Author: Brian H. Black D.O.

  • Managing Expectations in Hospice

    Managing Expectations in Hospice

    The Underrated Skill That Impacts Everything

    Written by

    Brian H. Black D.O.

    in

    ,

    When It Doesn’t Seem Like Enough: A Story in Two Voices

    “It was awful,” she said. “I had to give the meds. And no one was there. We were alone.”

    In those final hours, Nicki wasn’t just grieving. She was the caregiver, the one holding the morphine. She felt guilty, afraid to do it wrong, and overwhelmed with her own swirling questions.

    The triage team dispatched a nurse. But for Nicki, in that moment, it wasn’t enough. She had some information, but no clear forecast of what to do if the meds didn’t work. No one had explained that “on call” could mean support was an hour away.

    She wasn’t clinically unsupported, but her grief was compounded by uncertainty.

    On the other side of that same midnight story:

    “I got the page and headed out immediately. Triage said the caregiver was worried, so they gave some tips on dosing existing meds. The GPS said 47 miles to go.”

    Susan, the on-call nurse, dropped everything. She drove at the upper end of the speed limit and arrived promptly. She offered her full presence. But the patient had just died. She felt the brunt of arriving “too late.”

    Sometimes, this is a staffing problem. But much more often, it’s a systems problem. Hospice was designed for intermittent presence—but the public expects immediate on-site availability.

    Especially in rural areas, hospice teams cover wide territories with limited resources. One nurse may manage three counties. That’s the clinical reality. But the caregiver’s memory will often be based on one question: Was someone physically there when it mattered most?

    This situation was a failure in expectation alignment. To avoid this, we need to establish and review clear plans much earlier in the course of care. 

    Expectations Unspoken

    A 2021 study found nearly 50% of caregivers felt hospice didn’t meet their expectations. This is largely because they didn’t know what hospice actually included, how often support would arrive, or what their role was supposed to be. [1]

    I asked in a recent informal LinkedIn poll, “What is the biggest knowledge gap in hospice?” One answer stood out at nearly 50%: managing expectations.

    This insight came from seasoned clinicians, team leads, and front-line hospice staff. They tell me is this: trust doesn’t break from poor care. Trust frays when expectations remain unspoken.

    Families can’t understand what we never clearly said.

    The Gap Between Assumption and Reality

    Every person walks into a hospice consult with different expectations for the journey ahead. Few actually know the terrain they’re about to face.

    Families often think of hospice as a full service rescue mission. Instead, they often receive a simple well-meaning map and a comfort kit—just before a long, unfamiliar hike.

    • Many patients quietly hope they’ll get better soon: “That’s why I have hospice experts.”
    • Clinicians may assume families understand the limits of the benefit—a defined Medicare offering with clear regulatory edges.
    • Families often expect a panacea: constant nursing, instant relief, and full-day presence from admission through aftercare.
    • Referring providers or marketing teams may unintentionally set expectations we simply can’t meet.

    Across the board, assumptions differ. Mismatched expectations can’t all be true. What begins as a misunderstanding often ends as mistrust, just when families are looking for someone to help carry the weight.

    Forecasting Trust: Conversations That Prepare

    Managing expectations isn’t a script. But it should be!

    We call them Two-Minute Forecast Scripts—brief, teachable conversations that help families understand what hospice care truly includes and what to expect next. Delivered near the end of a visit, these Two-Minute Forecast Scripts clarify symptoms to watch for, explain roles, and build trust by previewing expectations until the next visit.

    These clinical tools are vital. When IDG teams train, model, and consistently use these scripts, they see success in real time. These scripts do more than inform. They turn communication into confidence and prepare families for what’s next. 

    This is how we deliver clarity as care.

    Research emphasizes that “Proactive communication that clarifies the scope and limitations of hospice services is critical to mitigating caregiver distress and fostering trust in the care process.” [2]

    “We’ll be here for you” sounds comforting. But families need specific orientation over vague reassurance. Imagine instead:

    “We’ll always be here for you—by phone, with guidance, and for urgent visits when needed. Call us early if the shortness of breath starts again anytime. Here’s how that works with your family regarding the meds for this weekend…”

    This isn’t about simply under-promising or over-delivering. Preparation itself is a form of presence. And the clarity that follows stays long after the visit.

    From Words to Practice

    Here are a few simple ways IDG teams can start today:

    • Reframe vague language (“We’ll be here” → “Here’s how we respond…”). That’s care planning in action, clear guidance with a timeline that families can trust.  
    • Include expectation alignment at every admission—and during any change in condition.
    • Share a simplified written care plan that outlines visit frequency, symptom response, and who does what and when. Review it with the family to ensure understanding.

    When we lead with clarity as care, we equip patients, families, and facilities with the expectations and tools they need – before a mismatch becomes a crisis.

    “Clarity is care. Simple, clear, honest communication is one of the most eloquent forms of clinical intervention.” Brian H. Black D.O.

    3 Key Insights

    Mismatched expectations are one of the leading causes of distress in hospice care.

    • Families don’t need perfection but they need clarity of expectations. It’s how we give care.
    • Managing expectations is a clinical skill. It is one we can teach, support, and systematize.

    Two Actionable Ideas

    • Use forecast scripts and simplified care plans to create clear, shared expectations.
    • Train IDG teams to revisit expectation alignment regularly—not just at admission.

    One Compassionate Call to Action

    Let’s stop assuming families know what hospice means. Try a forecast script of your own. Walk them toward what comes next with compassionate clarity.

