The question that all palliative care providers face is when it may be appropriate to transition a patient to hospice care.
As hospice is a type of palliative care, the demarcation is not easily identified. There are, however, distinct key indicators to help recognize when a patient may need to be evaluated for this transition.
Critical Decision Points in Disease Treatment
When a patient is facing choices about starting new technologies and treatments, a discussion is needed on goals of care and if the treatment option is going to help the patient with achieving those goals.
Choices, such as a left ventricular assist device or implanted cardioverter defibrillator for cardiac patients, ventilator support for pulmonary patients or dialysis for end-stage renal disease patients.
Starting a third-line or fourth-line chemotherapy agent during cancer treatments is another time to review goals of care and what the realistic outcome would be of additional chemotherapy.
For patients with late stages of neurological disease, the physician should have this discussion with the patient’s legal representative prior to starting artificial feeding tubes or after the development of pressure ulcers and frequent infections.
Another decision point is when the patient can no longer tolerate the advanced technology treatments and other disease-modifying treatments, or if the patient is having other complications, including infections and hospitalizations because of the treatments.
For all late-stage and end-stage disease processes, repeated hospitalizations are an indicator that the patient is declining in status.
The palliative care team works to reduce hospitalizations by providing symptom management and early intervention for signs of disease exacerbation or infections. If the patient is still having repeated hospitalizations, they may need increased interventions that can be provided by the hospice interdisciplinary group (IDG).
Review Local Coverage Determinations
While the Medicare Administrative Contractors (MACs) have differences in their Local Coverage Determinations (LCDs) that show eligibility for hospice, all of them focus on non-disease-specific measures and the functional impact of the disease.
Non-disease-specific measures that indicate late-stage disease processes are:
- Decreased functional status
- Increased symptom burden
- Worsening lab values
- Secondary conditions, such as pressure ulcers, weight loss and infections
Cigna Government Services (CGS), National Government Services (NGS) and Palmetto have some disease-specific LCDs to specify other findings that could indicate a six-month prognosis or less. If the patient is showing both the non-disease-specific and disease-specific indicators of eligibility for hospice, consider discussing the option of hospice care with the patient and their legal representative.
Goals of Care
Goals of care discussions are a large part of palliative care visits, reviewed on the initial visit and at subsequent visits. When a patient’s goals of care are shifting away from disease-modifying treatments, hospice may be appropriate to discuss as an option.
Election to hospice is a choice for patients and their legal representatives. While a patient may be clinically eligible for hospice care, if the goals of care do not align with hospice, the patient and their loved ones may be less satisfied with hospice care than continuing palliative care.
Ultimately, the role of the palliative provider is to identify when the discussion about hospice transition is appropriate and to give compassionate, accurate information to assist a patient or their legal representative to make the best decision.
Axxess Hospice, a cloud-based hospice software, includes a palliative care workflow to assist hospice and palliative care professionals with accurate documentation at the point of care.