1. Hospice Eligibility

2. The 6 months rule
Appropriate for hospice if life expectancy <6months if the disease follows its natural course.
Prognosis is only one factor that needs to be considered to determine if a patient will benefit from hospice
Medicare gives life expectancy excessive weight when determining eligibility

3. Cancer
“A patient with advanced cancer who has taken to bed without a correctable cause will usually die within weeks to a few months”
Palliative Care Perspective by James L. Hallenback
Should we wait until a patient is “taken to bed” to start hospice?
No. A patient with cancer can decline from 70% Karnofsky to 40% Karnofsky in a matter of days or weeks.
Over 60% Karnofsky may be a good candidate for Palliative care as chemotherapy and treating some complications may add quality and time.
Would not otherwise be feasible to provide on hospice care.
The patient can be monitored for a rapid decline and referral to hospice when they no longer benefit or desire therapies.

4. Dementia Stage 7 or higher on the FAST scale No walkie, no talkie.
Unable to ambulate alone
Unable to dress alone
Unable bathe self
Incontinent Bowel and Bladder
Speech limited to 6 or less intelligible words in a day
No walkie, no talkie.

5. Dementia, continued
In the previous 12 months at least one of the following
Aspiration pneumonia
Pyelonephritis or other UTI
Septicemia
Multiple decubs, stage 3 or 4
Fever recurrent after antibiotics
Insufficient fluid or calorie intake with 10% wt loss during previous 6 months
Serum albumin <2.5 gm/dl

6. Debility A study published in American Journal of Hospice and Palliative Medicine Vol. 13, No. 6, (1996)
Debility ICD 799.3
Multiple comorbid conditions
Major organ system impairment
Central nervous System (96%)
Cardio-pulmonary (76%)
Skin integrity (42%)
The average survival for these patients was 67 days and the median survival was 20 days.
In none of the 50 patients was there a single major system impairment of a degree to warrant a specific terminal diagnosis.

7. Failure to Thrive Hospice and Physician Team Newsletter, Fall, 2004 (a publication of the Center for Hospice and Palliative Care, Inc)
Characterized by unexplained weight loss, malnutrition and disability
BMI <22 kg/m2
Significantly disabled
40% or less on a Karnofsky scale
Unlike Debility, this patient may have no real primary diagnosis, just wasting away

8. Cardiac Congestive Heart Failure Class IV failure-
physical activity causes discomfort
Ejection Fraction <20%
Optimally treated on cardiac meds
Recurrent signs and symptoms
Dyspnea at rest, orthopnea, pitting edema of lower extremities, rales, gallop, liver enlargement, etc.
2 or 3 acute care admits for heart failure in the past year

9. Pulmonary Oxygen dependent Unresponsive to bronchodilators
FEV1 after bronchodilator <30% of predicted
At best able to walk a few steps without tiring
Resting pCO2 >50
O2 Sat OFF of O2 <88%
pO2 <55 on oxygen
Unintended weight loss >10%
Resting tachycardia >100
2 or 3 acute care admits for COPD in past year

10. Renal Chronic Renal failure with
Creatinine >8.0
Usually off dialysis
Dialysis may be considered palliative at advanced stages and paid for by hospice as a palliative treatment.
A mean average of only 8 days to live after dialysis is discontinued
Still need hospice prior to “pulling that plug”
Hospice supports the psych/social devastation that comes with this decision.
Deserve a “good death”
Hospice services are utilized by 13.5% of ESRD patients as opposed to 25% non-ESRD patients

11. Medicare Benefit Policy Manual Chapter 11- End Stage Renal Disease
Coverage under the Hospice Benefit
(Rev )
“If the patient’s terminal condition is not related to ESRD, the patient may receive covered services under BOTH the ESRD benefit and the hospice benefit. A patient does not need to stop dialysis treatment to receive care under the hospice benefit. Consequently hospice agencies can provide hospice services to patients who wish to continue dialysis treatment.”

12. Current Hospice Benefit
ESRD diagnosis may be used as the terminal diagnosis if:
Patient is not seeking dialysis or transplant and:
Cr Clearance <10 ml/min (15 for DM)
Serum Creatinine >8 (6 for DM)
Signs and symptoms of renal failure
Hospice pays for continued dialysis treatments.

13. Bottom Line
2 government benefits cannot pay for the same illness/condition in one beneficiary
2 government agencies CAN pay for 2 different illnesses/conditions in one beneficiary
If dialysis patient elects hospice, they cannot use the ESRD benefit, meaning hospice must pay for treatments related to ESRD (including dialysis)
Averages $ per day
Statistically hospice patients withdraw from dialysis within 2 weeks

14. Stroke, Acute phase
Coma or persistent vegetative state secondary to stroke beyond 3 days duration.
Coma with any of 4 of the following:
Abnormal brain stem response
Absent verbal response
Absent withdrawal response to pain
Serum creatinine >1.5
Age >70
Dysphagia severe enough to prevent a patient from receiving food or fluids
Declines or not a candidate for artifical nutrition and hydration

15. Stroke, Chronic phase
Clear-cut predictors have not been well classified
Consider the following
Karnofsky <50%
Post-stroke dementia with FAST score >7
Poor nutritional status
Artificial nutrition or not
10% weight loss over past 6 months
Serum albumin <2.5
Recurrent medical complications
Aspiration pneumonia
Pyelonephritis
Sepsis
Refractory Stage 3 or 4 decubiti
Recurrent fever following antibiotics

16. Sine-Waving
“a vacillating dying trajectory in which patients with certain illnesses such as congestive heart failure and dementia may deteriorate and then improve - over and over again. For sine-waving trajectories, it is more difficult to state definitively that any given clinical deterioration will, in fact, lead to death. “
James L. Hallenback from Palliative Care Perspectives

17. “Would you be surprised if this patient died within the next 2 years?”
What? 2 years? I thought it was 6 months?
If the answer is yes
The patient would benefit from serious discussion and planning relative to end-of-life care
This trajectory is extremely common.
They are the “frequent fliers”
Once “fixed”, they do not stay fixed
Patients and their families live miserably on a roller coaster of decline and transient improvement.
Will care be defined by what WILL be done or what WILL NOT be done?
We see these patients often in home health. They are in and out of the hospital and Palliative Care should be considered to educate the patient and family in determining the benefit vs. burden of interventions that will be presented to them.

18. Open Access
Now, both Aetna and UnitedHealth, along with some of the nation's 4,200 hospice programs, have begun to allow patients to receive medical treatment while enrolled in hospice care -- an approach that supporters call "open access." Some doctors believe that the "either-or approach”, if it ever made sense, is less valid now that continued advances in medicine can allow even patients with very advanced disease to benefit from new treatments.

19. What does this mean for us?
We review patients on a case-by-case basis
Never say Never
Sometimes TPN
Sometimes chemo
Sometimes radiation
Sometimes dialysis
What is best for the patient? That’s what is best for us.
Hospices must be good stewards when making treatment decisions and use ethical principals when making decisions:
Autonomy
Non-Maleficence
Beneficence
Justice