733–742.

Section 2 Objective 1: Identifying the Right Patients Slides 6–10 ▶

Slide 6 — Medicare Hospice Eligibility: The Basics

Physician certifies: prognosis ≤ 6 months if illness runs its normal course
Patient elects comfort-focused care (waives curative treatment for terminal illness)
Two 90-day benefit periods, then unlimited 60-day periods — recertification required
Myth to bust: "Once on hospice you can't get off." — False. Patients can and do revoke.

Slide 7 — The Surprise Question

"Would you be surprised if this patient died within the next 12 months?"

If the answer is No → this patient deserves a palliative care conversation NOW
Simple, validated, evidence-supported screening tool — not a death sentence, a conversation trigger
Combining with Palliative Care Screening Tool (PCST) improves 12-month mortality prediction

PCNOW Fast Fact #360; BMJ Supportive & Palliative Care 2022;12:211

Slide 8 — Disease-Specific Referral Triggers

Condition	Referral Triggers
Cancer	Stage IV + declining performance status
CHF	NYHA Class III/IV despite optimal therapy; repeated hospitalizations
COPD	FEV1 <30%, home O₂, declining function
Dementia	FAST Stage 7, unable to walk/dress/bathe, recurrent infections
Renal	GFR <15 declining, refusing dialysis
Liver	Child-Pugh C, refractory ascites, hepatic encephalopathy

Slide 9 — Prognostic Tools

PPS (Palliative Performance Scale): functional status → mortality correlation
ECOG Performance Status: widely familiar, maps to prognosis
PCST: combines with Surprise Question for better accuracy
Use the tools + trust your gut + ask the Surprise Question — together they outperform any one alone

Slide 10 — Non-Cancer Diagnoses (Often Missed)

CHF, COPD, dementia, renal failure, liver cirrhosis — all hospice-eligible
Family physicians own these patients — often the ONLY one who can initiate this

"You are the gatekeeper. No one else in their care team has the relationship you have."

Section 3 Objective 2: The Conversation Slides 11–15 ▶

Slide 11 — Why We Avoid the Conversation

"I don't want to take away hope"
"The family isn't ready"
"I don't have time"
"They'll think I'm giving up on them"
Reality: Studies consistently show patients with serious illness want more prognostic information, not less

Slide 12 — Palliative Care ≠ Giving Up

Reframe: it's adding a layer of support, not removing treatment
Can be concurrent with disease-directed therapy
Language that works: "We're going to focus on making sure you feel as good as possible, for as long as possible."

Slide 13 — REMAP Framework (Goals of Care)

Reframe — "I want to make sure your care matches your priorities"

Expect emotion — make space; don't rush past the feeling

Map out patient goals — "What's most important to you?"

Align with goals — "Based on what you've told me…"

Propose a plan — connect their goals to a concrete next step

Childers JW et al. JCO Oncology Practice. 2017. PMID: 28445100

Slide 14 — SPIKES for Delivering Bad News

Setting — private, seated, no interruptions

Perception — what does the patient already know/believe?

Invitation — does the patient want information? how much?

Knowledge — share news clearly, without jargon, in chunks

Emotions — respond to emotions first, before more information

Strategy/Summary — next steps, plan, follow-up

Baile WF et al. Oncologist. 2000;5(4):302–311.

Slide 15 — Practical Office Tips

Schedule a dedicated "goals of care" visit — don't tack it onto a 15-min med check
Invite family to be present
Use teach-back: "Can you tell me in your own words what we talked about today?"
Document: shared decision-making conversation, patient preferences, surrogate

Section 4 Objective 3: Palliative Care Across the Continuum Slides 16–19 ▶

Slide 16 — The Critical Distinction [DIAGRAM SLIDE]

Timeline: Diagnosis ──────────────────── Death
Palliative care: starts at diagnosis, runs the full course
Hospice: specific program, begins when curative intent ends + prognosis ≤ 6 months
"Hospice is one type of palliative care. Palliative care is not just hospice."

Slide 17 — Symptoms Across the Continuum

Pain, fatigue, dyspnea, nausea, anxiety, depression — present throughout, not just at end
Caregiver burden: often the most underaddressed issue
Social determinants: finances, housing, isolation — all affect outcomes
Spiritual distress — often unspoken; often the most important thing to the patient

Slide 18 — The Interdisciplinary Approach

The hospice/palliative team: physician, NP, RN, social worker, chaplain, home health aide, volunteer, bereavement counselor
Family physician's role: quarterback, not solo player
"You don't have to do all of this alone — that's what the team is for"

Slide 19 — Advance Care Planning

POLST/MOLST forms — actionable medical orders
Advance directives — legal documents
Surrogate designation — who speaks if the patient can't?
Pearl: The time to have this conversation is before the crisis, not during it
Family physicians are uniquely positioned — you have the relationship and the continuity

Section 5 Objective 4: Imminent Death — What to Expect Slides 20–23 ▶

Slide 20 — Recognizing the Final Days

Clinical Signs of Imminent Death (days to hours)

Decreased/no oral intake
Mottled, cold, cyanotic extremities
Cheyne-Stokes breathing; "death rattle" (pooled secretions)
Decreased urine output, dark urine
Unresponsiveness, eyes half-open

"This is normal. This is not suffering."

