Hospice Care Guidelines

Introduction to Hospice Care

• The American Thoracic Society recommends that patients in hospice care are not required to withdraw all medical treatments, but rather focus on comfort-oriented care rather than curative treatments for their terminal illness 1, 2
• Hospice care is defined as support and care for patients and their families in the last phase of an incurable disease, allowing them to live as fully and comfortably as possible, as stated by the American College of Chest Physicians 1, 2

Eligibility and Requirements

• Medicare and other insurers require certification that the patient has a terminal prognosis (likely less than 6 months of life) for hospice eligibility, according to the Centers for Medicare and Medicaid Services 2
• Medicare requires patients to agree in writing that hospice care (not other Medicare services like curative care) will be used to treat their terminal illness, as mandated by the Medicare guidelines 2

Symptom Management and Treatment

• Palliative treatments aimed at managing symptoms such as pain, dyspnea, anxiety, and other distressing symptoms continue and are often enhanced, as recommended by the American Academy of Hospice and Palliative Medicine 3
• Supplemental oxygen, medications for symptom control, and other interventions that improve quality of life can be maintained, according to the American Academy of Pediatrics 4

End-of-Life Care Distinctions

• Withdrawing or withholding life-sustaining treatments is ethically and legally different from physician-assisted suicide or euthanasia, as stated by the American College of Physicians 5, 6
• Discontinuing ineffective, futile, or burdensome treatments is not intended to hasten death but acknowledges the natural progression of disease, according to the American College of Physicians 6

Patient Autonomy and Refusal of Treatment

• Patients can refuse specific treatments while continuing to receive others based on their goals of care, as supported by the Academy of Nutrition and Dietetics 7
• Hospice focuses on quality of life rather than extending life at all costs, as recommended by the American Thoracic Society 3

Common Misconceptions

• Many incorrectly believe hospice care is only for the last hours to days of life, when in fact earlier referral is associated with better outcomes, according to the American College of Chest Physicians 8
• There's a misconception that hospice requires patients to have a "do not attempt resuscitation" order, which is not true, as stated by the American College of Chest Physicians 2

Decision-Making and Clinical Considerations

• Decisions about which treatments to continue or discontinue should be guided by the patient's goals of care and what provides more benefit than burden, as recommended by the American Academy of Pediatrics 4
• Patients with non-cancer diagnoses (like COPD or heart failure) often receive less timely referrals to hospice despite potential benefits, according to the American Thoracic Society 1, 2

Hospice Care for Terminally Ill Patients

Introduction to Hospice Care

• When a patient expresses desire for hospice care, refer immediately to a hospice agency to ensure timely enrollment and prevent common problems, according to the National Comprehensive Cancer Network 9
• The average hospice stay for cancer patients is only 17-19 days, with one-third dying within 7 days of enrollment, indicating a failure to refer early enough, as reported by the National Comprehensive Cancer Network 9

Eligibility and Referral Timing

• Patients qualify for hospice when both the treating physician and hospice medical director certify a terminal prognosis with life expectancy likely less than 6 months if the disease follows its expected course, although specific certification requirements are not detailed here 9
• Optimal timing for hospice referral is when the patient's prognosis is months to weeks, at which point advance directives should be completed, as recommended by the National Comprehensive Cancer Network 10, 9
• For patients with a prognosis of weeks to days, hospice should already be engaged, with a focus on symptom management and family support, according to the National Comprehensive Cancer Network 10

Advance Care Planning

• When life expectancy is months to weeks, essential steps include completing MOLST/POLST and documenting patient values, preferences, and decisions in the medical record, as advised by the National Comprehensive Cancer Network 10
• Confirming the patient's wishes regarding their place of death is also crucial, with most cancer patients preferring to die at home, and dying in ICU associated with higher distress and prolonged grief in caregivers, as noted by the National Comprehensive Cancer Network 10

