Background: Hospice and palliative care are underutilized among patients at the end of their lives despite evidence that they improve patient satisfaction and reduce costs.

Objective: To synthesize evidence regarding interventions to increase hospice referral/enrollment.

Design and Measurements: We conducted a systematic review of the literature and selected studies that evaluated interventions aimed at increasing hospice use. We performed a MEDLINE search (1979 to April 2013) supplemented by manual searches of bibliographies of key articles. Study design, quality criteria, population, interventions, and outcomes for each study were extracted. The main outcome evaluated was hospice referral/enrollment.

Results: Our search strategy yielded 419 studies, of which only 6 met our eligibility criteria. Three studies included nursing home populations; 1 included home care patients, 1 targeted care managers, and 1 reported on heart failure patients. Three studies had a cohort design, 2 were pre–post, and only 1 was randomized. Two studies evaluated a process to identify eligible subjects. Two evaluated the impact of advance care planning programs and 2 only provided education. Interventions that only provided education showed a median increase in referral of 5% (2.8%–17%) while interventions that identified hospice candidates showed a median increase in hospice referral of 19.5 % (19%–20%).

Conclusions: Interventions of different levels of complexity can improve the use of hospice services among subjects with high mortality risk. An approach that allows the medical team to assess patients' treatment goals and that engages the treating physician seems to be the most successful one.