Hospice

Aka: Hospice, Hospice Referral

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II. Indications: Examples of Terminal Conditions for which to consider Hospice

  1. Cancer
    1. Significant functional decline (e.g. Karnofsky Performance Scale score <50)
    2. Distant metastases or multiple tumor sites
    3. Cancer Complications (e.g. Bowel Obstruction)
    4. Patient refuses further disease-directed therapy
  2. Chronic Obstructive Pulmonary Disease
    1. Persistent hypercapnia (e.g. PaCO2>50 mmHg)
    2. Resting Dyspnea despite maximal medical therapy
    3. Oxygen-dependent at rest
    4. Right-sided Heart Failure due to pulmonary disease (Cor Pulmonale)
    5. Resting Tachycardia
  3. Congestive Heart Failure
    1. NYHA Class III-IV with symptoms refractory to maximal medical therapy
    2. Supportive factors
      1. Ejection fraction <20%
      2. Symptomatic Supraventricular Tachycardia
      3. Prior Cardiac Arrest
      4. Unexplained Syncope
      5. Cardiogenic Shock
  4. Dementia
    1. Non-ambulatory, with assistance required in ADLs (e.g. dressing, bathing)
    2. Functional Assessment Staging Tool (FAST) Stage 7a or worse
    3. Urinary Incontinence and Fecal Incontinence
    4. Limited verbal communication (6 words or less)
    5. Comorbid conditions related to increased mortality
      1. Recurrent Aspiration Pneumonia
      2. Pyelonephritis
      3. Septicemia
      4. Pressure Ulcers
    6. Nutritional Impairment
      1. Decreased oral intake
      2. Weight loss >10% in prior 6 months
      3. Serum Albumin <2.5 g/L
  5. Renal
    1. Creatinine Clearance or Glomerular Filtration Rate (GFR) <15 ml/min or Serum Creatinine >8.0
    2. Uremia signs or symptoms
    3. Hyperkalemia persistent
    4. Intractable Fluid Overload
    5. Patient declines Hemodialysis
  6. Debility (over age 65 years without typical terminal illness)
    1. Weight loss >10% over prior 6 months
    2. Serum Albumin <2.5 g/L
    3. Decreased functional status (e.g. requiring assistance with all ADLs such as bathing, dressing,ambulating)
    4. Dysphagia with secondary aspiration or chronic inadequate nutritional intake
    5. Progressive Pressure Ulcers refractory to standard nursing preventive strategies and wound care
    6. Escalating emergency department visits or hospitalizations secondary to chronic conditions (e.g. CHF, COPD)
  7. References
    1. (1996) Hosp J 11(2): 47-63 [PubMed]

III. Criteria: Hospice eligibility

  1. Terminal illness with less than a 6 month Life Expectancy and
  2. Medicare Part A eligible (or commercial insurance with similar benefits) and
  3. Patient chooses Hospice for Palliative Care (not curative)
    1. Exception: Pediatric patients may continue to receive life-extending interventions

IV. Protocol: Initiation

  1. Referral initiated
    1. Hospice Referral is not limited to physicians, nurses, and social workers
    2. Office evaluation need not precede Hospice entry
    3. Family and friends may also refer a patient to Hospice
  2. Hospice duration (not limited to 6 months)
    1. Certification period 1: First 3 months
    2. Certification period 2: Next 3 months
    3. Subsequent certifications: Increments of 2 months each
      1. Require Hospice physician or Hospice nurse practioner evaluation
  3. Attending physician responsibility
    1. Responsible for primary medical care and admissions
    2. Physician or covering partners are readily available for phone Consultation by Hospice staff
    3. Orders prescriptions for patient's Palliative Care (many are on standing order)
  4. Attending physician billing criteria (Medicare, care oversight code)
    1. Physician who signed Hospice certification does oversight and
    2. Physician does not recieve separate compensation from the Hospice agency and
    3. Physician chart review, phone calls and care coordination exceed 30 minutes/month and
    4. Patient seen by physician or collaborating practitioner (e.g. NP) at least every 6 months
  5. Allowed services (typical misconceptions about Hospice)
    1. Hospice patients are not mandated to be DNR (some local agencies may require this)
    2. Hospice patients may reside at a nursing facility
    3. Conditions unrelated to the terminal illness may still be treated, including hospitalization
    4. Chemotherapy, radiation and Blood Transfusions are not excluded if Palliative Care
    5. Grief counseling for family for as long as 1 year after a patient's death

V. Management: Emergency Department presentation of a Hospice patient

  1. Notify Hospice agency caring for patient
    1. Especially important if patient or family came directly to emergency department without notifying Hospice
    2. Hospice agencies are responsible for patient's care plan and medical costs
  2. Address specific trigger for current emergency visit
    1. Manage Cancer Symptoms
    2. Evaluate and manage device malfunction or displacement (e.g. Gastrostomy Tube, Nephrostomy Tube)
    3. New reversible conditions (e.g. Urinary Tract Infection)
    4. Mood Disorders in Cancer (e.g. Preparatory Grief)
  3. Evaluate patient's goals
    1. Discussion with patient and their family in an area as quiet and private as possible
    2. Ask patient and family about their understanding of the patient's underlying condition an current status
    3. Review provider's understanding of the patients condition, status and any new acute changes
      1. Avoid medical terminology
      2. Summarize status in clear terms (e.g. getting worse)
    4. Ask patient their goals for care
      1. Address a patient's hopes and fears
      2. Ask whether a patient is interested in possible life preserving measures (e.g. IV hydration, Hemodialysis)
      3. Ask whether patient wishes to continue with comfort care measures only
  4. Employ appropriate diagnostics and management
    1. Testing and treatment should remain true to a patient's goals
      1. Withholding or withdrawing interventions is an ethically valid approach if this meets a patient's wishes
    2. Consider Consultation (as indicated and if available)
      1. Patient's primary care provider
      2. Palliative Care provider (esp. if uncertain diagnosis)
      3. Social services (e.g. family disagreement, sibling support)
  5. Disposition
    1. Stabilization of current condition is paramount prior to determination of disposition
    2. Review options
      1. Hospitalization (with or without continued Hospice care)
      2. Returning home (with or without Hospice care)
      3. Other facility (e.g. Nursing Home, Hospice residence)
    3. Notify Hospice agency of disposition

VI. Resources

  1. National Hospice and Palliative Care Organization
    1. http://www.nhpco.org

VII. References

  1. Marks and Barnosky (2013) Crit Dec Emerg Med 27(8): 2-8
  2. Weber and Marks (2014) Crit Dec Emerg Med 28(8): 11-8
  3. Casarett (2007) Ann Intern Med 146:443-9 [PubMed]
  4. Weckmann (2008) Am Fam Physician 77:807-18 [PubMed]

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