A physician refers a patient to hospice care – what role does this physician play in the care of the patient and in certifying the patient? It depends. Let’s look at the various hospice requirements that involve a physician.
- Certification of terminal illness – for an initial hospice election, the hospice must obtain certifications from the patient’s attending physician (if any) and the hospice medical director
- Attending physician – the patient must have an opportunity to choose his/her attending physician but is not required to have one
- Medical director/hospice physician – this individual is a core member of the hospice IDG and if the attending physician is unavailable or unresponsive, the hospice physician must assume this role
For an initial hospice election, both the attending physician and the medical director or physician member of the IDG must provide a certification of terminal illness. When a physician refers a patient to hospice, we often see hospices obtaining the certification from this referring physician.
WARNING: A referring physician is not necessarily the attending physician.
The attending physician, by definition, is the one chosen by the patient as having the most significant role in the determination and delivery of the individual’s medical care. This automatically precludes some referring physicians from being an attending physician as they will not be able to have a significant role in the patient’s care. A hospitalist, for instance, would not be able to fulfill this role. Hospices can ask the referring physician if he/she will fulfill the role of the attending physician if the patient chooses him/her; however, the patient has the final say. The patient can choose a nurse practitioner as the attending physician, but the nurse practitioner cannot certify the patient. In this case, only the medical director/hospice physician will certify the patient.
The attending physician does not “falloff” after the initial benefit period. Because both the attending and hospice physicians are required to provide the initial certification of terminal illness and only the medical director/hospice physician is required for recertifications, hospices assume the attending physician no longer plays a role. This is not the case. The attending physician is still the physician chosen by the patient as having the most significant role in their care, there is just no recertification statement required of the attending.
Both the attending physician and the medical director/hospice physician must be involved in the completion of the comprehensive assessment and development of the plan of care as well as updates to the assessment and review of the plan of care. Because the attending physician is the one chosen by the patient as having the most significant role in their medical care, the hospice should be contacting the attending physician first for collaboration on the assessment, plan of care, and for orders. We often see hospices contacting the medical director/hospice physician for orders and collaboration. This should happen only when the attending is unavailable or consultation from the medical director/hospice physician is needed (be either the hospice staff or the attending physician).
What should a hospice do if the chosen attending does not want to fulfill this role? The hospice should let the patient know of the physician’s decision and ask if there is another physician the patient would like to choose. The hospice should not automatically assign one of its hospice physicians or presume there will be no attending physician, even if this is the likely outcome of the conversation with the patient. Again, the patient always has the right to choose his/her attending and may decide not to choose one. In some cases, the physician will state that he/she will be the attending physician; however, the physician will not accept any calls after business hours. This is acceptable, and in this case, the hospice physician should be contacted after hours.
Another common scenario is the chosen attending physician indicating he/she wants to turn care over to the hospice medical director/hospice physician. This can be done temporarily, when a patient goes into a hospital or hospice inpatient unit for general inpatient care, for instance. In these cases, the attending physician does not change so there is no need to fill out a change of designated attending physician form.
NOTE: The location of care does not determine the attending physician.
Hospices should not ask or encourage the patient to change attending physicians when the patient moves from their home to a facility. This is true regardless of facility type and whether the stay is temporary or permanent. Likewise, when a patient resides in a nursing facility, the facility’s medical director does not have to be the patient’s attending physician.
In summary, a hospice must look to the patient to determine the attending physician and must respect the role of the attending as being the most involved in the patient’s medical care. Key points to share with staff include:
- Always, the patient chooses the attending physician and may choose not to have an attending
- The referring physician is not necessarily the attending physician
- The location of care does not determine the attending physician
- A change of location does not require a change in attending physician
- The attending physician does not “falloff” after the initial benefit period
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