Slide 21 — Comfort Medications at End of Life

The Standard Comfort Kit — Anticipatory Prescribing

Morphine / oxycodone — pain and dyspnea (SL or SQ when oral not possible)
Lorazepam / midazolam — anxiety, terminal agitation
Haloperidol — delirium, agitation
Glycopyrrolate / hyoscine — secretion management ("death rattle")

Key message: These medications treat suffering. They do not hasten death when used appropriately. (Double effect — well established in medical ethics and law.)

Slide 22 — What to Tell the Family

Normalize the process: what they'll see, what it means
"Hunger and thirst decrease — this is the body's way. Forcing fluids can increase discomfort."
Hearing may be the last sense to go — encourage them to keep talking
It's okay to say goodbye. It's okay to give permission to go.
After death: call hospice first, not 911

Slide 23 — Bereavement Care

Hospice provides bereavement services for up to 13 months after death
Complicated grief is real — family physicians should watch for it
"Your job doesn't end when the patient dies. The family is still your patient."

Section 6 Objective 5: How Hospice Works Slides 24–30 ▶

Slide 24 — The Four Levels of Medicare Hospice Care

Routine Home Care — standard; IDT visits, medications, equipment at home
Continuous Home Care — crisis management; near-continuous nursing (8–24 hrs/day) at home
General Inpatient Care (GIP) — acute symptoms that can't be managed at home; short-term inpatient
Respite Care — up to 5 consecutive days inpatient to give caregiver a break

CMS Medicare Benefit Policy Manual Ch. 9; PCNOW Fast Fact

Slide 25 — What's Covered Under the Medicare Hospice Benefit

Nursing visits (RN + LPN)
Physician services (hospice medical director)
Social work, chaplaincy, volunteer services
Home health aide (personal care)
Medications related to terminal diagnosis (typically $0 or very low copay)
Durable medical equipment: hospital bed, wheelchair, commode, O₂, etc.
Bereavement counseling (up to 13 months post-death)
NOT covered: treatments aimed at curing the terminal illness

Slide 26 — How to Refer: Step by Step

1. Identify the patient (Surprise Question + eligibility criteria)
2. Have the conversation (REMAP)
3. Contact your local hospice agency — they do the intake assessment
4. Sign the certification of terminal illness (you don't have to be the hospice physician)
5. Stay involved — you remain the attending physician if you choose
Tip: Build a relationship with 1–2 local hospice agencies; know who to call

Slide 27 — Hospice and Your Practice

Myth: "Hospice takes the patient away from me." Reality: You stay the attending physician.
Reduces after-hours crisis calls, unnecessary ER visits
Better outcomes → better patient satisfaction scores

"Patients deserve to die with dignity, at home, with people they love, without unnecessary suffering. You can make that happen."

Slide 28 — Call to Action / Key Takeaways

1. Ask the Surprise Question at every serious illness visit
2. Use REMAP — you have the framework; now practice it
3. Palliative care starts at diagnosis — don't wait for hospice eligibility
4. Know the signs — prepare families in advance; comfort kits save crisis calls
5. Hospice is a team — refer early, stay involved, let them support your patient

Slides 29–30 — Resources & Thank You

PCNOW Fast Facts (mypcnow.org), CAPC (capc.org), VitalTalk (vitaltalk.org), NHPCO (nhpco.org), AAFP resources
Contact info for Dr. Haas (optional)
Acknowledgment of hospice workers, families, patients

📚Key Literature Anchors

Section	Citation	Key Finding
Opening	Temel JS et al. N Engl J Med. 2010;363(8):733–742	Early palliative care → better QoL + longer survival in metastatic NSCLC
Identification	PCNOW Fast Fact #360 (Palliative Care Network of Wisconsin)	Surprise Question validated for triggering palliative referral
Identification	BMJ Supportive & Palliative Care. 2022;12:211	SQ + PCST together outperform either alone for 12-month mortality prediction
Communication	Childers JW et al. JCO Oncology Practice. 2017. PMID: 28445100	REMAP framework for goals-of-care conversations
Communication	Baile WF et al. Oncologist. 2000;5(4):302–311	SPIKES protocol for delivering bad news
Utilization	NHPCO Facts & Figures 2024	Utilization data, length-of-stay statistics
EOL Care	NICE Guidelines: Care of Dying Adults 2015 (NBK356005)	Clinical signs of imminent death; anticipatory medications
Structure	CMS Medicare Benefit Policy Manual, Chapter 9	Four levels of hospice care, coverage rules
Structure	MedPAC March 2025 Report to Congress, Chapter 9	Hospice utilization trends and policy analysis

❓Questions for Dr. Mike

These are the key inputs needed before building the actual slides. Bring these to him this week.

Clinical stories: Do you have 1–2 patient stories you'd be comfortable sharing (de-identified)? A case where early referral made a difference, or one where you wish you'd referred sooner?

Communication style: Do you prefer frameworks like REMAP on slides, or would you rather teach from your own clinical approach and experience?

Audience sophistication: How experienced do you expect the audience to be with palliative care? Rural family docs vs. academic? Any prior hospice exposure assumed?

Spiritual/religious dimension: How much do you want to lean into the spiritual component? Given the Louisiana audience, this may resonate strongly.

Tone: Lecture-style, conversational, or case-based teaching format?

Slide aesthetic: Data-heavy and clinical, or more visual and story-driven?

Anything to avoid? Topics, controversies, anything too sensitive for this particular audience?

Personal connection: What drew you to hospice work? This story — if he's willing to share it — could be a powerful way to open the entire talk.