Hospice care provides compassionate end-of-life care for people with terminal illnesses. The goal of hospice is to make patients as comfortable as possible by managing their pain and symptoms. Hospice also provides support for patients’ families. In the United States, the Medicare Hospice Benefit covers the costs of hospice care for eligible patients. In order to qualify for hospice care under Medicare, two physicians – the patient’s attending physician and the hospice medical director – must certify that the patient has 6 months or less to live if their disease follows its normal course. This certification is based on specific clinical markers and other evidence that suggests the patient is terminally ill. This article will provide an overview of the key markers used to determine hospice eligibility for terminal illnesses like cancer, heart disease, lung disease, kidney disease, Alzheimer’s disease, and other conditions.
What are the general guidelines for hospice eligibility?
In general, patients are eligible for hospice care if they meet the following criteria:
– Have a terminal illness with a prognosis of 6 months or less if the disease runs its normal course
– No longer seeking curative treatment for their underlying terminal illness
– Choosing palliative/comfort care rather than aggressive medical interventions
Some of the signs that may indicate a patient is declining and approaching end-stage disease include:
– Frequent hospitalizations or ER visits for their illness
– Difficult to control physical symptoms like pain, shortness of breath
– Increasing dependence on assistance for activities of daily living
– Unintentional weight loss of 10% or more in the last 6 months
– Recurrent infections like pneumonia, UTIs, sepsis
– Difficulty swallowing foods and liquids
– Confusion or impaired thinking
– Words like “hospice” and “palliative care” mentioned by the patient and family
Markers for hospice eligibility in cancer
For patients with terminal cancer, some of the specific markers that can indicate hospice eligibility include:
– Metastatic cancer that has stopped responding to first-line chemotherapy
– Cancer that has returned after a remission or regressed after initial therapy
– Inability to perform normal activities of daily living without assistance
– Losing >10% of body weight in the last 6 months due to cancer
– Difficult to control cancer-related pain, nausea, dyspnea that requires high doses of opioids and other medications
– Brain or bone metastases present
– Albumin <2.5 g/dL due to cancer physiology
- Recurring infections and fevers
- Platelet count <100,000/μL due to bone marrow infiltration
- Hypercalcemia with calcium >12 mg/dL
Common types of end-stage cancer
Some of the most common types of end-stage cancers that can qualify a patient for hospice include:
– Metastatic lung, breast, prostate, colon, pancreatic, and ovarian cancers
– Glioblastoma and other aggressive end-stage brain cancers
– Advanced hepatocellular carcinoma
– Diffuse large B cell lymphoma
– Multiple myeloma with organ failure
– Metastatic melanoma
– Mesothelioma
Markers for hospice eligibility in heart disease
Patients with end-stage heart disease may qualify for hospice if they exhibit factors like:
– Left ventricular ejection fraction <20% along with symptoms like fatigue, dyspnea, and edema
- Significant heart failure symptoms at rest or with minimal activity (NYHA class IV)
- Recurring hospitalizations or ER visits for acute decompensated heart failure
- Weight loss >10% in 6 months due to advancing heart failure
– Difficult to control edema and ascites despite high dose diuretics
– History of cardiac arrest or life threatening arrhythmias
– Concomitant severe lung disease like COPD
– Angina pain at rest despite optimal medical management
– Hypotension with systolic blood pressure frequently <90 mmHg
- Persistently elevated B-type natriuretic peptide (BNP) >800 pg/mL
– Cardiac cachexia with muscle wasting and loss of fat stores
– Oliguria with urine output <400 mL/day
- Decreased alertness and orientation from poor cerebral perfusion
Markers for hospice eligibility in lung disease
For patients with chronic end-stage pulmonary diseases like COPD, pulmonary fibrosis, and cystic fibrosis, some hospice markers include:
– FEV1 <30% of predicted even with maximally tolerated medical therapy
- Severe resting dyspnea with oxygen saturation <88% on room air
- Recurring pneumonias, pulmonary emboli, or respiratory failure
- Using accessory muscles for breathing at rest, active pursed lip breathing
- Right heart failure secondary to lung disease with edema and engorged neck veins
- Unintentional 10% weight loss over 6 months attributed to advancing lung disease
- Dependent on oxygen for activities of daily living and continuous oxygen while sleeping
- Pulmonary hypertension with right ventricular dysfunction on echocardiogram
- Hypercapnia with pCO2 >50 mmHg on ABG despite supplemental oxygen
– Difficulty walking across room or performing ADLs due to shortness of breath
Markers for hospice eligibility in kidney disease
For patients with end-stage renal disease, hospice evaluation is appropriate when:
– Choosing to stop or forgo dialysis after discussion of prognosis and options
– Experiencing uremic symptoms like nausea, vomiting, anorexia that persist despite dialysis
– Difficult to control fluid overload with effusions, edema, and pleural effusions
– Hyperkalemia >6.5 mEq/L or other electrolyte imbalances refractory to medical management
– Pericardial effusion or tamponade due to uremia
Additional markers that can indicate poor prognosis in 6 months include:
– Cachexia and muscle wasting with severe hypoalbuminemia <2.5 g/dL - Platelet count <50,000 due to reduced production - Metabolic acidosis with pH <7.25 and HCO3 <15 mEq/L - Recurring infections like pneumonia, UTIs, and gangrene - Severe anemia with hemoglobin <9 g/dL and transfusion dependence - Difficult to control nausea, vomiting, anxiety due to uremia - Cognitive impairment with confusion and somnolence as glomerular filtration rate declines
Markers for hospice eligibility in Alzheimer’s disease and dementia
Patients with end-stage dementia may qualify for hospice if they exhibit:
– Inability to ambulate without assistance
– Minimal to no verbal communication
– Urinary and fecal incontinence
– Difficulty swallowing food and liquids with aspiration risk
– Recurring fevers and infections like pneumonia and UTIs
– Functional Assessment Staging Test (FAST) score of 7A or greater
– Assistance required for nearly all activities of daily living like dressing, bathing, and eating
– Weight loss from muscle wasting and poor nutrition
– Severe rigidity, contractures, and restricted movement
– Skin breakdown from prolonged immobility
When to consider hospice evaluation
In general, hospice evaluation is appropriate when a patient’s conditions suggests they are declining and may have a prognosis of 6 months or less. Some signs a hospice assessment may be beneficial:
– The primary illness is no longer responding to standard treatments aimed at cure or control
– Patient has lost significant weight, strength, and function in recent weeks
– ER visits and hospitalizations are becoming more frequent
– Medications and interventions provide limited symptom relief
– Patient expresses wishes focused on quality of life and comfort rather than longevity
– Family is struggling to provide complex care at home
A hospice evaluation does not mean someone must forgo all treatments—many patients continue disease modifying interventions. But hospice provides an added layer of support focused on optimizing comfort and quality of life. Patients and families can revoke hospice care if their situation stabilizes. But early evaluation helps ensure patients have access to comprehensive palliative services when their disease reaches an advanced stage.
Conclusion
Determining when a patient is appropriate for hospice care depends on many factors. Both clinical markers related to their specific terminal illness as well as their overall physical, social, and emotional needs have to be considered. While specific lab values, test results, and clinical criteria help guide hospice eligibility in diseases like cancer, organ failure, and dementia, the decision also relies heavily on the judgement of experienced physicians. With a compassionate, patient-centered approach focused on relieving suffering and maximizing quality of life, hospice provides invaluable support for those nearing the end of life.