    Bibliography

    [1] Kehl, K. A., Kirchhoff, K. T., Kramer, B. J., & Hovland-Scafe, C. (2021). Caregiver perceptions of the quality of hospice care: A prospective cohort study. American Journal of Hospice and Palliative Medicine, 38(3), 258–266. https://doi.org/10.1177/1049909120963600

    [2] Head, B. A., & Faul, A. C. (2013). Development and Validation of a Scale to Measure Satisfaction with End-of-Life Care. Journal of Palliative Medicine, 16(9), 1093–1100. https://www.liebertpub.com/doi/10.1089/jpm.2013.0062

  • Hospice vs. Palliative Care: A False Divide That Still Matters

    Hospice vs. Palliative Care: A False Divide That Still Matters

    The Six-Month Trap

    Written by

    Brian H. Black D.O.

    in

    , ,

    The Clock is a Trap

    To qualify for the hospice benefit, two physicians must certify a prognosis of six months or less. That’s an arbitrary billing checkbox, regulatory scaffolding that is a barrier to care. Medicare didn’t invent compassion. It put a clock on it.

    The rule was never meant to test worthiness for care. But that’s how it’s used. Families get lost in a maze of ‘not yet’ and ‘maybe later’ while time and peace slip away.

    In a more humane system, palliative care would begin at diagnosis, or better at birth! Hospice would not be the last stop, but the first. It would include hospice’s full A-team without barriers. But that is not our clinical reality.

    Instead, our system splits a shared philosophy into two programs. One for admissions. One sidelined waiting for a deadline. In doing so, it breaks the very continuity that patients deserve.

    Prognosis is a nuanced and difficult art. Even experienced hospice physicians overestimate how much time is left. The LCD guidelines we use to justify eligibility? They were never meant to predict time left. They help us document, but not decide. 

    The six-month rule isn’t about biology. It’s about budget, a reimbursement artifact. And if we don’t name it for what is, we can’t navigate around it.

    This isn’t just about policy. It’s about people. It’s heartbreaking to consider patients and families who do not want hospitalization and ready for help at home, but are told to wait. That is lost time and worse, lost peace.  

    It is time we make comfort-first the default in all timelines. It’s time to rewrite the rules and the benefit itself. 

    But to understand the divide, we have to trace its origins. 

    Twin Origins, Diverging Paths

    Picture two identical twin doctors born in the house of medicine. They were raised with the same textbooks, training, and white coat. But one was adopted by hospice. The other, by palliative care.

    At first, they seem inseparable. Both value comfort, communication, and dignity. But over time, their paths diverge—not by philosophy, but by the systems that raised them.

    The hospice twin was raised from the grassroots work of Dame Cicely Saunders. Hospice became a Medicare benefit in 1982, formed with strict eligibility rules, shaped outside academia, and built as a full team to walk with patients near the end of life.

    The palliative care twin was raised in a later era and stayed in the hospital. Surrounded by academic rounds, peer-reviewed journals, and consult codes, this twin took hospice’s philosophy upstream, earlier in the illness, but without the structure or coverage to stay after discharge.

    Medicare divided their support. Part A funded hospice’s team: RNs, MSWs, chaplains, physicians, available wherever you called home. Palliative care? Covered by Part B: hospital care and clinic visits, no full team, and no 13-month bereavement follow-up. 

    They were never meant to be isolated. But billing codes, institutional inertia, and policies made them strangers over time. And now? Families are asked to choose between silos of care—before they understand much about either.

     If the values are the same, why does the door of entry matter?

    Because twins raised apart grow into different roles despite shared values. 

    Palliative Care: Comfort Without a Clock

    It was cancer. Surgery complete. Chemo underway. There was real hope for a cure, but also relentless nausea that no one could fix. Zofran had stopped working. Nothing stayed down.

    That’s when palliative care was called. They started Haldol. And John finally slept.

    His wife exhaled. Not because the cancer was gone—but because, for the first time in days, he could rest.

    They didn’t treat the tumor. But they made the treatment possible.

    At its core, palliative care is a mindset. A commitment to relieve suffering, clarify goals, and improve quality of life. It can be delivered by a dedicated interdisciplinary team or by any clinician willing to plan comfort in center their care plan. 

    It’s not owned by one specialty, or limited by a prognosis. It begins at diagnosis and adapts across the course of illness. The goal? Cure when possible. Comfort always.

    The World Health Organization calls it “an approach that improves the quality of life of patients and their families facing life-threatening illness…” But for most families, it means something simpler: being seen, heard, and helped.

    Core traits

    • Philosophy: Relieve suffering. Improve quality of life.
    • Focus: Symptom control, communication, and alignment with patient goals.
    • Eligibility: Any serious illness, any stage.
    • Team: Physicians, nurses, social workers, chaplains—ideally working together.
    • Settings: Hospitals, clinics, homes, long-term care, dialysis units, infusion centers, telehealth.

    Despite a growing evidence base, palliative care remains underutilized. A 2019 JAMA study found that fewer than 50% of U.S. hospitals with more than 50 beds had a formal palliative care program. [2]

    In principle, palliative care is the broad foundation on which hospice rests. In practice, it’s still often siloed. Relegated to hospital consultations.

    Palliative care is supposed to be upstream. But most patients don’t see it until they’re already drowning.

    Hospice: A Team with a Timeline

    It’s the nurse who shows up at 2 a.m. when the pain breaks through. It’s the chaplain who sits quietly beside a son who doesn’t know what to say. It’s the aide who learns how Mom liked her coffee. Hospice isn’t just a benefit. It’s a way of being present when presence matters most.

    But that presence is scaffolded by structure. 

    Hospice is palliative care with time limits and accountability. 

    To qualify, two physicians must agree that life expectancy is six months or less. The patient must choose to step away from life-prolonging treatments for their terminal illness—not all treatments, but those meant to cure. The focus shifts fully to comfort, clarity, and connection.

