Position Statements

Statement on Credentialing in Hospice/Palliative Medicine

Approved by the Board of Directors
April 2006

The American Academy of Hospice and Palliative Medicine recognizes the need for a process to credential physician specialists who seek employment in hospices, hospitals, long-term care facilities, palliative care clinics, and managed care organizations. This document is written to provide guidance to credentialing organizations as hospice and palliative medicine gains recognition as a medical sub-specialty.

The American Board of Hospice and Palliative Medicine (ABHPM) has certified physicians since 1996. ABHPM will offer its last examination in 2006, and it is anticipated that the first American Board of Medical Specialties (ABMS) exam in hospice and palliative medicine will be given in 2008. During an initial period which is expected to run from 2008 through 2012, physicians with substantial experience in hospice and palliative medicine may be admitted to the examination on the basis of their experience. After this period is over, only those who complete an ACGME-accredited hospice and palliative medicine fellowship will be eligible for certification as a specialist.

As the sub-specialty of hospice and palliative medicine evolves, the Academy’s position on credentialing will be reviewed.

Credentialing should be guided by the following principles:

• Physicians may practice hospice and palliative medicine at a generalist level or a specialist level. Through the credentialing process, organizations seek to ensure that physicians who engage in specialist-level practice have appropriate education or experience, and demonstrated knowledge and skills consistent with standards for specialists developed by the specialty itself.


• For hospice programs, credentialing indicates that a physician can apply the skills of a specialist in hospice and palliative medicine to the tasks of a hospice staff physician or medical director. In all practice settings, credentialing indicates that a physician can apply the skills of a specialist in hospice and palliative medicine as a consultant or primary care provider.


• The privilege to practice as a specialist in hospice and palliative medicine should be considered separate from other privileges, such as those applied to the practice of Internal Medicine or Family Medicine or Pediatrics, which may overlap with these privileges but should be credentialed separately.


• Board certification or board eligibility in hospice and palliative medicine or training in the sub-specialty is assumed to define a basic set of knowledge and skills. Other physicians can document by their training and experience that they are competent to care for patients with life-limiting illnesses and their families.


• Credentialing should rely, if possible, on processes already established by the specialty, such as Board certification, but also must build on these processes by specifically designating and evaluating a set of specialist-level skills and practices which must be offered by credentialed specialists in hospice and palliative medicine.


• These guidelines may have the most utility when put into the format of a competency checklist.


• The privileges to offer additional procedures performed on patients with life-limiting illnesses should be granted only to those physicians who specifically request them and can demonstrate the appropriate training and skills.

Healthcare organizations may credential a physician in hospice and palliative medicine who demonstrates evidence of specialist-level knowledge and skills in this discipline. The following principles apply to this process:

• Certification by ABHPM, or certification in hospice and palliative medicine by an ABMS board, indicates that a physician has met criteria for training and experience established by the specialty and passed an examination demonstrating specialist-level knowledge of palliative care. Certification is highly desirable among those who seek credentialing and, in the absence of conflicting information, is sufficient evidence of the ability to provide core elements of care.


• Eligibility for certification indicates that a physician has met the criteria to sit for the examination but has not yet taken it or performed satisfactorily. In the absence of conflicting information, Board eligibility should be viewed as good evidence that a physician is able to provide core elements of care including the assessment and management of physical, psychosocial, and spiritual sources of suffering experienced by patients with life-limiting illnesses and their families as well as has attained the specific knowledge and skills to encompass the following domains:
• Prognostication, course of illness, and the nature of illness burden during the advanced phase of disease in diverse populations with life-threatening diseases


• Neuro-psychiatric co-morbidities in populations with life-threatening diseases


• Psychosocial complications in populations with life-threatening diseases


• Specialist-level management of pain and non-pain symptoms


• Effective and empathic communication, particularly surrounding salient issues at the end-of-life


• Management of spiritual distress associated with life-threatening diseases


• Management of the dying process and events surrounding death


• Ethical and legal decision making, particularly surrounding issues in end-of-life care


• Grief and bereavement support for the family and broader community


• Interdisciplinary care planning and the optimal use of hospice and other systems of palliative care for populations with advanced illness


• Goals and specific tasks—clinical and administrative—within the purview of a medical director employed by a certified hospice program


• Regulatory requirements of the Hospice Medicare Benefit


• Quality improvement methodology in populations with advanced illnesses
• Credentialing organizations seeking evidence of training, clinical experience or specific knowledge consistent with specialist-level hospice and palliative medicine should consider the physician’s participation in relevant types of graduate medical education, continuing medical education, employment experience providing either primary care or consultative services, and volunteer experience.

Physicians who are credentialed to provide specialist-level care should be assumed to have the knowledge and skills to provide the core elements of hospice and palliative care. Accordingly, credentialing should subsume the following core privileges:

• Provision of primary care or consultative services to all patients with life-threatening illness who require, or may require, specialist-level palliative care services


• Development of an interdisciplinary institution-based palliative care consultation service, or participation in a hospice interdisciplinary team, as appropriate


• Provision of all physician care appropriate to institution-based palliative care consultation services or a hospice team, including patient and family assessment, empathic communication with patient and family, care planning and coordination of care, clarification of goals of care, management of common medical disorders commensurate with training and experience, appropriate referral to consulting services and community resources, and quality improvement activities


• Provision of appropriate advanced symptom control techniques such as parenteral infusional techniques. Invasive symptom control therapies such as neural blockade and neuraxial infusion are not considered core elements and should be credentialed separately.


• Provision of physician care in the management of the imminently dying patient, including care of medical disorders, effective communication, coordination with the medical care team, and decision making grounded in the principles of hospice and palliative medicine, ethics, and appropriate law.