II. Indications: Examples of Terminal Conditions for which to consider Hospice
- Cancer
- Significant functional decline (e.g. Karnofsky Performance Scale score <50)
- Distant metastases or multiple tumor sites
- Cancer Complications (e.g. Bowel Obstruction)
- Patient refuses further disease-directed therapy
-
Chronic Obstructive Pulmonary Disease
- Persistent hypercapnia (e.g. PaCO2>50 mmHg)
- Resting Dyspnea despite maximal medical therapy
- Oxygen-dependent at rest
- Right-sided Heart Failure due to pulmonary disease (Cor Pulmonale)
- Resting Tachycardia
-
Congestive Heart Failure
- NYHA Class III-IV with symptoms refractory to maximal medical therapy
- Supportive factors
- Ejection fraction <20%
- Symptomatic Supraventricular Tachycardia
- Prior Cardiac Arrest
- Unexplained Syncope
- Cardiogenic Shock
-
Dementia
- Non-ambulatory, with assistance required in ADLs (e.g. dressing, bathing)
- Functional Assessment Staging Tool (FAST) Stage 7a or worse
- Urinary Incontinence and Fecal Incontinence
- Limited verbal communication (6 words or less)
- Comorbid conditions related to increased mortality
- Nutritional Impairment
- Decreased oral intake
- Weight loss >10% in prior 6 months
- Serum Albumin <2.5 g/L
- Renal
- Creatinine Clearance or Glomerular Filtration Rate (GFR) <15 ml/min or Serum Creatinine >8.0
- Uremia signs or symptoms
- Hyperkalemia persistent
- Intractable Fluid Overload
- Patient declines Hemodialysis
- Debility (over age 65 years without typical terminal illness)
- Weight loss >10% over prior 6 months
- Serum Albumin <2.5 g/L
- Decreased functional status (e.g. requiring assistance with all ADLs such as bathing, dressing,ambulating)
- Dysphagia with secondary aspiration or chronic inadequate nutritional intake
- Progressive Pressure Ulcers refractory to standard nursing preventive strategies and wound care
- Escalating emergency department visits or hospitalizations secondary to chronic conditions (e.g. CHF, COPD)
- References
III. Criteria: Hospice eligibility
- Terminal illness with less than a 6 month Life Expectancy and
- Medicare Part A eligible (or commercial insurance with similar benefits) and
- Patient chooses Hospice for Palliative Care (not curative)
- Exception: Pediatric patients may continue to receive life-extending interventions
IV. Protocol: Initiation
- Referral initiated
- Hospice Referral is not limited to physicians, nurses, and social workers
- Office evaluation need not precede Hospice entry
- Family and friends may also refer a patient to Hospice
- Hospice duration (not limited to 6 months)
- Certification period 1: First 3 months
- Certification period 2: Next 3 months
- Subsequent certifications: Increments of 2 months each
- Require Hospice physician or Hospice nurse practioner evaluation
- Attending physician responsibility
- Responsible for primary medical care and admissions
- Physician or covering partners are readily available for phone Consultation by Hospice staff
- Orders prescriptions for patient's Palliative Care (many are on standing order)
- Attending physician billing criteria (Medicare, care oversight code)
- Physician who signed Hospice certification does oversight and
- Physician does not recieve separate compensation from the Hospice agency and
- Physician chart review, phone calls and care coordination exceed 30 minutes/month and
- Patient seen by physician or collaborating practitioner (e.g. NP) at least every 6 months
- Allowed services (typical misconceptions about Hospice)
- Hospice patients are not mandated to be DNR (some local agencies may require this)
- Hospice patients may reside at a nursing facility
- Conditions unrelated to the terminal illness may still be treated, including hospitalization
- Chemotherapy, radiation and Blood Transfusions are not excluded if Palliative Care
- Grief counseling for family for as long as 1 year after a patient's death
V. Management: Emergency Department presentation of a Hospice patient
- Notify Hospice agency caring for patient
- Especially important if patient or family came directly to emergency department without notifying Hospice
- Hospice agencies are responsible for patient's care plan and medical costs
- Address specific trigger for current emergency visit
- Manage Cancer Symptoms
- Evaluate and manage device malfunction or displacement (e.g. Gastrostomy Tube, Nephrostomy Tube)