    Unlike general palliative care, hospice is a defined Medicare Part A benefit. It brings a full interdisciplinary team and a regulatory framework that ensures continuity:

    • An RN case manager coordinates care and works to adjust as things change.
    • A hospice physician consults, confirms eligibility, signs orders, and oversees the plan.
    • A social worker supports emotional, logistical, and practical needs.
    • A chaplain provides spiritual care on the patient’s terms.
    • Together, they meet as an IDG to align care weekly, not reactively.

    There are daily notes. Face-to-face visits. After-death bereavement follow-up that lasts more than a year. It’s medicine with mercy.

    And when it’s done well without delay and without shortcuts, it transforms the end of life. Not by fixing what’s failing. But by honoring what remains.

    Hospice doesn’t erase the clock. But it helps make the last stretch count.

    Category Comparison Table

    CategoryPalliative CareHospice Care
    WhenAny stage of serious illnessLast 6 months of life (if condition follows expected course)
    Can pursue cure?YesNo (must decline life-prolonging treatment)
    TeamVariousFull IDG required (Physician, RN, MSW, Chaplain, etc.)
    After-death careRareRequired (13-month bereavement benefit)

    Why the Difference Matters

    Years ago, during training, I saw a patient in the outpatient clinic. He was a young man with midline thoracic back pain. Nothing alarming at first glance, but pain in that area is never a good sign. 

    I ordered imaging. An X-ray, then MRI, and then a PET scan. They confirmed the worst: widespread bone metastases from an unclear primary cancer.

    He was referred to oncology immediately and they took quick action. He had a wife. Young kids.  I remember hoping, maybe foolishly, that treatment might deliver the unexpected: a cure or at least a prolonged remission.  

    Several months later, on what became his final days, we had our last visit. Radiation hadn’t helped. Chemo had drained him. He was tired and a shell of the person I had once met. His body was failing but the treatments pressed on. More treatments were on the schedule even as we all sensed this could be his final week.

    No one ever said the word Hospice. Not me and not the Oncology team. He died without ever being told there was another path. 

    When I found out he had died was the moment I learned: It is not enough to understand the medical system. Notice the fracture before it become a chasm. We should have said “Hospice” sooner and given him understanding of his choices early. 

    This wasn’t a failure of compassion. It was a failure of culture. A failure in how we train clinicians to speak openly when standard medical care is no longer heroic. 

    When we don’t frame informed choice early, and with skill:

    • Patients lose time by spending it in the hospital or receiving treatment that won’t help
    • Families are left wondering: why weren’t we told sooner?
    • Clinicians miss the moment when hospice and palliative care could be most effective
    • And most of all, patients lose the chance to prepare emotionally, practically, and rationally for their own death.  

    This difference matters. Because palliative and hospice care aren’t competing. They are complementary tools: palliative to ease the burden of treatment; hospice to support the whole family at the end. When timed well together, they are transformative.

    We can’t collapse the systems into one today. But we can name the gap. We can teach the transition. And we can guide patients toward the path that honors what time remains.

    First Principles for Clinicians

    Palliative care is both a specialty in medicine and an overarching philosophy—a mindset that prioritizes comfort, clarity, and alignment across the continuum of serious illness.

    Hospice is that philosophy made actionable. It’s a federally defined, time-limited benefit under Medicare that brings structure, coverage, and accountability to the end of life.

    Palliative care brings the mindset and the tools. Hospice brings the infrastructure with sustained presence.

    You need both. Patients and families deserve care at the right moment, in the right way. But the mistake usually isn’t choosing the wrong one. It’s waiting too long to consider either.

    That’s the cost of the false divide: When we treat these as separate instead of sequential, we delay the very thing both are designed to do—reduce suffering, preserve dignity, and make the hardest weeks of life more meaningful.

    If you’re unsure which path to recommend, ask:

    1. What is the patient hoping for?
    2. How much time might be left?
    3. And what kind of support would help right now?

    Start there. Start early. Your leadership can walk both lanes, and bridge that divide.

    Closing Reflection: Building a Better Map

    In a more humane world, the pain, the fear, and the complexity of serious illness wouldn’t require a new diagnosis or a six-month prognosis to justify hospice-level care. Palliative care’s hospital-based model would fully complement hospice’s home-based strength.

    I think we should eliminate the six-month guideline and merge the two. That would create a clear, cohesive path for people living with serious illness.

    Imagine a system where palliative care begins at diagnosis, supported by AI tools that flag symptom distress early and escalate support before a crisis. A nurse arrives before you need to call. A doctor speaks the truth early to give more options. Hospice becomes a seamless escalation, not a last resort.

    Until that world arrives, let’s use the tools we have with clarity and courage. Let’s advocate for a Medicare reform that funds this full continuum.

    Let’s make sure families know the difference. Let’s make sure clinicians understand the timing.

    Let’s stop treating philosophy as a benefit and start treating people with aggressive comfort.

    Let’s build a future where care isn’t conditional. Where presence isn’t something you have to qualify for.

    Because the real goal isn’t to choose one path. It’s to chart the one that leads to more good days.

    Be the clinician who listens to the quiet cues.

    Be the guide who maps meaning.

    Be the one who thinks comfort first.

    Three Key Insights

    1. Hospice and palliative care share a philosophy—but diverge due to systems, structures, and how they are paid.
    2. Palliative care is the beginning of support; hospice is the structured framework for its final chapter.
    3. Confusing the two delays access to the very thing both are meant to protect: time, trust, and dignity.

    Two Actionable Ideas

    1. Reframe hospice,  not as a last resort but as the structured form of palliative care for the final phase of illness.
    2. Normalize early comfort conversations, especially when the system itself still waits too long.

