Category: Mindset & Culture

Posts that challenge assumptions, reframe beliefs, and address public misunderstandings. Includes policy, advocacy, and big-picture reform themes.
Examples: Hospice vs Palliative Care, Hospice is a Promise, Language That Hurts

  • Racing to a Good Day

    Racing to a Good Day

    How Hospice Teams Drive Meaningful Moments at the End of Life

    Introduction

    Pancho just wanted one last lap around the track.

    His heart was failing. I worried about the risks, the meaning, the safety, the weight of the request. At IDG we planned a way forward: a car show and a vehicle that could give rides to anyone able.

    We brought a racing UTV to the nursing home. A lightweight off-road vehicle, open-sided with roll bars, easy to enter and safe at low speed. Residents gathered outside, smiling as the engine rumbled. We ran slow laps in the cleared parking lot.

    He came outside, placed a hand on the hood, and whispered: “Fun.” That single word became the memory staff return to again and again. The ride wasn’t only his wish. It became a shared joy for the whole facility.

    Hospice often begins with one simple question: “What would make today a good day?” The question anchors dignity therapy, which helps patients reflect on meaning and legacy (Chochinov, 2007), and aligns with person-centered outcomes research, which emphasizes tailoring care to individual values.

    The answer might be woodworking or card night. Often, it’s simply not being alone. Sometimes, it’s the thrill of the racetrack.

    When hospice is done well, “a good day” is not chance. It’s created by a team, an IDG, working together to make meaning possible. That’s what we were racing toward when Pancho touched the hood and whispered his truth.

    The Power of the Team: Who Shows Up, and Why It Matters

    In hospice, care is never the work of one. It belongs to the interdisciplinary group (IDG). Each brings a distinct lens. Together, they steer the day toward peace.

    When it works, it sounds like:

    • A chaplain singing hymns bedside because the patient once led worship
    • A social worker securing additional aide coverage from a payor
    • A massage therapist easing agitation so meds aren’t needed as often
    • A nurse finding a way to get a patient to her daughter’s backyard wedding
    • A PA signing off and attending a boating trip for a patient with special needs

    These moments rarely appear in the chart, but they shape what families remember as the why in “why hospice, why now”.

    Moments That Made the Day: True Stories of Wishes Come True

    • The Home Prom: A young woman with Huntington’s disease never got to go to prom. So her ECF team helped her pick a dress. Family decorated the commons. Staff showed up in suits. She danced the night away.
    • The Final Adventure: A patient with two young children shared one wish: to create joyful memories at the zoo. The social worker and volunteer coordinator made it happen with help from our hospice foundation. A dolphin encounter and dinner. A weekend full of laughter.
    • The Almost Missed Moment: We nearly missed a patient’s final porch visit because the DME vendor canceled last minute. The aide called three suppliers. The social worker drove 40 minutes to secure backup equipment. By nightfall, the patient sat under the stars with his brother. No chart could capture what that moment of mobility and freedom meant to the family. 

    These weren’t mapped routes. They were turns we took because someone asked, ‘Can we?’—and the team found a way. These moments answered the question: What would bring peace today?

    These moments remind us that presence is the foundation of care, even when wishes can’t be fully realized. The National Hospice and Palliative Care Organization (NHPCO) offers resources to help teams navigate such challenges (nhpco.org).

    The Good Day Loop: A Practice Worth Repeating

    Good days don’t happen by accident. They happen when teams stay curious, responsive, and reflective. The Good Day Loop offers a rhythm for everyday care:

    1. Ask  — What would make today a good day?
    2. Act — Try one thing, big or small.
    3. Reflect — What worked? What was missed?
    4. Care Plan — Document it. Build on it.
    5. Share — Who made it possible? What did it teach?

    Quarterly Prompt for IDGs: Pick one good day story each quarter. Review it as a team. Teach it to new staff. Share it in a Legacy Round to build culture from lived examples.

    Example: A nurse documented that a patient wanted to sit outside. The next week, the chaplain arranged music in the garden. What began as a line in the chart became a shared act of care.

    Each Role, One Voice

    Like driver and pit crew, each move depends on trust, timing, and a shared direction.

    Closing Reflection: We Don’t Just Witness Good Days. We Build Them.

    Hospice doesn’t always mean a ride around the track. Sometimes it’s motion brought to stillness. Sometimes it’s joy in a parking lot. Sometimes it’s presence when the plan falls apart.

