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)
- FAST Stage 7a or worse
- Urinary Incontinence and Fecal Incontinence
- Limited verbal communication (6 words or less)
- Comorbid conditions related to increased mortality
- Aspiration
- Pyelonephritis
- Septicemia
- Pressure Ulcers
- 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
- 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
- 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]