    One Compassionate Call to Action


    Help patients write a different story. One where support starts early, and suffering isn’t the price we pay for not knowing the system.

    Bibliography

    World Health Organization. (2020). WHO Definition of Palliative Care. https://www.who.int/news-room/fact-sheets/detail/palliative-care

    Kamal, A. H., et al. (2019). The Use of Palliative Care Services in the United States. JAMA Internal Medicine, 179(9), 1231–1232.

    U.S. Congress. (1982). Tax Equity and Fiscal Responsibility Act of 1982.

    Meier, D. E. (2011). Increased Access to Palliative Care and Hospice Services: Opportunities to Improve Value in Health Care. The Milbank Quarterly, 89(3), 343–380.

  • Never Words in Hospice

    Never Words in Hospice

    “There is nothing more we can do.”

    Written by

    Brian H. Black D.O.

    in

    Words That Close the Door

    I walked into the doorway to ICU bed 3 when I heard the dreaded phrase.

    “There is nothing more we can do.”

    The attending, trying to introduce me as the palliative consultant, intended to help. But his words sparked fear in the patient.

    The room was quiet and reflective, but tension immediately rose. I watched the patient’s daughter glance down, hands clenched, bracing for impact. That one sentence changed the energy in the room. An emotional door closed—and I hadn’t even sat down yet.

    Not only was that phrase untrue—it caused harm. Postulating the answer as “nothing” closes the door and locks it, isolating the patient and family from hope, connection, and choice.

    Language Isn’t Neutral: It Builds Trust or It Breaks It

    Clinicians face one of the highest-stakes conversations in medicine when sitting with someone who is seriously ill. In hospice, these conversations often happen in an ICU or a living room, where you’re not just discussing medical options. You are honoring hopes and dreams that may be about to be cut short.

    Too often, we mean to comfort or clarify but do the opposite. Never-Words, as defined by Awdish, Grafton, and Berry in their 2024 Mayo Clinic Proceedings [1] paper, are phrases that take away choice, frighten, or unintentionally sever connection. They are not just poor phrasing. They are missed opportunities for trust, clarity, and dignity.

    This post reviews the seminal article by Awdish et al., adds hospice-specific insights, and offers practical replacements for common Never-Words. It builds on Think with the End in Mind to support Clarity First dialogue.

    What Are Never-Words?

    “Never-Words” are phrases that clinicians should avoid in serious illness conversations. 

    They often:

    • Shut down dialogue
    • Impose authority over patient agency with declarative communication
    • Sound reductive or dismissive

    Examples include:

    • “There is nothing more we can do.”
    • “You failed treatment.”
    • “We will withdraw care.”
    • “He needs a transplant.”

    Why They Harm

    Never-Words reinforce power imbalances in emotionally charged moments. They suggest judgment, finality, or abandonment. Take the question: “Do you want us to do everything?”

    It sounds like collaboration—but it conceals a failure to lead. In asking it, we dodge our duty to name prognosis and give informed consent. It’s moral abdication, disguised as respect.

    In busy hospital settings with fragmented care, harmful phrases persist because no one owns the language. EMRs default to jargon. New clinicians receive little coaching on how to speak at the bedside.

    We need to normalize communication training. We need to model better language.

    Patients hear more than words. They hear tone. They feel intention. And when the words land poorly, they linger. They echo. “Patient failed treatment” might land in the chart, but it isn’t respectful to the patient or family.

    The profession needs to own the language and cannot allow a prognostic burden shift. We need to own the lack of role modeling, poor EMR defaults, and poor word choices.  

    There is a chance to do better in the moment and implement clear teaching moving forward.

    Practical Alternatives

    Never-WordAlternative PhraseWhy It Works
    “There’s nothing we can do.”“We can shift our focus to comfort and quality of life.”Conveys continued presence and care
    “She failed treatment.”“The treatment hasn’t had the effect we hoped for.”Removes blame from the patient
    “Withdrawing care”“We’re continuing care that aligns with what matters to them.”Reframes as a shift, not a stop
    “Do you want everything done?”“Let’s talk through what care would be most meaningful.”Avoids false binaries; invites shared decisions
    “He needs a transplant.”“His heart is worsening. May we talk about what that means?”Shares concern and invites exploration

    Print this table for your next IDG meeting or keep it handy to guide your language.

    Hospice Perspective

    Far too often in the ER and even in hospice IDG meetings—I hear the phrase “He is a DNR.” It always stops me cold. No one is a code status. Reducing a person’s full narrative to a three-letter shorthand flattens nuance, erases deliberation, and risks signaling finality. It is also dehumanizing.

    A better option? “Mr. Smith has chosen a DNR order to prioritize comfort. It is noted on file.” That framing reflects a choice made with thought, intention, and context. In hospice, where identity and dignity reign, this isn’t a matter of semantics. It’s a matter of respect.

    The Never Words article struck a nerve for me. Families often remark, “Those words still haunt us.” Language lingers. Your choices can echo and impact grief long after you leave the room. It creates moral residue for clinicians too. There are many reasons why language matters.

    I’ve seen how phrases like “comfort only” or “withdraw care” can send families into emotional free fall. I’ve also seen language bring calm, restore clarity, and invite collaboration. Words shape tone. Tone shapes trust. And we need more trust in medicine. Trust that we will work together and never abandon the patient. Trust that there is a doctor, a nurse, a social worker, a chaplain, an aide, a volunteer, and more. Trust that there is a whole team available.

    When we say, “Let’s talk through this together and consider all options” it shifts the dynamic from detachment to solidarity. That’s the essence of hospice. We comfort. We show up—deliberately and consistently.

