A critical discourse analysis of the language of hospice enrollment: A multiple case study of patient, family, nurse, and physician discourse in the United States

The Medicare Hospice Benefit, established in 1982, is integral to end-of-life care. Despite the demonstrated benefits, hospice enrollment among Medicare beneficiaries continues to decline. In 2021, only 47.3% of eligible Medicare decedents utilized hospice services. Although all racial and ethnic groups’ enrollment numbers are low compared to the opportunity for enrollment, the underrepresentation is most significant of non-White populations. The overall underutilization of hospice services calls for a reevaluation of the hospice dialogue. Our investigation adopted the principles of critical discourse analysis, as conceptualized by Fairclough in 1993 to answer the question: How do discourses of patients, caregivers, nurses, and medical directors reveal the social structures and power relationships that shape hospice enrollment? Using critical discourse analysis, we examined the role of language used to reveal hospice enrollment discourses. Using a multiple case study design, we recruited and segmented participants into four distinct case groups: patients, their primary family caregivers, the hospice registered nurses, and medical directors responsible for the initiation of hospice enrollment. We then incorporated critical discourse analysis as a secondary design by using Fairclough’s three-dimensional framework to analyze the structural, relational, and symbolic dimensions of discourse in the interview texts based on the case groups positional reference to the study’s question. Our aim was to reveal the power relationships and social structures to emphasize or minimize hospice enrollment decisions. This study’s findings revealed three dominant discourses: Decision Dynamics, Help, and Beliefs and Believe. The inferences drawn from this study emphasize the need for a patient-centric modality in hospice enrollment decisions that fully recognizes and engages with the interrelated connections of familial dynamics, societal norms, and personal sovereignty.