The American Journal of Managed Care
November 2012
Volume 18
Issue 11

Physician Factors That Influence Patient Referrals to End-of-Life Care

This study used multivariate models to identify physician specialty and comfort with end-of-life discussions, both of which are associated with end-of-life referrals.


To identify factors associated with physician referrals to end-of-life (EOL) care.

Study Design:

Cross-sectional, web-based survey.


Participants were managed care physicians (n = 545) from the Southern California region of a national nonprofit health maintenance organization who treated a patient in their office within 6 months of the patient’s death from a chronic condition. Measures included self-reports of referrals to EOL services, comfort level discussing EOL with patients, personal/family experience with hospice, and demographic characteristics.


Participants were most commonly US born (69.1%), married (83.8%), and male (66.0%) with a mean age of 47 years (SD = 8.9 years). About half were Caucasian (51.7%). Logistic regression revealed that family/internal medicine physicians were nearly 9 times more likely to make EOL referrals (95% confidence interval [CI] 3.879-19.434), and physicians comfortable discussing EOL care were nearly 7 times more likely to refer (95% CI 3.465-12.750). Younger age was significantly associated with EOL referrals; with every 1-year decrease in age, physicians were 5% more likely to refer (95% CI 0.911-0.985). Family/internal medicine physicians (95% CI 1.259-2.899) and those comfortable discussing EOL care (95% CI 2.964-9.685) were also more likely to make frequent (4 or more) referrals


This study highlights factors associated with EOL referrals that may be enhanced at the organizational level through training and educating physicians. Results suggest that organizations should work toward improving physician ease and comfort with EOL conversations. This study serves as an important step toward understanding and reducing physician-level barriers to EOL referrals.

(Am J Manag Care. 2012;18(11):e416-e422)This study is the first to examine physician experience and comfort with end-of-life (EOL) discussions in multivariate models and shows the important contribution these characteristics make.

  • Family/internal medicine physicians and comfort conducting EOL conversations were associated with making single and frequent referrals to EOL care.

  • Younger physician age was associated with making 1 or more EOL referrals; however, age was not a significant determinant of frequent referrals.

  • Results support efforts to reduce physician-level barriers to EOL referrals, support strategies to improve comfort with EOL conversations, and suggest areas organizations might consider to influence physician behavior.

Over the last decade, Americans’ preference to die at home1 has increased the use of hospice2 and palliative care3,4 for end-of-life (EOL) services. In 2009, hospices provided care for 41.6% of US decedents,5 up from 28.6% in 2000.6 Studies indicate that such EOL programs maximize quality of life through palliation of pain and symptoms,7,8 although initiation and timing of referral may impact the effects of symptom severity caused by disease progression.9 Referrals to EOL services are commonly initiated by physicians, who, for hospice care, must certify that the patient has a terminal condition and estimated life expectancy of 6 months or less. With physicians as gatekeepers,10,11 variation in referral, enrollment, and utilization of EOL services exists, particularly for certain racial groups12 such as African Americans.13 Studies have found that many physicians do not discuss EOL with terminally ill patients. For example, in one study only 53% of stage IV lung cancer patients had had a hospice discussion with their provider.13 Physicians have identified discomfort with death and dying, including the hospice concept, as a barrier to initiating EOL discussions and hospice referrals.14-16

Research on EOL referrals has tended to focus on patient-level characteristics rather than physician factors. Among the few studies of physician behavior, results are mixed; some indicate that age,17,18 sex,11,17 and practice variations11,17-19 impact EOL referral rates, whereas others do not.18,19 These results highlight the need to better understand how physicians’ personal characteristics (eg, sex, age, race, area of practice) influence EOL referrals to hospice and palliative care. Additionally, studies have found that hospice enrollment is affected by familiarity with hospice because of having had a close friend or relative under hospice care20-22; however, this factor has not been explored among physicians. Although previous studies have analyzed individual physician barriers to EOL referrals, physicians’ personal experience and comfort have been largely unexamined. To address this gap, we explored the impact of multiple physician-level variables, adjusting for fixed demographic characteristics, on referrals to hospice among a sample of Southern California-based physicians from a large health maintenance organization (HMO).