    Vision That Lights the Way

    If we want families to see the paths ahead, we have to illuminate them. That means guiding families through goals-of-care discussions with empathy to ensure they feel supported. We have to help them understand why hospice may be the best option—not the last option.

    In our prior post, Hospice is not a Place, It’s a Promise, we discussed how hospice prioritizes showing up for patients. Avoiding Never-Words builds on that foundation by ensuring our language honors choices and uplifts patients.

    Hospice is about showing up. It’s understanding the patient’s voice—and honoring their decisions. Now is the right time.

    To avoid Never-Words, training programs should include role-playing serious illness conversations and reviewing phrases like those in the table above. New providers can practice these during on-boarding to build confidence.

    It all begins with recognition—and learning to carefully craft powerfully positive words.

    Three Key Insights

    1. Never-Words are rarely intentional—but they still cause harm.
    2. Better phrases build trust, agency, and clarity.
    3. Communication training should be standard in serious illness care.

    One Actionable Ideas

    • Review your own scripts and swap out one habitual Never-Word this week and seek out other resources like VitalTalk or the REDE Model.
    • Practice walking back a phrase that didn’t land well: “That came out wrong. Can I say that another way?”

    One Actionable Item

    Speak as though your words will echo—because for many families, they do. Share Never-Words with your team at IDG. Bring up this topic at your next staff meeting. Link to this Blog. Let’s learn together!

    Glossary

    • Never-Words (new): Harmful phrases that sever connection in serious illness conversations, often unintentionally.
    • Language Shift (new): The practice of replacing default or harmful clinical phrases with language that builds trust, clarity, and compassion.
    • Words That Heal (new): A Hospice Synopsis communication principle promoting language that honors patient dignity and supports informed, shared decisions.
    • IDG (existing): Interdisciplinary Group – the full hospice team that includes physicians, nurses, social workers, chaplains, aides, and others.
    • DNR (existing): Do Not Resuscitate – a medical order indicating no CPR or advanced cardiac life support if breathing or heartbeat stops.

    Quote

    “Speak as though your words will echo, because for many families they will.” — Brian H. Black, D.O.

    Bibliography

  • The Big R: Legacy & Leverage

    The Big R: Legacy & Leverage

    “What’s the one thing that would bring the most peace today?”
— Brian H. Black, D.O.

    Written by

    Brian H. Black D.O.

    in

    I. A Friendship that Changed my Life

    We were wrestlers who talked statistics, and everything else—from fighter jets to philosophy. Both driven with challenge and a search for meaning.

    Dennis was the kind of mentor who didn’t just help you solve problems—he helped you believe they were worth solving. Over the course of two decades, he became a touchstone in my life. A steady voice.

    I still smile thinking of him gleefully commandeering my computer to tweak an Excel formula. His quiet joy made every problem feel solvable. What I wouldn’t give to hear him say “Hey Brian” one more time.

    When he got sick, I walked with him through the long arc of decline. Through his final weeks. His voice became a whisper. But he never stopped teaching.

    I grew as a person by being his friend. Not as a clinician charting decline, but as someone sitting by his side, trying to offer support a man who had always lifted up others. Now, we wrestled mainly with the weight of shrinking time.

    In that space—between data and dying, numbers and meaning—I learned something I now carry into every hospice room I enter.

    II. From Math to Meaning

    We were out jogging when Dennis turned to me and said, “You don’t need to solve everything—just find the variable that matters most.”

    We’d been talking about leverage and statistics—specifically R-squared, the formula that shows how much one variable explains an outcome. But you don’t need to be a data analyst to understand the lesson. It’s about tuning out the noise until the signal comes through clear.

    I did not know it then, but that one conversation would reshape how I think about caring for the dying. 

    I’ve come to think of it as finding the BigR—the one thing that brings the most peace today. Not the most dramatic change. Not the most advanced intervention. The thing that truly matters.

    In hospice, those factors are rarely additional treatments. They’re personal: a long-awaited goodbye, a pain-free moment. For one patient, it was simply hearing his granddaughter’s laugh on the porch.

    This isn’t just philosophy. It’s strategy that sharpens our focus. When time is short, precision matters. Not everything can be fixed. But the sacred can still be honored.

    Every moment at the bedside is a chance to refocus, to ask: What’s the BigR today?

    III. A Compass for the Final Chapter

    What is the one thing that would bring the most peace today?

    We ask it quietly. Sometimes aloud. Sometimes silently, as we enter the room.

    In hospice, that question is more than a courtesy—it’s a compass. When time is short, it’s how we avoid wasted motion. It centers the care plan, realigns overwhelmed families, and reminds us why we’re here.

    I used to think hospice work required encyclopedic knowledge. Now I know it demands something harder: precision with presence.

    The BigR isn’t just a metaphor—it’s a mindset. It sharpens our focus on what matters most. And its power comes from three forces that shape the way we show up:

    BigR = Legacy + Leverage + Leadership

    • Legacy is what we leave behind.
    • Leverage is using the smallest effort for the biggest peace.
    • Leadership is the clarity to act on it.

    We don’t need to fix everything. But we do need to find the one thing that matters most—for this moment, this visit, this person.

    That’s the power of the BigR. It doesn’t point to everything. It points true north.

    IV. Real-Time Leverage

    Hospice is the practice of presence.

    BigR doesn’t live in formulas. It lives in moments. It surfaces in a pause, a quiet question, or a gentle truth finally spoken.

    • For patients, it’s often the moment they choose to stop a burdensome treatment and reclaim comfort.
    • For families, it’s a conversation—raw, real, and without regret.
    • For clinicians, it’s standing steady while others sway. It’s calmly naming what no one else wants to say.

