A Qualitative Investigation of Cross-domain Influences on Medical Decision Making and the Importance of Social Context for Understanding Barriers to Hospice Use

Abstract

Hospice utilization has the potential to improve quality of life for patients while also decreasing healthcare costs at end of life. Barriers to hospice utilization have been identified, but less is known about how patient, provider, and system domains influence one another. We use in-depth interviews with physicians to examine the social, cultural, and economic contexts of decision making and how physician and organizational domains influence patient decision making around hospice. We identify sources of delay in physicians advocating for hospice referrals for their late-life patients that show how patient, physician, and system factors interact. Our results reveal incentives to postpone discussion of hospice that are not fully captured in policy perspectives, clinical guidelines, or current research paradigms focused on individual domains of influence. Opportunities to address previously identified barriers to hospice will benefit from consideration of how seemingly separate domains function in an integrated social context.