    Ask the question. Let the answers guide care. Some answers lead to joy. Some to stillness. Some to nothing at all. But asking still matters. Showing up still matters.

    As Blog #1 reminded us: Think with the End in Mind. As the BigR reframes: focus on the high-leverage moments that build legacy. Good days in hospice are not accidents. They are the legacy of an IDG that asks, acts, and adapts together.

    Three Key Insights

    • The question “What would make today a good day?” is a compass for meaningful care.
    • IDG members bring unique and essential tools to make moments matter.
    • Hospice’s greatest impact is often in the non-medical moments it protects and makes possible.

    Two Actionable Ideas

    • Hold quarterly Legacy Rounds where each team member brings one story, one moment, or one line from a patient that brought meaning.
    • Add a “Good Day” section to routine IDG documentation: what mattered, what was tried, what was noticed. Remember: You are not just documenting decline. You are helping someone live. Ask the question. Make the moment. Share the story.

    One Quote

    “In hospice, good days don’t happen by chance. They’re driven by presence, steered by trust, and tuned by teamwork.” — Brian H. Black, D.O.

    Bibliography

    • Chochinov, H. M. (2007). Dignity and the essence of medicine: the A, B, C, and D of dignity-conserving care. BMJ, 335(7612), 184–187. https://doi.org/10.1136/bmj.39244.650926.47
    • National Hospice and Palliative Care Organization. (2024). Standards of Practice for Hospice Programs. Retrieved from https://www.nhpco.org

    Glossary

    Dignity Therapy – A structured interview method that helps patients reflect on meaning, purpose, and legacy at the end of life.

    Person-Centered Outcomes – Research and practices that measure success by how well care aligns with the individual patient’s values, not just clinical metrics.

    Good Day Loop – A repeatable hospice practice framework of asking, acting, reflecting, documenting, and sharing patient-centered goals to create meaningful days.

    Today Was a Good Day – A Hospice Synopsis phrase highlighting that small, values-driven interventions can define the impact of hospice care.

    IDG Storyboard – A practice tool for capturing, teaching, and passing on good-day stories within the interdisciplinary group to shape culture and morale.

    To Do: Future Project

    The Good Day Tracker – A companion tool for IDGs to record, reflect, and share “good day” moments. Includes:

    • Printable template for quotes, wishes, follow-through notes
    • Weekly prompts for IDG morale and inspiration
    • Integration into onboarding and staff storytelling efforts

  • The Shape of Dying: The Four Illness Trajectories

    The Shape of Dying: The Four Illness Trajectories

    The Shape of Dying: The Four Illness Trajectories

    Written by

    Brian H. Black D.O.

    in

    , ,

    The Shape of Dying

    By noon, she was unconscious. But earlier that morning, her mother had eaten three good bites of oatmeal. Every similar quiet breakfast prior had felt like proof she would recover—until that day. The daughter remarked to us, “No one said it could go this fast.” 

    To relieve suffering, we need to know a little about future. “We can’t predict an exact date of death, but we can trace its path and prepare for what’s likely.”

    Doctors often overestimate how long patients will live—sometimes by a factor of five ( Christakis & Lamont, 2000). This can delay hospice signup and leave families unprepared. We speak of “unexpected deaths” in people who are seriously ill, even on hospice. Paradoxically those professionals who know the patient the best are often the worst at prognostication. 

    Knowledge of basic illness trajectories—Sudden Death, Terminal Illness, Organ Failure, and Frailty—helps you plan. These patterns, described by first in the early 2000s, are maps of future decline.

    “Death never arrives unannounced. It simply finds us unprepared.” — adapted from Seneca.

    That’s why we ask: “Is this patient likely to live six months or less?” The answer informs hospice eligibility. Another question is the Surprise question: “Would you be ‘shocked’ if this patient were still alive in 12 months?” This framework from UK’s Gold Standards prompts planning over prediction. Use these two questions to think about eligibility broadly. Then consider disease trajectory and how if might advance. 

    “Trajectory recognition is how we move from hospice eligibility to hospice strategy. It transforms IDG from reactive to prepared.” — Brian H. Black, D.O.

    The Four Common Trajectories of Decline

    Each broad category of slope carries its own pace and preparation. Imagine four lines on a graph—one drops like a cliff, one plunges after a long plateau, one dips and rises in jagged waves, and one slopes so gently at times you almost miss it.