    When time is short, clarity matters more than complexity. Sometimes the most important thing we offer is witness with our care. We need to earn the trust to hold space.

    These aren’t just tasks—they’re acts of leadership, rooted in intention. That’s how we honor the sacred work of hospice. We find the BigR in little moments. This is a foundational guide to a lasting legacy.

    Dennis lived this mindset long before I had a name for it. He didn’t just teach me how to solve problems; he showed me how to search for what mattered most. And that is real leverage we carry into each day in hospice.

    Three Key Insights

    
• BigR helps identify the most meaningful, high-impact action in moments of limited time.


    • In hospice, a few grounded decisions shape how patients experience dying—and how families remember it.

    
• BigR combines legacy, leverage, and leadership into a mindset that guides presence, not just practice.

    Two Actionable Ideas


    • Start IDG meetings by asking: What’s the BigR for this patient today? Make it part of your team’s shared language.


    • In difficult conversations, offer a frame: “If we only had a few days, what would matter most to you?”

    One Compassionate Call to Action


    Don’t wait for a crisis to seek clarity.

    Ask the question now:

    What’s the one thing that matters most—today, and in the days that follow?

    Let it lead you.

    Quote

    “When time is limited, precision matters. What is the one thing that will bring the most peace?  Lead with it.”
— Brian H. Black, D.O.

    Bibliography:

    Temel, J. S., Greer, J. A., Muzikansky, A., et al. (2010). Early palliative care for patients with metastatic non–small-cell lung cancer. New England Journal of Medicine, 363(8), 733–742. https://doi.org/10.1056/NEJMoa1000678

    Block, S. D. (2006). Medical education in end-of-life care: The status of reform. Journal of Palliative Medicine, 9(4), 774–786. https://doi.org/10.1089/jpm.2006.9.774

    Quill, T. E., & Abernethy, A. P. (2013). Generalist plus specialist palliative care—Creating a more sustainable model. New England Journal of Medicine, 368(13), 1173–1175. https://doi.org/10.1056/NEJMp1215620

    Arias-Casais, N., Garralda, E., Rhee, J. Y., et al. (2019). EAPC Atlas of Palliative Care in Europe 2019. European Association for Palliative Care. https://www.eapcnet.eu

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  • What is Hospice Synopsis?

    What is Hospice Synopsis?

    It’s where clarity, compassion, and clinical wisdom meet.

    “To teach is to touch the future.”
    — Anonymous

    Hospice Synopsis began like most important things in medicine do — quietly, at the bedside.
    Refined through IDG meetings and late-night urgent patient consults.
    A few sticky notes turned into a growing folder of reflections, infographics, and clinical frameworks.
    And eventually, a question that won’t let me go:

    Can we keep doing this work better?
    Not just faster.
    Not just more compliantly.
    But more humanely — with clarity, courage, and evidence that truly matters.
    Together?

    I’ve worn many hats — scrubs, suits, masks… even helmets.
    But the one thing I return to most often is teacher.

    Welcoming new teammates into hospice is still one of my great joys.
    This platform?
    It’s an extension of that welcome — to you.
    It’s my way of honoring the pioneers who came before us,
    and the patients who shaped me.
    A place to gather the best tools, the deepest insights, the clearest language —
    and offer them back to the field that changed my life.

    Who Is This For?

    For the medical director sorting eligibility from ambiguity.
    For the nurse wondering how to explain “comfort care.”
    For the IDG leader trying to keep a team grounded in soul, not just stats.

    It is for the kind of person who wonders:

    • Is this how I would want to be cared for?
    • Is this how the patient wants to be cared for?
    • Are we saying the right things?
    • Are we doing what matters most, now?

    Hospice Synopsis exists to serve hospice leaders — and those they’re called to care for.
    It’s a space.
    A compass.
    A digital home for people who care deeply about how we care for the dying.
    The place where you start, with the end in mind.

    What You’ll Find at HospiceSynopsis.com

    You’ll find blog posts that make complex ideas simple.
    We honor nuance, but get straight to the point.

    Big questions — like What really matters at the end of life?
    From these questions come posts, and then reflections —
    short insights, clinical gems, and quotes —
    meant to grow your acumen, fuel your team, and steady your heart.

    Those reflections?
    I hope they set things in motion:

    • In how we talk about death
    • In how we practice
    • In how we teach the next generation about hospice care

    What We’re Building

    • Posts that educate
    • Tools that resonate
    • Courses that mentor
    • Language that matters

    Over time you will find teaching tools, myth-busting explainers, and practical guides — all crafted for clinicians who lead with BigR, clarity, and care.

    If you’ve ever thought:

    • There has to be a better way to explain this…
    • I wish someone had taught me this sooner…
    • We can do this better…

    You’re not alone.
And you’re in the right place.

    Thank you for being beside your patients — listening, learning.
    Thank you for supporting your teams — teaching, sharing.
    Thank you for believing this work is worth doing — with skill and soul.

    Hospice Synopsis is the place we go together.
    Let’s build something that lasts. Together.

    Go to HospiceSynopsis.com — which will become the full roadmap of resources, clarity tools, and teaching assets to serve your teams well.
Give feedback. Let us know what you think should come next!

    3 Key Insights

    1. Hospice Synopsis is a clinician-led space for clarity, courage, and community in end-of-life care.
    2. It’s built to simplify complexity, support IDG teams, and elevate how we teach and talk about hospice.
    3. This platform exists because too many people are doing hard, sacred work without the tools or language they need.

    2 Actionable Ideas

    1. Bookmark HospiceSynopsis.com and use it to strengthen your mindset and share leadership tips with your team.
    2. Invite a colleague to join the community by sharing your reaction to this blog.