METHODSProcedures and Sample

We conducted a cross-sectional study of Southern California-based physicians from a large HMO. Potential participants included all HMO physicians practicing in the specified geographical region who had seen a patient in their office within 6 months of the patient’s death from a chronic condition. Individuals were contacted via e-mail by the physician co-principal investigator and were given a link to an anonymous web-based survey. All were first contacted in September 2008; nonresponders were sent reminder e-mails in each of the next 2 months. This study was approved by the institutional review boards of the participating institutions.


We developed a 43-item survey that included physicians’ self-reported number of patient referrals to EOL services (home-based palliative care and hospice), knowledge of EOL services, attitudes toward EOL services, perceived barriers to referring patients to EOL services, personal and family experience with utilizing EOL services, and demographic characteristics. Prior to administration, the survey had been reviewed for face validity, comprehension, and completeness by the research team and then pretested by 2 physicians.

Referral to EOL Services. Home-based palliative care is provided by this HMO for seriously ill patients with cancer, congestive heart failure, and chronic obstructive pulmonary disease who are expected to have about 1 year to live. The service is similar to hospice with the exception that patients do not have to forgo curative measures, and life expectancy may exceed 6 months (see Brumley et al23). Physicians’ EOL referral behaviors (dependent variable) were assessed based on self-reports in response to the following survey item: Estimate the number of patients you refer to hospice or home-based palliative care on an annual basis.

Rate of referral was recoded into 2 separate dichotomous variables to analyze differences between referrers and nonreferrers to EOL care and between those who made frequent (4 or more) referrals as opposed to no referrals. Frequent referrals were defined as 4 or more annual referrals because the original variable was categorical (none, 1-3 referrals, 4-6 referrals, 7-9 referrals, or 10 or more referrals).

Demographics. Physicians were asked to record their sex, race, marital status, age, nativity, and length of time practicing medicine (postresidency). Additionally, physicians were asked to select their area of medical practice from a list of common areas of practice or to indicate their specialty in an open-ended field.

Comfort. Physicians’ comfort level discussing EOL services with terminally ill patients was measured on a 5-point Likert scale in response to the statement: I feel comfortable discussing hospice and palliative care options with terminally ill patients during outpatient visits. The response set ranged from “strongly disagree” to “strongly agree,” coded with a higher score reflecting stronger agreement.

Personal Experience With EOL Care. Physicians were asked to indicate whether they had a family member who had received hospice care.


Descriptive statistics were used to describe key characteristics of the sample, and c2 tests were conducted to analyze differences between physicians’ EOL referral behaviors and demographic characteristics. We performed t tests to examine variations in mean age between referrers and nonreferrers to EOL care and between those who made frequent referrals versus those who made no referrals. Logistic regressions were conducted to identify predictors of any EOL referral and frequent referrals. In each condition, 3 models were entered: model 1 (a and b) fit demographic variables, model 2 (a and b) included all variables in model 1 and physicians’ comfort with conducting EOL discussions with patients, and model 3 (a and b) included all variables in models 1 and 2 along with physicians’ personal/family experience with hospice. Based on comparisons in the c2 change statistic, the most parsimonious model was selected. SPSS statistical software for Windows version 18.0 (SPSS Inc, Chicago, Illinois; released 2009) was used in all analyses.


Table 1

Between September and November 2009, 2084 physicians were contacted; of these, 554 completed the survey (response rate = 26.65%); 1525 were unresponsive to the emails; and 5 opted out of the study. Most respondents were US born (69.1%), married (83.8%), and male (66.0%), with a mean age of 47 years (standard deviation = 8.9 years). About half (51.7%) were Caucasian, 31.2% Asian, 8.7% Latino, 3.3% multiethnic, 3.1% African American, and 1.1% were other races. Of those born outside the United States, more than half were from Asia (57.1%) followed by North America (Canada and Mexico) (11.4%), the Middle East (9.3%), Africa (8.6%), Europe (7.9%), and South America (5.7%). Area of practice was most commonly a specialty (46.2%) or family/internal medicine (45.6%). Specialty areas included surgery (24.3%), oncology (11.7%), and psychiatry (11.3%) among 26 reported specialties. Fewer than half (43%) reported that a family member received hospice care, and most (83.2%) reported making at least 1 EOL referral in the last year and feeling comfortable (80.4%) conducting EOL discussions with terminally ill patients (). Half (50.5%) reported making 4 or more referrals in the last year.

