Hospice Care in Long-Term Care Facilities

Introduction to Hospice Care Settings

• Hospice care can be provided in various settings, including home-based hospice, inpatient facilities, integrated hospice care, and nursing home-based hospice, allowing patients to receive care in their current living environment, including Long-Term Care (LTC) facilities 1

Benefits of Hospice Care in LTC Settings

• Keeping the patient in their familiar LTC environment rather than transferring to an infirmary offers several advantages, including maintaining continuity of care with familiar staff, reducing stress of relocation for the terminally ill patient, preserving established relationships with caregivers, allowing for dignity and comfort in a familiar setting, and supporting quality of life in the patient's final days 1

Implementation of Hospice Care in LTC Settings

• General guidelines suggest that when implementing hospice care in an LTC setting, it is crucial to ensure clear communication between hospice providers and LTC staff, establish protocols for symptom management, provide appropriate staff education on end-of-life care, create a supportive environment for the patient, and document the patient's preferences and advance directives 1
• The American Heart Association and American Stroke Association recommend documenting the exact time of death, who pronounced the patient, the patient's status at the end of care, location of death, and who was present at the time of death, as well as providing emotional/spiritual support and noting any cultural or religious rituals performed 2, 3
• The National Comprehensive Cancer Network and European Society of Cardiology recommend documenting final symptom management interventions, including pain control, dyspnea management, anxiety management, and terminal secretions management, to ensure patient comfort and dignity at the end of life 4, 5, 6
• Effective symptom management is crucial for ensuring patient comfort and dignity at the end of life, with a focus on pain control, respiratory support, and emotional support 6
• The following template can be used to document end-of-life care:

2, 3, 4, 5, 6, 7

Eligibility and Referral for Hospice Care

• Patients with advanced pulmonary disease may qualify for hospice if they meet specific required criteria, including severe chronic lung disease, decreased functional capacity, and disease progression, as well as hypoxemia or hypercapnia, according to the American Thoracic Society 8
• The following criteria are used to determine hospice eligibility for non-cancer conditions:

• The "surprise question" is a valuable tool for clinicians to assess hospice appropriateness: "Would you be surprised if the patient dies within the next six months?" If the answer is "no," this should trigger hospice evaluation, as supported by the American College of Respiratory and Critical Care Medicine 9

Settings and Delivery of Hospice Care

• Hospice care is available in four primary settings: home-based hospice, inpatient facilities, integrated hospice care, and as a Medicare benefit subject to specific regulations and accreditation requirements, as outlined by the Centers for Medicare and Medicaid Services 3
• Home-based hospice care includes routine home care, medical social services, consultation and oversight from a hospice medical director, home health aide and homemaker services, and medications and medical supplies for symptom management, as recommended by the National Hospice and Palliative Care Organization 3
• Inpatient hospice care is provided in dedicated settings, such as free-standing hospice facilities or dedicated hospice units within hospitals or nursing homes, staffed by specialized interdisciplinary teams trained in palliative care, as accredited by The Joint Commission 3

Palliative Care

• Palliative care should be initiated at diagnosis and provided concurrently with disease-directed therapies, focusing on symptom management and quality of life, with the primary goal of facilitating patient autonomy, access to information, and choice, delivered concurrently with disease-directed, life-prolonging therapies, as recommended by the National Comprehensive Cancer Network and supported by the American College of Respiratory and Critical Care Medicine 4, 8
• Patients should be screened at every visit for uncontrolled symptoms, moderate to severe distress, serious comorbid conditions, life expectancy of 6 months or less, and patient/family concerns, to determine the need for palliative care, which can be provided alongside curative treatments without requiring a terminal diagnosis, as supported by the American College of Respiratory and Critical Care Medicine 4
• Palliative care can improve quality of life, reduce symptom burden, potentially improve survival, and enhance patient understanding of prognosis and goals of care, with benefits also extending to caregivers, as recommended by the American College of Respiratory and Critical Care Medicine 4, 8
• Underutilization of hospice care for non-cancer diagnoses, such as COPD, is a concern, with patients often receiving less palliative care than those with cancer, as noted by the American Thoracic Society 8
• Delayed referral to palliative care services limits their benefits, and underutilization in certain populations, such as patients with non-cancer diagnoses, is a common issue, often due to confusion about eligibility, communication barriers, and lack of advance care planning, as noted by the American College of Respiratory and Critical Care Medicine 8, 5