Category: Foundational

Posts that define key terms, philosophies, and the “why” behind hospice. These anchor the rest of the content.
Examples: Think with the End in Mind, The Big R, What is Hospice

  • NYHA in Hospice: Turning Breathlessness into Shared Language

    NYHA in Hospice: Turning Breathlessness into Shared Language

    The NYHA Still Matters

    Every hospice nurse knows the moment: the patient gasps two steps after standing, already on oxygen, swollen despite diuretics, worsening each week. Families call it weakness. Hospitals call it criteria. We should name it New York Heart Scale (NYHA) Class IV with clinical clarity.

    “NYHA Class IV” alone in the chart invites denials, audits, and mistrust. It was never a checkbox. Paired with PPS ≤40% and functional decline, it tells a tale. Without context, it erases that story and costs patients’ care. Much like other metrics that matter, NYHA remains essential in hospice: not a number, but a narrative of breath and function. It’s all about the score plus the story.

    Case Example

    Mr. Lowe, 78, a retired truck driver, had severe heart failure. His EF sat near 30%. His daughter asked, “Does that number mean he qualifies for hospice?”

    What mattered wasn’t just a static EF. He became short of breath just pulling on his socks. He had two hospitalizations in 60 days. He had 10lbs of fluid gain, despite diuretics.

    EF didn’t tell that story. However, NYHA classified it as Class IV, with symptoms present at rest. Paired with PPS 40% and documented declines. The record was clear, defensible, and compassionate. His daughter finally understood: “his heart can’t get him through the day anymore.” She was right, it’s not just about numbers. 

    The Essentials

    Definition. NYHA is a four-class system quantifying functional limits in heart failure:

    • Class I: No symptoms with ordinary activity
    • Class II: Symptoms with ordinary activity
    • Class III: Symptoms with less-than-ordinary activity
    • Class IV: Symptoms at rest

    Nature. NYHA is subjective. It depends on clinician judgment, patient report, and observed capacity. It predicts mortality, but reproducibility suffers from interobserver variability.

    Theme. NYHA is essential but insufficient. Alone it misleads. In context it clarifies.

    Application. “Symptoms at rest” is the textbook line, but Class IV is broader:

    • Minimal effort counts. Even standing, dressing, or talking may trigger symptoms.
    • Not just dyspnea. Fatigue, palpitations, and angina also qualify.
    • Fluid symptoms count. Orthopnea, paroxysmal nocturnal dyspnea, bendopenia.
    • Dynamic status. Patients may fluctuate between III and IV; document the worst functional state.
    • Prognosis. Class IV signals poor survival, but hospice eligibility still requires PPS ≤40%, weight loss, or hospitalizations.

    At the bedside, Class IV means:

    • “Patient breathless pulling on socks.”
    • “Requires chair after 10–15 feet.”
    • “Needs 2–3 pillows to sleep.”

    NYHA IV should always be written as lived narrative, not just noted simply as “at rest.”

    History

    NYHA classification first appeared in 1928, refined in 1964 and 1994. Why has it lasted nearly a century? Not for perfection. It is subjective and inconsistent. It lasted because it is simple, human, and functional.

    Before PPS or ECOG, cardiology needed a way to say what patients could do and what they could not. NYHA gave that answer. Hospice inherits the same need: a language of limitation understood in the clinic, in the living room, and in audits.

    Clinical Relevance

    In advanced heart failure, NYHA still provides clarity:

    • Class IV signals serious limitation, usually with PPS <50%.
    • CMS LCDs cite NYHA IV plus decline markers: hospitalizations, EF <20%, weight loss.
    • Ejection Fraction (EF) is often a lagging indicator. Echo numbers may look stable or go unmeasured while patients continue to decline. Functional change over time always carries more prognostic weight.
    • Families and physicians outside hospice know the scale, making it a bridge between worlds.
    • Scope: Validated in HF and valvular disease, sometimes in congenital or right-sided failure. For non-cardiac illness, use tools like PPS or FAST.

    Used wisely, NYHA supports eligibility, teaches teams, and reassures families that what they see is real.

    Interdisciplinary Voice

    What each discipline brings to NYHA:

    • Nurse: Record distance and recovery. “Needs two rests in 15 feet.”
    • Social Worker: Capture role loss. “Stopped grocery shopping due to breathlessness.”
    • Chaplain: Note spiritual or community loss. “Unable to attend church after 50 years.”
    • Physician/NP/PA: Synthesize. “NYHA IV, PPS 40%, 5% weight loss, two CHF admissions, decline consistent with terminal heart failure.”