    Visual Reference: The Four Trajectories of Functional Decline

    Source: Lunney JR, Lynn J, Hogan C. Patterns of functional decline at the end of life. JAMA. 2003;289(18):2387–92.

    This model helps you recognize patterns early. Published in JAMA in 2003, it not only introduced this now-familiar above visual but confirmed clinical relevance with more than 4,000 patients. The study remains a grounded source for hospice trajectory education. 

    TrajectoryConditionWhat to ExpectHow to Prepare
    Sudden DeathStroke, Heart AttackAbrupt end, no warningDiscuss Advance Directive Early
    Terminal IllnessCancer, ALSSteady, then fast declineEducate on Symptom Mgt.
    Organ FailureHeart Failure, COPDUps and downs, less recoveryPrepare Comfort Kits at Admit
    Frailty/DementiaDementia, AgingSlow decline, sudden dropsReassess after minor event
    1. Sudden Death – High function until abrupt end; often precedes hospice referral.
    2. Terminal Illness – Stable function with steep decline.
    3. Organ Failure – Repeated crises, incomplete recoveries.
    4. Frailty/Dementia – Long, slow decline until a minor event causes collapse.

    Prognostication: A Skill Worth Pursuing

    Why Prognostication Matters

    Families don’t need certainty. They need orientation.

    Tools for Better Forecasting

    A 2014 study by Paiva and Bruera showed that function and symptom burden predict better than diagnosis alone. The Palliative Performance Scale (PPS), which measures a patient’s ability to perform daily activities, reveals what lab tests can’t always show. While symptom burden, tracked over time, reveals the shape of decline. 


    Naming the trajectory aligns care with reality. It informs—not replaces—clinical judgment.e. What begins as a misunderstanding often ends as mistrust, just when families are looking for someone to help carry the weight.

    The Interdisciplinary Group’s (IDG) Role in Trajectory Recognition

    When the Team Misses the Pattern

    When the Interdisciplinary Group (IDG), the team of nurses, social workers, aides, and chaplains, fails to name the trajectory:

    • The nurse under-forecasts decline.
    • The social worker misses anticipatory grief cues.
    • The aide’s instincts are ignored.
    • The chaplain senses withdrawal but can’t explain it.
    • The family is unprepared.

    Common Pitfalls

    • Over reliance on labs
    • Making inferences with limited information
    • Hesitating to name a trajectory due to fear of being wrong, thereby delaying preparation. 
    • Underestimating the observations of experienced staff

    When the Team Names It Clearly

    • Expectations align.
    • Medications make contextual sense.

    The team plans for what’s coming—not just what is.
    A seasoned social worker said: “When families think they have months and we know it’s days, their grief gets ambushed.”
    No single discipline owns trajectory recognition. It’s a shared clinical mosaic, and as a new physician, you’ll rely on your IDG to refine this skill.

    Turning Recognition into Action

    How to act on a trajectory as a new hospice physician:

    • Document it: “Organ failure trajectory, likely more and worse heart failure flare-ups.”
    • Say aloud: “This pattern may repeat—with poorer recovery.”
      Example: You notice a COPD patient’s recent hospitalization signals an Organ Failure trajectory. Document this in the chart and propose a comfort kit at the next IDG to prepare for worsening crises.
      This informs your team and the family, building confidence in your clinical decisions.

    First Steps checklist: 

    • Assess present and historical function with patient, family, and via the clinical records.
    • Ask IDG about recent trajectory shifts during reviews.
    • Practice the family forecast script in team discussions 
    • Care Plan and frequently reassess

    Mapping Trajectories: From Pattern to Practice

    Note: Some patients shift trajectories after new injuries, infections, or weight loss. For example, a COPD patient may follow a frailty-like course after an aspiration event. IDGs should re-map trajectories after major clinical changes.

    Steps for Teams

    Tip for IDG Chairs: Use a 2-minute teach-in to normalize trajectory talk. “Let’s name the likely trajectory—then check if our care plan matches it.”

    Caution: Trajectory slope doesn’t dictate visit frequency, but steeper declines may require rapid plan revisions or urgent physician follow-up.

    1. During IDG Review
      • Identify the primary trajectory.
      • Note changes in slope, crises, or recoveries.
    2. As a Documentation Anchor
      • In notes or visits: “Continues on a frailty trajectory with PPS of 40%, minimal reserves. Now a 2-person assist to chair in the last 2 weeks.”