- New reversible conditions (e.g. Urinary Tract Infection)
- Mood Disorders in Cancer (e.g. Preparatory Grief)
- Evaluate patient's goals
- Discussion with patient and their family in an area as quiet and private as possible
- Ask patient and family about their understanding of the patient's underlying condition an current status
- Review provider's understanding of the patients condition, status and any new acute changes
- Avoid medical terminology
- Summarize status in clear terms (e.g. getting worse)
- Ask patient their goals for care
- Address a patient's hopes and fears
- Ask whether a patient is interested in possible life preserving measures (e.g. IV hydration, Hemodialysis)
- Ask whether patient wishes to continue with comfort care measures only
- Employ appropriate diagnostics and management
- Testing and treatment should remain true to a patient's goals
- Withholding or withdrawing interventions is an ethically valid approach if this meets a patient's wishes
- Consider Consultation (as indicated and if available)
- Patient's primary care provider
- Palliative Care provider (esp. if uncertain diagnosis)
- Social services (e.g. family disagreement, sibling support)
- Testing and treatment should remain true to a patient's goals
- Disposition
- Stabilization of current condition is paramount prior to determination of disposition
- Review options
- Hospitalization (with or without continued Hospice care)
- Returning home (with or without Hospice care)
- Other facility (e.g. Nursing Home, Hospice residence)
- Notify Hospice agency of disposition
VI. Resources
- National Hospice and Palliative Care Organization
VII. References
- Marks and Barnosky (2013) Crit Dec Emerg Med 27(8): 2-8
- Weber and Marks (2014) Crit Dec Emerg Med 28(8): 11-8
- Casarett (2007) Ann Intern Med 146:443-9 [PubMed]
- Weckmann (2008) Am Fam Physician 77:807-18 [PubMed]
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Related Studies
Definition (CHV) | program that provides spiritual, emotional, and physical care to terminally ill patients and their family |
Definition (CHV) | program that provides spiritual, emotional, and physical care to terminally ill patients and their family |
Definition (CCC) | Actions performed to support the provision of offering and/or providing care for terminally ill persons |
Definition (NCI) | An establishment that provides palliative and supportive care for terminally ill patients and their families via physical, psychological, social and other forms of care. |
Definition (MSH) | Facilities or services which are especially devoted to providing palliative and supportive care to the patient with a terminal illness and to the patient's family. |
Definition (PSY) | Supportive palliative care of terminally ill patients, usually in their own home, by a treatment team and family members; sometimes involves residential care. |
Definition (CSP) | facility that provides palliative and supportive care for terminally ill patients and their families. |
Concepts | Health Care Related Organization (T093) , Manufactured Object (T073) |
MSH | D006738 |
SnomedCT | 393322002, 394272007, 284546000 |
English | Hospices, hospice, hospices, HOSPICE, Hospice, hospice environment, Hospice (finding), Hospice (environment) |
Spanish | centro de cuidados paliativos (medio ambiente), hospicio, centro de cuidados paliativos (hallazgo), hospicio (hallazgo), centro de cuidados paliativos, Hospitales para Enfermos Terminales |
Swedish | Hospis |
Czech | útulky pro dlouhodobě nemocné, hospice |
Finnish | Saattokodit |
Russian | KHOSPISY, PRIIUTY, ПРИЮТЫ, ХОСПИСЫ |
French | Services de soins palliatifs, Services de fin de vie, Établissements de soins palliatifs, Établissements de fin de vie |
Croatian | HOSPICIJI |
Polish | Hospicja |
Norwegian | Hospicer |
German | Hospize, Palliativ-Pflegeeinrichtungen |
Italian | Strutture per malati terminali |
Dutch | Hospice, Hospices, Verblijfhuizen voor terminale patiënten |
Portuguese | Hospitais para Doentes Terminais |
Ontology: Referral to hospice (C0584064)
Concepts | Health Care Activity (T058) |
SnomedCT | 183922008, 152150009, 306205009 |
Spanish | derivación al hospicio, derivación al hospicio (procedimiento), derivación a centro de cuidados paliativos (procedimiento), derivación a centro de cuidados paliativos |
English | Referral to hospice, Referral to hospice (procedure), referral hospice, Referral;hospice |