ICUs and Hospice: Good News and Bad News

In the last decade, palliative care and referrals to hospice have dramatically increased. Looking closer at the data, Dr. Teno and her colleagues saw something troubling – the sharp increase in hospice referrals is accompanied by an increase in transitions in care and an increase in intensive unit stays in the last month of life. So we are more likely to figure out that people are dying in an ICU and discharging to hospice after their ICU stay– sometimes for as little as the last three days of life.

I often say that 80 per cent of deaths in America are predictable by most physicians, and yet we do not have the training to do anticipatory guidance for our patients with serious illnesses. And ICU doctors, who oten do not have a relationship with the patients, are now asked to do the hardest task of all: to sit with families and sort out the medical options and the patients’ goals of care. So the good news is that ICU doctors appear to value hospice support. The troubling news is that we physicians are sending dying patients– even predictably dying patients– to the ICU.

The solutions are straightforward and exist in our community:

• Strong advance care planning where families share a conversation about what they value and what medical interventions are acceptable to them. Honoring Your Wishes in Johnson County is one such program.

• When patients appear to be in the last year of life, have a facilitated conversation about an Iowa Physician Orders for the Scope of Treatment (IPOST). Have you ever seen one of these?

• Ask ourself as health care worker—especially if you are in an outpatient clinic—Could the patient I am caring for die in the next year? How can I best guide them? How do I support them and myself? Let’s not hand that job to our ICU colleagues.

I finished my advance care planning document about 10 months ago with a great Honoring Your Wishes facilitator. I will revisit it in about 2 months. I said some black and white things in that document that I might want to change, but after I retire, I think I will be happiest staying outside of the hospital.



My Trip to Fort Madison


A new Iowa state law requiring physicians to have training in end of life care and pain management prompted the Fort Madison Community Hospital to invite me to give two hours of lectures and workshops today at the hospital. Their hospital has 50 inpatient beds and a strong community hospice.

It was a beautiful ride south to Fort Madison. This is the route my grandfather took in 1934 on a wintry day. He lost control of his car and died. The promising University of Iowa researcher planned to talk about liver disease to physicians in Mount Pleasant, Iowa.  I drive carefully on this road.


The audience included people from many disciplines, including chaplains, nurses and physicians.  It is always a challenge to engage a multidisciplinary audience, but the two hours passed quickly with an opiate problem solving workshop that Dr. Lee Kral and I designed over a decade ago to prevent sentinel events with opiates.  During the second hour, I presented the common symptoms at the end of life using video clips from patients, who can describe their symptoms better than any physicians can.

Here’s a few of my favorite things from my trip. What a surprise that a state law would bring a day of such richness:

  • The wintry brown countryside with cumulus clouds and outlines of farmhouses
  • The warm welcome from the staff at Fort Madison.
  • The news that Fort Madison Community Hospital is starting a palliative care program.  (Perhaps Iowa will become an “A” state on the Center to Advance Palliative Care website.) 
  • Hall’s ice cream parlor, which allows adults to have a kiddie-sized shake, is in its 29th year in Fort Madison.


  • The longest swing/pivot bridge in the world:  


I could make a habit of these therapeutic road trips!