Hospices Adopt New Strategies to Support End-of-Life Decisions

National Health Care Decisions Day takes on a new significance this year as COVID-19 sweeps critical illness and death across the country. With demand for hospice and palliative care services on the rise amid the pandemic, providers are adopting new strategies to highlight the benefits of advance care planning for patients and families.

Recently updated data from the U.S. Centers for Disease Control and Prevention reported nearly 25,000 deaths and more than 605,000 confirmed cases throughout the nation. The pandemic has not only increased the volume of patients in need of hospice and palliative services, but also impacted how they are receiving care in their final days. Advance care planning has become increasingly significant as more patients die every day in isolation and suffer with serious illnesses resulting from COVID-19.

“With the losses that we’ve felt in this country with COVID-19, this might be the turning point and a pivotal point for end-of-life discussions,” said Theresa Younis, chief administration & integration officer of end-of-life care Hospice Care of South Carolina/Agapé Hospice. “This year is an anomaly opportunity for people to really be engaged in health care decisions.”


As National Health Care Decisions Day arrives during the COVID-19 outbreak, many celebratory events have been cancelled, but efforts to raise awareness are ongoing. Sponsored by The Conversion Project, National Health Care Decisions Day (NHDD) was created to “inspire, educate and empower” providers and the public about the significance of advance care planning.

“Having these end-of-life discussions often helps open the door to broader conversations about what’s important to people,” Joseph Shega, M.D., senior vice president and chief medical officer, VITAS Healthcare, a subsidiary of Chemed Corp. (NYSE: CHEM), told Hospice News. “And as you start into those conversations, it often becomes clear that their goals really are consistent with hospice. Starting that conversation helps to open their eyes about what kind of care they do and don’t want, and what type of care best supports those wishes.”

VITAS Healthcare recently adopted the use of SPIKES to support effective and compassionate end-of-life and goals of care conversations. Initially an effort to spark discussions, SPIKES expanded into VITAS Healthcare’s advance care planning. SPIKES is an acronym for the six components of setting, perception, invitation, knowledge, emotion and summation.


The six-step SPIKES protocol is a health care decision-making tool providers can use in guiding these difficult conversations with patients and families. The tool highlights the important elements to consider such as a private setting, assessing the patient’s perception of their situation, offering them more information to increase their understanding and determining a strategy to proceed based on their wishes and mindset.

“We really start to need to help health care providers in the field feel more at ease about broaching these often challenging conversations with patients,” said Shega. “We look to evidence to help guide us on what really is the best approach. SPIKES really has demonstrated to be very effectively pragmatic, as well as being respectful of patient’s emotional and physical needs to our clinicians who are trained to use this framework.”

Boosting community outreach efforts has been another increasingly important methodology to support advance care planning. While not a new tactic, this approach has been challenging for hospices that have limited community access during the pandemic. Despite the challenges of making interpersonal connections, hospice providers are still finding ways to raise awareness.

Hospice Care of South Carolina/Agapé Hospice’s team communicated with individuals in local churches to get the conversation started within their communities. Response from women in the church was positive as they expressed interest in learning more about how to emphasize the benefits of advance care planning to friends and loved ones, with many having seen firsthand the stress, guilt and regret that can happen without it.

“Having these women really lead those conversations for their church family was something that we saw a tremendous amount of organic growth in,” said Younis. “People are coming to understand that advance care planning is not negative, it’s a gift.”

Given their expertise and training in end-of-life care, hospice providers are uniquely positioned to develop strategies like these and more as advance care planning becomes even more crucial during the outbreak. Proactively collaborating with providers in other health care settings, first responders and others on the frontline to develop resources and tools can alleviate some the anxieties and stresses surrounding death before patients reach the point of critical need.

“Advanced directives really are an opportunity,” Younis told Hospice News. “Planning ahead mitigates stress, disagreement, anxiety and remorse for patients and family members. It’s important to understand that decisions like these are best made before there is a health crisis and that providers realize advanced care planning is not a single conversation. It is a conversation that happens over time that patients and families may change as their situations change.”

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