Bivariate Analysis

Area of practice (χ2 = 45.748, P <.001) and comfort conducting EOL conversations (χ2 = 45.965, P <.001) varied significantly between physicians who made an EOL referral and those who did not. The number of years practicing medicine was also significantly different between EOL referring and nonreferring physicians (χ2 = 13.974, P = .007). Differences in physician mean age revealed a significant inverse relationship, such that younger physicians were more likely to report referring (mean age of referring physicians = 46.39 years, SD = 8.75 years; mean age of nonreferring physicians = 49.79 years, SD = 8.76 years; t = 114.078, P <.001; Table 1). There were no differences in sex, ethnicity, marital status, nativity, or personal experience in referral to EOL care.

Multivariate Analysis

Table 2A,

Logistic regression showed that family/internal medicine physicians and comfort with conducting EOL conversations with patients were significantly associated with making a referral. Family/internal medicine physicians were nearly 9 times more likely to make EOL referrals (95% confidence interval [CI] 3.879-19.434) compared with specialists and emergency medicine physicians. Physicians reporting comfort with discussing EOL care were nearly 7 times more likely to refer patients compared with physicians who were uncomfortable conducting these discussions (95% CI 3.465-12.750) ( model 1a). Age was a significant negative predictor of EOL referrals; with every 1-year decrease in age, physicians were .05 times more likely to make an EOL referral (95% CI 0.911-0.985). Other demographic variables and having had a family member receive hospice care were not significant predictors.

Table 2B

The second regression examined factors associated with frequent EOL referrals (also adjusted for demographic and practice variables) and identified family/internal medicine physicians and comfort in conducting EOL as significantly associated with frequent referrals to hospice. Family/internal medicine physicians were nearly 2 times more likely to make frequent EOL referrals (95% CI 1.259-2.899) compared with specialists and emergency care physicians, and those comfortable discussing EOL care were 5 times more likely to frequently refer compared with participants who reported a lack of comfort conducting these discussions (95% CI 2.964-9.685) (, model 2b). Demographic variables including age and having a family member who received hospice care were not significant predictors of frequent EOL referrals.


This study identified physician characteristics associated with referrals to hospice or palliative care. Respondents had a high rate of referral (83%) and expressed comfort conducting EOL conversations (80%). Comfort was positively associated with making single and frequent referrals. Previous studies on physician factors and EOL care comparing populationbased hospitals, HMOs, and Veterans Health Administration (VHA) sites found that physicians from HMOs and VHA managed care models reported conducting EOL conversations earlier in the disease process than physicians in populationbased settings,18 and that HMO patients enrolled in hospice at higher rates than patients in fee-for-service plans (17% vs 11%, respectively).24 Thus, the institutional environment may positively influence referral practices.

Practicing in the area of family/internal medicine was associated with making single and frequent referrals after adjusting for other factors. This finding reflects practice variations between family/internal and specialty physicians, which was found in previous studies,17,19 or a closer relationship between family/internal physicians and their patients, fostering greater comfort with sensitive discussions. Physician age was negatively associated with any EOL referral (but not frequent referrals), supporting previous studies, which found younger age11 or fewer years in practice (less than 10 years)17 to be associated with EOL referral. This may reflect an age-related cohort effect from the mandated inclusion of EOL care training and education in accredited US medical schools in the past 13 years.25,26


Several limitations should be considered. First, physician referral behavior was based on self-report. Supporting administrative data would strengthen this study. However, administrative data on the characteristics of nonresponders were not available. Although all possible respondents were identified for the survey, because the response rate was 26.6% nonresponse bias was a potential problem, with those most likely to make such referrals probably also more likely to complete the survey. In areas where previous research had been conducted, similarly low response rates have also been observed.17,19,27,28 This cross-sectional study focuses on a single HMO, though it surveyed a large number of physicians who were diverse in terms of race/ethnicity and practice specialization.


