Palliative care and family medicine

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

• Patient's are eligible for hospice care if they have a any terminal illness with an estimated prognosis of less than six months
  • This includes non-cancer diagnoses, such as congestive heart failure, chronic obstructive pulmonary disease, failure to thrive, and dementia

• 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

• National Hospice and Palliative Care Organization

Tools for determining patient prognosis

• Karnofsky Performance Scale
• Palliative Performance Scale
• Palliative Prognosis Score

References

• Weckmann, MT. The Role of the Family Physician in the Referral and Management of Hospice Hospice Patients. Am Fam Physician. 2008;77(6): 807-812.