Palliative care and family medicine

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Hospice

Overview

  • Hospice is a philosophy that addresses the physical, psychological, social, and spiritual aspects of death and dying
    • Patients elect to pursue palliative rather than curative treatment
  • Hospice care can be provided in any setting- patient's home, hospice home, nursing home, or hospital
  • Hospice benefits cover all expenses related to the patient's terminal diagnosis that are deemed "reasonable and necessary for palliation"
    • This includes medications, skilled nursing, nursing aides, and hospital equipment, such as a hospital bed for the patient's desired location
    • Medicare pays hospice on a per diem basis that covers all medical care; this payment method often requires the attending physician to consider the cost of individual medications and treatments when multiple methods are available to treat the same symptom
  • Hospice benefits provide the patient's family with bereavement support for up to one year following the death of the patient
  • Patients appear to benefit most when hospice care is initiated at least two months prior to death

Eligibility

  • Medicare covers hospice care for if the following four criteria are met:
    • The patient is eligible for Medicare Part A
    • The patient enrolls in a Medicare-approved hospice
    • The patient has given written consent for hospice care
    • The patient's physician and the hospice medical director certify that the patient has a terminal illness with an estimated prognosis of less than six months

Clarification of common misconceptions

  • As long as a disease is running its "normal course," there is no penalty and the patient will not automatically be discharged from hospice if they survive longer than six months
    • Hospice care is initiated with two 90 day periods followed by unlimited extensions in 60 day intervals
  • Patients are not required to have a do not resuscitate order
  • The patient's primary care physician can and often does serve as a member of the patient's hospice care team
    • The attending physician is often the patient's primary care physician
    • The attending physician is required to write admission orders, be available by telephone, and handle the routine day-to-day medical needs of the patient
  • Most private insurers offer a benefit that is modeled after the Medicare Hospice Benefit
  • Patients may leave and reenter hospice care if there are unforeseen fluctuations in their disease course
  • Anyone, including friend's and family members, can refer a patient to hospice; the referral does not have to come from a physician or other medical professional
  • Medical problems and hospital admissions that are unrelated to the patient's terminal diagnosis generally are still covered by the patient's insurance plan while a patient pursues hospice care

Resources

General resources

Tools for determining patient prognosis

References