Patients and family caregivers consider control over treatment decisions a high priority for those with life-limiting illnesses. There are studies that show improved satisfaction with healthcare and improved communication between of patients and physicians when the patient and family preferences about healthcare decisions are discussed. Treatment preferences are part of the Hospice Composite Measure which is one of the newest components of the Hospice Quality Reporting Program (HQRP). The goal of this quality measure in hospice is to improve the ability of patients and legal representatives to advocate for their wishes at the end of life. This makes it more likely that the patient has care that matches their values.
Having the Discussion
For agencies to achieve this quality measure, the hospice agency must discuss – or attempt to discuss – at least one of three preference items in the seven days prior to or five days after hospice admission. The evidence of this discussion must be documented in the clinical records of your hospice software. The preference items in the Hospice Item Set (HIS) are:
- F2000A: The patient and/or responsible party were asked about preferences regarding the use of cardiopulmonary resuscitation (CPR)
- F2100A: The patient and/or responsible party were asked about preferences regarding life-sustaining treatments other than CPR
- F2200A: The patient and/or responsible party were asked about preference regarding hospitalization
For F2000A, the presence of a signed Do Not Resuscitate Order (DNR) is not proof of a discussion if the DNR was signed prior to the patient electing hospice. Reconfirm the preference for the DNR order if it was signed in another care setting. Also, a preference regarding DNR is not required to be made for this discussion to be documented as occurring. For this measure, the discussion is more important than the result.
For F2100A, the measure is looking for discussion about any potentially life-sustaining treatments, such as feeding tubes, dialysis, or IV fluids. Again, documentation of the discussion needs to be in the clinical record of the hospice software and does not need to have any final decisions made at the time of the initial discussion.
For F2200A, be clear in your documentation that the discussion regarding hospitalization does not include inpatient or respite care under hospice services. The discussion is for inpatient hospital care not under hospice services. The initial discussion and opening the door for future discussions is more important than a final decision.
How to Document Treatment Preferences
For the date entry in F2000B, F2100B, and F2200B, enter the dates of the first documented discussions regarding preference items. Although there may be many discussions, the HIS items are only asking about the initial documented discussion. Discussions that occur up to seven days prior to hospice admission that are documented in the clinical records can be used for evidence of the discussion on preference items and the date of the discussion.
Ensure your agency is documenting the educational sessions and pre-admission visits in the hospice software to best report your performance on this measure. Discussions that occur during the comprehensive assessment period of five days after hospice election can also be noted in the Admission HIS document. Also, the HIS Manual version 2.01 is clear that the “responsible party” is referring to the legally responsible or authorized person. When able, it is best to ask the patient for their preferences, but when asking a family member, ensure that the person is legally authorized as a decisionmaker for the patient for the documented discussion to count for this quality measure.
Prior to finalizing the Admission HIS for submission, the person responsible for reviewing the HIS should look in multiple documents for validating documentation of the treatment preferences discussion. While it may be addressed in the initial RN assessment, this could also be documented in the psychosocial or spiritual counselor documentation.