Symptom Management

• For dyspnea, opioids are the first-line treatment, followed by glycopyrrolate for secretions, and scopolamine or benzodiazepines in specific cases, as recommended by the National Comprehensive Cancer Network 10
• Non-pharmacologic interventions, such as handheld fans directed at the face, are also effective in reducing breathlessness, according to the National Comprehensive Cancer Network 10

Conversation Framework

• The conversation about integrating supportive care and eventual hospice should start early in the management of any serious illness, not when death is imminent, as suggested by the Journal of Clinical Oncology 11
• This conversation requires ongoing candid discussions about treatment goals and preferences, balancing risks and benefits of additional therapy with careful assessment of overall clinical status, as outlined in the Journal of Clinical Oncology 11

Hospital Admission for Hospice Patients

Indications for Hospital Admission

• The American Thoracic Society states that hospital admission for hospice patients is indicated when satisfactory symptom control cannot be achieved in the current care setting, such as severe dyspnea or pain, acute symptom crises, or the need for specialized procedures, with the goal of improving symptom management 12
• Hospital admission is appropriate for hospice patients requiring intensive monitoring or interventions beyond what can be provided in the current setting, including situations where curative treatment is not the primary focus but symptom control is necessary 12

Coordination of Care

• The American Academy of Hospice and Palliative Medicine emphasizes that palliative care consultation during hospitalization can facilitate appropriate transitions, including discharge back to hospice care at home, and reduce 30-day readmission rates 13
• The hospice team should coordinate with the hospital to ensure continuity of the comfort-focused care plan when a hospice patient requires hospitalization 12

Patient Care Settings

• Hospice care can be delivered in multiple locations based on patient and family needs, including the patient's home, long-term care facilities, dedicated hospice facilities, and hospitals when needed for symptom control 14

Goals of Care

• Hospital admission should align with the patient's documented goals of care, and before any hospitalization, ensure that the patient and family understand the purpose of the admission and how it fits within their overall hospice care plan 15
• The American College of Physicians recommends that patients in hospice programs have a clear understanding of their goals of care and how hospitalization aligns with these goals, including the role of palliative care consultation in symptom management 15

Hospice Care and Survival

Evidence for Extended Survival

• A retrospective analysis of 4,493 Medicare patients with terminal illnesses found that those referred to hospice had a mean survival time 29 days longer than those not referred, particularly for patients with congestive heart failure, lung cancer, and pancreatic cancer 16
• There was a positive correlation between length of hospice stay and survival days, with an estimated longer survival of 0.8 times the number of days actually in hospice 16
• The American College of Chest Physicians states that patients receiving hospice tend to have a better sense of hopefulness and a longer survival 16
• Patients avoid the complications and burdens of futile aggressive treatments that may actually shorten life through adverse effects, infections, and treatment-related morbidity 16, 17
• Palliative sedation at the end of life, when employed, uses the "doctrine of double effect"—the intent is symptom relief, not to produce death, which differentiates it from euthanasia 17

Addressing Misconceptions

• Many incorrectly believe hospice care is only for the last hours to days of life, when in fact earlier referral (at 80-90 days) is associated with better outcomes and allows hospice to reach its full impact 16
• There's a misconception that hospice requires withdrawing all treatments or having a "do not attempt resuscitation" order, which is not true—patients can continue comfort-oriented medications and interventions 18
• The belief that treating symptoms of discomfort at the end of life hastens death is contradicted by evidence showing the opposite effect 16

Clinical Implications

• Delay in referral until death is near reduces the potential value of hospice services at consolidating grief preparation and acceptance, providing only death care rather than comprehensive end-of-life support 17
• Physicians should counsel patients and families that hospice enrollment is associated with longer survival, not shorter, directly addressing this barrier to timely referral 16

Heart Failure Hospice Eligibility Criteria

Criteria for Advanced Heart Failure

• Patients with advanced heart failure should be considered for hospice when guideline‑directed optimal therapy no longer controls symptoms and there is evidence of progressive decline. 19