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Exploring Barriers Among Primary Care Providers in Referring Patients to Hospice

Torres, Lisa DNP, MSN, FNP, PNP; Lindstrom, Kathryn PhD; Hannah, Liane BSH; Webb, Fern J. PhD

Journal of Hospice & Palliative Nursing: April 2016 - Volume 18 - Issue 2 - p 167–172
doi: 10.1097/NJH.0000000000000233
Feature Articles

The increasing baby boomer population entering Medicare will increase the number of patients with complex chronic conditions who can potentially benefit from hospice care. Hospice continues to be underused in the United States, and primary care providers have been identified as being a possible barrier for referring to hospice. The purpose of this project is to explore attitudes, knowledge about, referral practices, and other barriers to hospice care among providers in a primary care practice setting. A cross-sectional quantitative study using a previously designed survey by Mayo Clinic (Jacksonville, Florida) was used to evaluate 75 providers in a northern Florida primary care practice affiliated with a Level 1 trauma center and academic university. The study had 65% provider participation. Providers had a generally positive response toward hospice (70%) and none reported a bad experience with hospice. Most (90%) supported living wills, but less than half (46%) personally had one. Providers were comfortable discussing hospice with patients (70%) and discussing living wills (70%). Time was a significant barrier to initiating discussions about hospice (45%). A needs assessment revealed 0 referrals in a 6-month period before the survey implementation.

The results from this survey show that there may be a discrepancy between provider attitudes toward hospice and their actual referral practices. In addition, studies have reported that when providers complete their own living will they are more apt to discuss these documents with patients’ and families. The Diffusion of Innovation theoretical framework suggests steps to improve providers' ability to adopt new practices, thereby increasing hospice referrals. Addressing barriers to hospice referral in primary care will serve to increase the likelihood of patients and families being referred to hospice and improve care at the end of life.

Lisa Torres, DNP, MSN, FNP, PNP, is nurse practitioner I, Mayo Clinic, Division of Regional Medicine, Jacksonville, Florida.

Kathryn Lindstrom, PhD, is assistant professor, Vanderbilt University School of Nursing, Nashville, Tennessee.

Liane Hannah, BSH, is research associate/family medicine clerkship coordinator, Departments of Community Health and Family Medicine and Epidemiology, University of Florida, Jacksonville.

Fern J. Webb, PhD, is assistant professor, department of community health and family, Department of Family Medicine, University of Florida Health Science Center Jacksonville.

Address correspondence to Lisa Torres, DNP, MSN, FNP, PNP, Mayo Clinic, Division of Regional Medicine, Gate Parkway Mayo Clinic Primary Care, 7826 Ozark Drive, Jacksonville, FL 32256 (

The authors have no conflicts of interest to disclose.

© 2016 by The Hospice and Palliative Nurses Association.