    In IDG, NYHA language should not sit only in the physician’s note. When nurses, social workers, and chaplains mention the same functional language: dyspneic at rest, limited to 10 feet. Then whole record speaks with one voice.

    Number + Narrative

    NYHA should always be Number + Narrative.

    • Number: Class I–IV
    • Narrative: Functional loss proving the class

    Examples:

    • “NYHA IV, dyspneic at rest, PPS 40%, two CHF admissions, 5% weight loss in 3 months.”
    • “Paused twice in 10 feet, needed chair after 20 seconds standing.”

    Pair with PPS and weight trends to strengthen eligibility notes. Never rely on EF alone. Function carries more prognostic weight.

    Beyond Self-Report: Anchors That Hold

    NYHA is subjective. Frail or cognitively impaired patients may understate symptoms or forget limits. To anchor classification:

    • Use proxy reports from caregivers.
    • Document observed tasks: “Paused twice in 10 feet, needed chair after 20 seconds standing.”
    • Add objective tools: PPS, FAST, etc…

    Anchors improve reproducibility and strengthen eligibility notes.

    Blind Spots and Misuse

    • Equating EF with prognosis: Low EF alone does not qualify. Function drives prognosis.
    • Confusing PPS with NYHA: PPS is global; NYHA is disease-specific. They complement, not replace, each other.
    • Assuming Class IV is enough: Documentation must show decline over time.
    • Over-jargon in charting: “NYHA IV” without narrative is not defensible.

    Compliance pitfall: A chart that only says “NYHA IV” is not very helpful. In audits, NYHA without narrative is treated as noncompliant. Eligibility rests on narrative: distance, frequency, functional loss. Without it, coverage and credibility collapse.

    Say This / Not That

    Say ThisNot That

    “NYHA IV, dyspneic at rest; PPS 40%; unable to walk 10 feet; two hospitalizations this year.”
    		“NYHA IV.”

    “EF 25% with functional collapse, symptoms now daily at rest.”

    “Low EF, so hospice.”

    “Decline in activity and self-care, no longer dresses without stopping for breath.”
    		“PPS 40%, meets criteria.”

    “Observed dyspnea after 8–10 feet, accessory muscle use, needed chair after 20 seconds, PPS 30%.”
    		“Nonverbal patient, severe CHF.”

    Closing

    NYHA is essential but insufficient. Alone it risks becoming a checkbox that hides truth. Paired with PPS, weight loss, and hospitalizations, it tells a story of decline families and auditors can trust.

    Like PPS and FAST, NYHA follows our Hospice Synopsis rule: every metric must live through story. The number points. The story proves.

    When decline is measured, NYHA gives us the language. Our job is to add the narrative that makes hospice clear today.

    3 Key Insights

    • NYHA remains one of the oldest and clearest functional tools in heart failure, still vital in hospice.
    • It is subjective. Anchor it with PPS, weight loss, and observed decline.
    • A number alone fails. Narrative makes eligibility defensible and care plans clear.

    2 Actionable Ideas

    • Standardize CHF notes: always pair NYHA with PPS and recent hospitalizations.
    • Teach every IDG member how their notes shape NYHA class.

    1 Compassionate Call to Action

    Use NYHA not as a checkbox but as a bridge. Turn breathlessness into language that families, teams, and auditors can trust.

    “Breathless at ten feet tells a truer story than EF alone. NYHA gives us the words; PPS and trajectory make them matter.”

    Bibliography

    • The Criteria Committee of the New York Heart Association. (1994). Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Great Vessels (9th ed.). Little, Brown & Co.
    • Centers for Medicare & Medicaid Services. (2025). Local Coverage Determination (LCD): Hospice – Heart Disease. https://www.cms.gov/medicare-coverage-database
    • Levy, W. C., Mozaffarian, D., Linker, D. T., et al. (2006). The Seattle Heart Failure Model: Prediction of survival in heart failure. Circulation, 113(11), 1424–1433. https://doi.org/10.1161/CIRCULATIONAHA.105.584102
    • O’Connor, C. M., & Whellan, D. J. (2005). Evolving role of functional classification in heart failure: NYHA and beyond. American Heart Journal, 149(2), 209–214. https://doi.org/10.1016/j.ahj.2004.03.010

    Glossary Terms

    • NYHA (new): The New York Heart Association classification—a four-stage functional system (I–IV) originally designed for heart failure, still used in hospice to document decline and support eligibility.
    • Class IV Heart Failure (new): The most severe NYHA stage, defined by symptoms at rest. In hospice, often paired with PPS <50% and recurrent hospitalizations to support eligibility.

  • 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.

  • 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

    Table of Contents

  • 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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