Chapter 2: Integrating a Palliative Approach 19 The Next Steps for Hospice and Palliative Care Despite all the positive benefits of hospice and palliative care, and the move to address the needs of people with a non-​ cancer diagnosis, less than 30% of dying people in Canada receive specialty hospice and palliative care services (CHPCA, 2015), and referrals often occur in the last few weeks of life. In the United States, in 2014 ap- proximately 46% of all people who died were under the care of a hospice program; however, half of those received hospice services for less than 17 days (NHPCO, 2015). Late referrals result in dying people and their families not receiv- ing the full benefits of the program (NCHS, 2015). Given the benefits of hospice and palliative care, why do more people not access hospice and palliative care programs? Current Barriers to Accessing Hospice and Palliative Care While hospice and palliative care is founded on the prin- ciple of equal accessibility, there are barriers that prevent people from accessing such care. Belief of Ineligibility The belief persists that hospice and palliative care is only for people dying with cancer or people who are expected to die soon. In 2014, 34% of Canadians were not aware that hospice and palliative care services were available for people with non-​ cancer diagnoses, and that palliative care programs could serve dying people and their family from the time of diagnosis right through to and following death (CHPCA, 2015). This false belief that palliative care is for the imminently dying person was supported recently when news reports announced that a prominent politician was “now receiv- ing palliative care” only to be followed by another an- nouncement a few hours later that he had died. Addition- ally, countries, provinces, states, and communities differ in terms of the criteria people must meet before they can access hospice and palliative care services. This adds to the confusion and lack of understanding about such care. Insufficient Training for HCPs Research indicates that only 3% of physicians or nurses in the United States receive training in palliative or end-​ of-​ life care in their core curriculum (Diamond et al., 2016; Temel et al., 2010). (There is no current data on nursing education in Canada.) Without this education, an HCP may not fully understand the needs of the dying person and their family, or the value of talking about disease pro- gression, goals of care, and the benefits of hospice and palliative care. The result is that an HCP who is not taught the philosophy, principles, and practices of hospice and palliative care will not be able to integrate them into car- ing for the dying. Taboos and Fear of Talking about Death and Dying HCPs may not talk about dying or death because they are not comfortable with the topic, they do not want to cause the dying person or their family to lose hope, or they sense that the dying person and family may not be receptive to such a discussion (Beernaught et al., 2014; Synder et al., 2012). HCPs may struggle to say “You’re dying,” opting instead to use vague euphemisms. This can result in a mis- communication of the diagnosis or prognosis. The dying person and family may also be uncomfortable talking about death and dying, and often believe that the “specialist” will talk about death and about hospice or palliative care at the appropriate time (Friedman, Har- wood, and Shields, 2002; Temel et al., 2010 ). Lack of Clear Prognosis, Especially with a Non-​ Cancer Diagnosis In the United States in particular, and in many programs in Canada, the dying person needs to have a prognosis of less than six months in order to qualify for hospice care. As mentioned in Chapter 1, “Understanding the Dying Pro- cess,” the trajectory of a person dying with chronic illness has many ups and downs. The person with chronic illness may be “on death’s doorstep” and recover several times before actually dying. Geriatrician, hospice physician, and author Joanne Lynn suggests that 50% of people suffering with chronic illness will not know they are in their last week of life a week before they die (Lynn, 2004). She says, “If you are waiting for a drum roll to announce that you are going to die, it is not going to happen in most cases.” The family and HCPs also may not know that death is near. Ethics Touchstone What are some ways that every nurse can help reduce barriers to providing excellent care of the dying?