    Steps for Families

    1. Teach the Pattern
      • Example: “Here’s the pattern we often see in dementia.”
      • Two-Week Forecast: “She seems steady, but these small changes are expected to continue without improvement.”
    2. Sample Family Forecast
      • Explain: “Your loved one may have good and bad days.”
      • Prepare: “Over time, bad days may increase, and recovery may be harder.”
      • Reassure: “We’ll stay close and offer help for shortness of breath, like a comfort kit, if needed.”
    3. Respect Family Beliefs
      • Ask: “How do you talk about serious illness in your family?”
      • Adjust: “We’re planning for comfort as her body slows.” to respect cultural norms.

    Closing Reflection

    Patients do not decline in straight lines. But when you recognize the shape of likely decline, you can ready the road ahead. You can’t stop what’s coming, but you can guide patients and families through it.


    As a new hospice physician, you don’t predict death’s arrival—you name the shape it takes and give guidance. That’s your work now, and your IDG team will help you refine it.

    Three Key Insights

    • “Unexpected” hospice deaths often reflect system failures, not clinical error.
    • Recognizing trajectory patterns helps you plan, forecast, and communicate effectively.
    • Preparation reshapes grief: when families know what’s possible, they suffer less shock.

    Two Actionable Ideas

    • Use the Two-Minute Forecast in IDG to normalize unpredictability and reduce panic.
    • Name each patient’s illness trajectory in IDG to guide visit strategy and family education.

    One Compassionate Call to Action

    Don’t wait for surprise. Speak clearly. Speak early. Speak often. Trajectory recognition equips you and steadies families. Lean on your IDG’s seasoned nurses or social workers to refine your skills.


    Share your story: Do you have tips for understanding illness trajectories as a new physician? Comment below or tag us on Instagram and Facebook (@HospiceSynopsis) to join the conversation.

    Contact us: Discuss trajectory challenges and we can grow our skills together.

    Glossary Terms

    Trajectory of Decline: A pattern of decline commonly seen in patients with terminal illness. Hospice care uses four primary trajectories: Sudden Death, Terminal Illness, Organ Failure, and Frailty. Recognizing a patient’s trajectory guides clinical decisions, caregiver education, and resource planning.

    Trajectory Mapping: The deliberate process of identifying and documenting the expected pattern of decline in a hospice patient, based on clinical observations and disease course. Used in IDG, charting, and caregiver teaching. Useful for Forecast Scripting.

    Surprise Question: A prognostic tool from the UK’s Gold Standards Framework: “Would you be surprised if this patient were still alive in 12 months?” Used to trigger early palliative planning.

    Six-Month Question: A formal inquiry guiding hospice eligibility: “Is the patient likely to live six months or less?” Requires clinical judgment—not certainty—but frames hospice certification decisions.

    Sparks

    “You can’t predict death’s timing, but naming its shape guides your care. #TrajectoryMatters”

    “Miss the pattern, and grief surprises families. Name it, and your IDG aligns care. #HospiceMedEd”

    “Trajectories are your roadmap to proactive hospice care. Start mapping today. #IDGReady”

    “Don’t chase ‘when.’ Focus on ‘what’ to prepare patients and families. #PrognosisIsCare”

    “How do you use trajectories to orient families? Share your tips! #HospiceTips”

    Bibliography

    Lunney JR, Lynn J, Hogan C. Patterns of functional decline at the end of life. JAMA. 2003;289(18):2387–2392. doi:10.1001/jama.289.18.2387

    Lynn J, Adamson DM. Living Well at the End of Life: Adapting Health Care to Serious Chronic Illness in Old Age. RAND Corporation; 2003

    FAQ: Common Questions Regarding Trajectory

    Q: How do I know which trajectory my patient is on?
    A: Ask in IDG for your teammates to describe the patient’s illness pattern, like stable periods or frequent crises. Use tools like the Palliative Performance Scale or others to clarify function patterns and discuss at IDG meetings.

    Q: What should I ask my IDG to improve my trajectory recognition?
    A: Ask, “What patterns have you seen in similar patients?” and “How can we adjust our care plan for this trajectory?” This leverages team expertise to guide decisions. Then care plan your changes. 

    Q: Can a patient’s trajectory change?
    A: Yes, events like infections or injuries can shift a patient’s trajectory. Reassess and update the care plan with your IDG after major changes.

  • 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.