    1 Compassionate Call to Action

    Join us in building something that lasts — a place where meaning, medicine, and mission meet.
    Explore what is here. Tell us what should come next!

    Bibliography

    National Hospice and Palliative Care Organization. (2024). NHPCO Facts and Figures: Hospice Care in America.
https://www.nhpco.org/hospice-facts-figures

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  • Hospice is not a Place, It’s a Promise

    Hospice is not a Place, It’s a Promise

    I hope I get to be a hospice patient one day. I hope you do too—not just for two weeks, but for its full support.

    The median length of hospice stay in the U.S. is 17.4 days, according to the 2023 NHPCO Facts & Figures report. But hospice does most of its best work long before the final week. This might mean pain finally under control, fewer hospital trips, or a family that gets to be present—not panicked.

    Hospice and palliative care can extend life, improve quality, and reduce healthcare costs. Hospice patients with terminal illnesses such as cancer have been shown to live longer than those who pursue aggressive end-of-life treatments. Multiple studies confirm that hospice care significantly lowers expenditures in the final month of life.

    Hospice offers personalized, whole-person care through an expert team: physicians, nurses, social workers, chaplains, aides, and trained volunteers. Together, they bring relief, dignity, and guidance in the final chapter of life.

    So why isn’t hospice offered earlier?

    Hospice is often misunderstood. It’s whispered in hospital rooms, buried in paperwork, or sadly seen as the final checkbox: “No treatment available. Discharge to hospice.”

    But when we Think with the End in Mind, hospice isn’t a last resort. It’s the right care at the right time—for the right reasons.

    If we could offer this support earlier, why wouldn’t we? We need to actively change this story by reaching more people to educate.

    Hospice is not about giving up. It’s about showing up—fully, honestly, and compassionately wherever the patient is now.

    Hospice Is Not a Place

    Let’s start by breaking up the clichés:

    Hospice is not:

    • A place you go to die
    • Just for people with cancer
    • Only for the last few days of life
    • A resignation, a failure, or a medical cop-out

    Hospice is:

    • A covered insurance benefit, not a location
    • A pivot from aggressive curative care to aggressive palliation
    • A defined clinical benefit that works best when embraced early
    • A team of experts who know how to treat pain and provide presence with skill
    • A shift from medical patchwork to coordinated comfort
    • A mindset that says, “Stop measuring life in years—and start honoring it in meaningful moments”

    When we correct these assumptions, we make room for the real story: hospice as a framework for presence and partnership.

    A Working Definition (And Why It’s Not Enough)

    Archaic definition: “A lodging for travelers” or “a home providing care for the sick.” Still the first thing you see when you search the term. That changed with pioneers like Dame Cicely Saunders.

    Modern definition: “Hospice is expert, team-based medical care focused on comfort, dignity, and quality of life for people with a terminal illness—when cure is no longer the goal.”

    It checks the policy boxes. It sheds the “place” myth. But it still doesn’t touch the humanity.

    Hospice, at its best, is:

    • Whole-person care—for bodies, minds, and souls
    • Support for families—before, during, and after the final breath
    • Delivered anywhere—home, hospital, long-term care, or places in between
    • Built on a philosophy—comfort over cure, presence over pressure
    • Supportive of patient autonomy—empowering informed consent
    • Timed with precision—ideally aligned with the last six months of life

    The six-month rule? Just a Medicare frame. We’ll unpack that later. The truth? It’s not about how much time is left, but what kind of time remains.

    Hospice Is a Team, a Philosophy, and a Promise

    It’s a team. Hospice care is never a solo act. The IDG model includes nurses, social workers, chaplains, CNAs, volunteers, and physicians—each contributing presence and expertise.

    What does this look like? Daily symptom reviews. Spiritual check-ins. Social work support. And physicians asking, “What brings peace today?” It’s trust, presence, and care designed as a team.

    It’s a philosophy. It’s not a product. It’s a mindset of presence over procedure.

    It’s a promise. When others say “There’s nothing more to do,” hospice says: “There is still important work to do. We’re just getting started.”

    Why Understanding Hospice Matters

    Most people come to hospice too late. Not because they don’t deserve care—but because they never understood it was an option.

    Mistrust, confusion, fear, and miscommunication delay access to what patients need most:

    • Relief
    • Connection
    • Clarity
    • A gentle goodbye

    The median length of stay is still just 17.4 days [NHPCO 2023]. Earlier access changes everything.

    We’ll go deeper in future posts—like our hospice eligibility checklist and PPS tools—but for now, remember this: earlier is better.

    The Truth

    Most people still don’t understand hospice. Even some clinicians don’t.

    Whether you’re new to hospice, a family member, or part of an IDG, this blog is your invitation.

    To see hospice with fresh eyes.

    To treat it not as a last stop, but as a door.

    To step through it—together.

    We’ll walk frame by frame, story by story, truth by truth.

    Where We’re Headed

    This post is the spark.

    Coming soon:

    • The six-month rule
    • Hospice vs. palliative care
    • PPS and CTI guides
    • IDG roles and misperceptions
    • What comes after death: bereavement

    Because hospice isn’t one idea. It’s a universe. We’re going to hospice the synopsis out of it—so you don’t have to do it alone.

    A Final Reflection

    If someone asked you, right now—”What is hospice?”

    Would you describe a place? A process? A last resort?

    Or would you describe a secret door—and give them the key?

    “You matter because you are you. You matter to the last moment of your life.” — Dame Cicely Saunders

    Let’s stop whispering hospice like it’s failure.

    Let’s start walking through the door—together.