We identified physician comfort as a factor associated with physician referral of EOL patients to hospice and home-based palliative care. Results support efforts to reduce physician-level barriers to EOL referrals by implementing strategies to improve physician comfort with EOL conversations, such as web-based learning modules and mentoring,28 group discussions of case studies and role-playing with colleagues,29 and shadowing physicians to model behavior.29 Increased focus on training specialists who work with EOL patients is also needed to help them see EOL referrals as part of their practice and not solely a task for primary care. At the organizational level, creating improved awareness of EOL care and shared responsibility around referrals may be beneficial. Recently, researchers have charged the professional societies of medical specialties with recognizing EOL communication skills and knowledge as equally important as learning about novel surgical techniques or pharmacologic interventions30 to establish a clear stance on EOL care delivery, normalize the behavior endorsed by the specialty, and keep physicians apprised of EOL care options, knowledge, and referral protocol. Promoting communication between physicians at EOL may lead to collaboration. Moreover, the availability of EOL resources such as inpatient and outpatient palliative care consult teams may support physicians through EOL discussions with patients or serve as a source for physicians to refer their patients for comfort care. This study points the way for improving EOL care and suggests that more research is needed to build a strong knowledge base in this area.Author Affiliations: From Davis School of Gerontology (ACK, KW, SE), University of Southern California, Los Angeles, CA; Kaiser Permanente Southern California Medical Group (RB), Downey, CA.

Funding Source: The Southern California Permanente Medical Group Innovation Fund.

Author Disclosures: Dr Brumley reports receiving a grant from the Southern California Permanente Medical Group for this study. The other authors (ACK, KW, SE) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (ACK, RB, KW, SE); acquisition of data (ACK, RB, SE); analysis and interpretation of data (ACK, KW, SE); drafting of the manuscript (ACK, KW); critical revision of the manuscript for important intellectual content (RB, KW, SE); statistical analysis (ACK); provision of study materials or patients (RB); obtaining funding (RB, SE); and supervision (KW, SE).

Address correspondence to: Alexis Coulourides Kogan, University of Southern California, Davis School of Gerontology, 3715 McClintock Ave, Los Angeles, CA 90089. E-mail: Kwak J, Haley WE, Chiriboga DA. Racial differences in hospice use and in-hospital death among Medicare and Medicaid dual-eligible nursing home residents. Gerontologist. 2008;48(1):32-41.

2. National Hospice and Palliative Care Organization. NHPCO Facts and Figures: Hospice Care in America. 2009 ed. Alexandria, VA: NHPCO;2009:1-15.

3. Patrizi P, Thompson E, Spector A. Improving Care and the End of Life. RWJF Retrospective Series. Princeton, NJ: Robert Wood Johnson Foundation; March 2011:1-39. Published March 2011. Accessed July 3, 2012.

4. Center to Advance Palliative Care. 2011 Public Opinion Research on Palliative Care: A Report Based on Research by Public Opinion Strategies. 2011. Published 2011. Accessed September 25, 2011.

5. National Hospice and Palliative Care Organization. NHPCO Facts and Figures: Hospice Care in America. 2010 ed. Alexandria, VA: NHPCO; 2010:1-15.

6. National Hospice and Palliative Care Organization. NHPCO’s Facts and Figures—2005 Findings. Updated November 2006. Accessed September 25, 2011.

7. Casarett D, Pickard A, Bailey FA, et al. Do palliative consultations improve patient outcomes? J Am Geriatr Soc. 2008;56(4):593-599.

8. Steele LL, Mills B, Hardin SR, Hussey LC. The quality of life of hospice patients: patient and provider perceptions. Am J Hosp Palliat Care. 2005;22(2):95-110.

