Hospice

1. 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)
   2. Chronic Obstructive Pulmonary Disease
      1. Persistent hypercapnia (e.g. PaCO2>50 mmHg)
      2. Resting Dyspnea and Tachycardia
   3. Congestive Heart Failure
      1. NYHA Class III-IV with symptoms refractory to maximal medical therapy
   4. Dementia
      1. Minimally verbal, non-ambulatory, with assistance required in all ADLs
2. Criteria: Hospice eligibility
   1. Patient chooses Hospice for Palliative Care (not curative) and
   2. Medicare Part A eligible (or commercial insurance with similar benefits) and
   3. Terminal illness with less than a 6 month life expectancy
3. Protocol
   1. Referral initiated
      1. Hospice Referral is not limited to physicians, nurses, and social workers
      2. 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
   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
4. Resources
   1. National Hospice and Palliative Care Organization
      1. http://www.nhpco.org
5. References
   1. Casarett (2007) Ann Intern Med 146:443-9
   2. Weckmann (2008) Am Fam Physician 77:807-18