    Summary

    3 Key Insights:

    1. Hospice is not a location—it’s a clinical benefit, a care model, and a mindset.
    2. Misunderstanding hospice delays access to comfort, dignity, and meaning.
    3. The interdisciplinary team (IDG) is the heartbeat of hospice—each role matters.

    2 Actionable Ideas:

    1. Try this: “Hospice isn’t about giving up—it’s about showing up. It’s a promise of coordinated comfort care.”
    2. Start one conversation this week by asking: “What would bring the most peace today?”

    1 Compassionate Call to Action: Let’s stop whispering “hospice” like it’s a failure. Share this post. Say the word out loud. Walk through the door with others. And if you’re already walking through that door—it’s okay to bring someone with you.

    Bibliography

    1. National Hospice and Palliative Care Organization. (2024). 2024 NHPCO Facts & Figures – National Coalition for Hospice and Palliative Care.
    2. Connor SR et al. J Pain Symptom Manage. 2007;33(3):238-46. https://pubmed.ncbi.nlm.nih.gov/17349493/
    3. Taylor DH Jr et al. Soc Sci Med. 2007;65(7):1466-78. https://pubmed.ncbi.nlm.nih.gov/17600605/
    4. Kelley AS et al. Health Aff. 2013;32(3):552-61. https://pubmed.ncbi.nlm.nih.gov/23459735/

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  • Think with the End in Mind

    Think with the End in Mind

    What if the end of life is the most meaningful beginning?

    Written by

    Brian H. Black D.O.

    in

    Imagine knowing exactly what matters most—every moment shaped by clarity and purpose. That’s the question at the heart of Hospice Synopsis. It’s the content I want to create. It’s the service I want to leverage so hospice teams can translate medicine into excellent patient care.

    “Begin with the end in mind.” — Stephen R. Covey

    When Covey wrote those words in The 7 Habits of Highly Effective People, he was teaching a principle of success:

    • Know where you are going before you begin.
    • Define what matters most and let it guide your actions.

    Nowhere is that wisdom more urgent—or more transformative—than in hospice care. That’s why I say, “Think with the End in Mind.” It’s the foundation of hospice when it’s done well—with clarity, presence, and purpose.

    Hospice Is About More Than Just an Ending

    Hospice is, at its heart, about beginnings. It’s about re-centering—not just navigating a transition, but discovering what truly matters at each step. It elevates each moment to honor a person’s life through deeply intentional care.

    It’s not just about time. It’s about the meaning in the time we have left. That is what drives me to share what more than 20 years in hospice medical direction has taught me.

    Why the First Hospice Synopsis Blog Begins Here

    This post launches Hospice Synopsis—a project built on this lens:

    • Ask hard questions
    • Think differently about life’s final chapter
    • Champion a better way to care—with intention

    Beginning with the end in mind isn’t just philosophy. It’s our operating system. The filter for every decision, every conversation, every act of care.

    Why Intention Matters in Hospice and Life

    Beginning with the end in mind means pausing to name what matters before momentum takes over. One patient told me, “Just a chance to do a little more woodworking.” He didn’t ask for a cure. He asked for purpose. That single phrase became our plan—and our presence.

    That clarity isn’t just for patients. It’s how we show up in our own lives too.

    In Japanese culture, there’s a word for this: “ikigai”—your reason for being. Even near the end of life, many patients still have one. It may be woodworking, listening to birds, or holding a grandchild’s hand. When we ask, “What matters now?”—we help them live at the end.

    How Hospice Care Redefines Meaning

    Modern medicine defaults to protocols and checklists. It’s easy to fall into motion over meaning. Hospice gives us pause. It gives us time to:

    • Listen
    • Think
    • Ask what truly matters

    We shift from doing more to doing what matters most:

    • Embrace their favorite story
    • Play their era’s music
    • Sit with their loved ones

    Hospice creates space to:

    • Define priorities
    • Tell untold stories
    • Choose peace over procedure
    • Heal with presence, not just meds

    Before you finish reading—pause. Ask yourself: What would make today a good day for someone in your care?

    Hospice Mindset Comes from Depth

    Hospice work is hard. Time is short. Emotions run high. A grounded mindset comes not from fear—but from clarity.

    Hospice care isn’t giving up. It’s showing up:

    • Presence over pressure
    • Story over silence
    • Purpose over protocol

    This mindset doesn’t just ground physicians—it empowers nurses, chaplains, aides, and every member of the hospice circle to show up with clarity and care. It steadies patients—and us. Whether you’re a hospice physician, nurse, MSW, chaplain, caregiver—or someone trying to understand this work—this blog is your invitation.

    This Is Where We Begin

    It’s been a journey. But purpose changes everything. Hospice demands we “Think with the End in Mind.”

    This mindset isn’t always easy to hold for me. There are days when urgency wins, when checklists crowd out clarity. But I’ve learned to return to this compass. Again and again.

    It’s my guiding philosophy. It’s the foundation of this project.

    Think with the End in Mind—because when we do, we don’t just plan better. We live better.

    Summary:

    Key Insights

    • Thinking with the end in mind focuses care around meaning, not just motion.
    • Hospice is about intentional living—not just dying.
    • Clarity on what matters most transforms how we show up.

    Actionable Ideas

    • Ask patients: “What would make today a good day for you?” or try starting your next IDG meeting with this prompt. You’ll be surprised how often it clarifies care plans more than any clinical metric.
    • Revisit your personal or team mission with this lens and share your findings with us!

    Call to Action

    Think with the end in mind. Then share it with someone who needs this compass too.

    Ask yourself: “What would make today a good day for someone in your care?” — Brian H. Black, D.O.

    Bibliography:

    Covey, S. R. (1989). The 7 Habits of Highly Effective People. Free Press.

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