9. Teno JM, Shu JE, Casarrett D, Spence C, Rhodes R, Connor S. Timing of referral to hospice and quality of care: length of stay and bereaved family members’ perceptions of the timing of hospice referral. J Pain Symptom Manage. 2007;34(2):120-125.

10. McGorty EK, Bornstein BH. Barriers to physicians’ decisions to discuss hospice: insights gained from the United States hospice model. J Eval Clin Pract. 2003;9(3):363-372.

11. Richards J, Takeuchi LR. Fators that influence physicians’ recommendation of hospice care: an exploratory study. J Hosp Mark Public Relations. 2006;17(1):3-25.

12. Ogle KS, Mavis B, Wyatt GK. Physicians and hospice care: attitudes, knowledge, and referrals. J Palliat Med. 2002;5(1):85-92.

13. Huskamp HA, Keating NL, Malin JL, et al. Discussions with physicians about hospice among patients with metastatic lung cancer. Arch Intern Med. 2009;169(10):954-962.

14. McNeilly DP, Hillary K. The hospice decision: psychosocial facilitators and barriers. OMEGA (Westport). 1997;35(2):193-217.

15. Miller KE, Miller MM, Single N. Barriers to hospice care: family physicians’ perceptions. Hosp J. 1997;12(4):29-41.

16. Weggel JM. Barriers to the physician decision to offer hospice as an option for terminal care. WMJ. 1999;98(3):49-53.

17. Johnson CE, Girgis A, Paul CL, Currow DC. Cancer specialists’ palliative care referral practices and perceptions: results of a national survey. Palliat Med. 2008;22(1):51-57.

18. Keating NL, Landrum MB, Rogers SO Jr, et al. Physician factors associated with discussions about end-of-life. Cancer. 2010;116(4):998-1006.

19. Carter CL, Zapka JG, O’Neill S, et al. Physician perspectives on end-of-life care: factors of race, specialty, and geography. Palliat Support Care. 2006;4(3):257-271.

20. Born W, Greiner KA, Sylvia E, Butler J, Ahluwalia JS. Knowledge, attitudes and beliefs about end-of-life care among inner-city African Americans and Latinos. J Palliat Med. 2004;7(2):247-256.

21. Chung K, Essex EL, Samson L. Does caregiver knowledge matter for hospice enrollment and beyond? pilot study of minority hospice patients. Am J Hosp Palliat Care. 2009;26(3):165-171.

22. Washington KT, Bickel-Swenson D, Stephens N. Barriers to hospice use among African Americans: a systematic review. Health Social Work. 2008;33(4):267-274.

23. Brumley R, Enguidanos S, Jamison P, et al. Increased satisfaction with care and lower costs: results of a randomized trial of in-home palliative care. J Am Geriatr Soc. 2007;55(7):993-1000.

24. Emanuel EJ, Ash A, Yu W, et al. Managed care, hospice use, site of death, and medical expenditures in the last year of life. Arch Intern Med. 2002;162(15):1722-1728.

25. Liaison Committee on Medical Education. Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree. Published May 2011. Accessed August 8, 2011.

26. Van Aalst-Cohen ES, Riggs R, Bylock IR. Palliative care in medical school curricula: a survey of United States medical schools. J Palliat Med. 2008;11(9):1200-1202.

27. Miccinesi G, Fischer S, Paci E, et al; EURELD consortium. Physicians’ attitudes towards end-of-life decisions: a comparison between seven countries. Soc Sci Med. 2005;60(9):1961-1974.

28. Sullivan AM, Lakoma MD, Billings JA, Peters AS, Block SD; PCEP Core Faculty. Creating enduring change: demonstrating the long-term impact of a faculty development program in palliative care. J Gen Intern Med. 2006;21(9):907-914.

29. Ross DD, Shpritz DW, Wolfsthal SD, et al. Creative solution for implementation of experimental, competency-based palliative care training for internal medicine physicians. J Cancer Educ. 2011;26(3):436-443.

30. Astrow AB, Popp B. The Palliative Care Information Act in real life. New Engl J Med. 2011;364(20):1885-1887. n

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