Overview: Discussion about the decision to plan for hospice care is an opportunity to have significant conversations about end-of-life care with patients and families. In addition to determining physical readiness or appropriateness for hospice care, conversations about goals and wishes for care can facilitate the process of maximizing the quality of remaining life.
Target Audience: Nurses and nurse practitioners in a geriatric setting.
Determining readiness for hospice care for a patient who is approaching the end stage of a chronic illness can be challenging. A specific question to ask the physician is, “Would you be surprised if the patient died in the next six months to a year?” Medicare offers specific guidelines for eligibility for the hospice benefit for common chronic illnesses such as end stage heart disease, Chronic Obstructive Pulmonary Disease (COPD),
renal disease, and dementia. In addition, two criteria (debility unspecified and adult failure to thrive) may be viable options when a patient is declining but does not meet disease specific criteria. Your local hospice can share the guidelines with you. Below are a few criteria on the adult failure to thrive to be eligible for the Medicare Hospice Benefit.
- Body Mass Index (BMI) below 22 kg/m2.
- Either declining enteral/parenteral nutritional support or has not responded to such nutritional support.
- Significant disability as defined by a Karnofsky or PPS value less than or equal to 40%.
As the patient’s condition changes and it becomes more likely that life expectancy is limited, conversations can begin about the plan for end-of-life care. These conversations or advance care planning should include the following:
- Specific discussions about the pros and cons of treatment options based on the likely progression of the patient’s chronic illness.
- Identify and address fears and concerns regarding end-of-life care. Remember that many older adults may have had past experiences that lead to present fears such as dying in pain or being overwhelmed with symptoms.
- Help establish priorities. “At this point, given your medical condition, how can we help you to live well?”
- Explore wishes for comfort or palliative care.
- Determine readiness for a hospice referral.
Once the determination has been made to move forward with the hospice referral, the following steps will help all concerned to work together:
- Participate in the hospice admissions conference.
- Clarify roles so that all concerned join together as an expert team.
- Collaborate to develop a plan of care that is centered on the patient/family goals and excellent palliative symptom management.
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Sharon Dixon, MPH, RN
Vice President for Clinical Care
Hospice of Charlotte
Mary Jo Dagney, RN,C
St. Joseph Villa