When Is It Time to Call Hospice? Signs that it's Time for Hospice Care

What is Hospice Care?

Hospice care is a holistic approach to treatment that focuses on the patient and family which addresses the physical, mental, emotional, and spiritual needs of the patient and family.

At Connecticut Hospice, we understand that it is a highly personal decision to begin receiving hospice care and we value the choices and goals of each patient and family. We are here to help you make the decision of when it's time for hospice care.

What Does the Hospice Benefit Cover?

Medicare Hospice Benefit Eligibility

1. Medicare Part A
2. Physician certified six months or less prognosis if the terminal illness runs its natural course
3. The individual is willing to forgo curative therapy for the terminal illness, elect the hospice benefit, and waive all rights to Medicare payments for the terminal illness and related conditions

Centers for Medicare and Medicaid Services, 2021

Patients are considered to have a life expectancy of six months or less if there is documented decline in clinical status.

• Presumes assessments are done over time
• Baseline and follow up data must be reported
• Other clinical variables that may support this prognosis should also be included

End-of-Life Physical Signs 

• Frequent or recurring infections
• Rapid decline in health despite aggressive medical treatment
• Frequent hospitalizations or emergency room visits
• Uncontrolled pain, nausea, or vomiting
• Increase in the amount of time sleeping
• Loss of urinary or bowel control
• Chest congestion and/or rapid breathing
• Decrease in food and fluid intake; weight loss
• Changes in body temperature (fever or feeling cool to the touch)
• Restlessness or repetitive motions
• Decreasing ability to perform daily tasks without assistance

End-of-Life Mental And Emotional Signs

• Withdrawal from family, friends, and loved ones
• Making statements or requests that seem out of character • Giving away personal belongings
• Making funeral plans
• Experiencing visions or hallucinations
• Making apologies or saying goodbye
• Expressing a desire to no longer seek medical interventions, hospitalizations, treatment

Weight Loss:

The patient is unable to be weighed on scales due to bed-bound status. MAC is 18cm to the right upper arm. During the interview with the daughter, who has been caring for the patient over the past year, she said that her mother has lost weight in the past 3 months but unable to state how much. The daughter states that she has been wearing clothing in a size 16 women’s but now she had to get mother new clothing gradually over the past few months due to her clothing “falling off of her”. The patient is now able to wear size 10 women's clothing.

Loss of Appetite:

The patient has been eating 4-6 child-size meals per day but has only eaten about 25% of each meal. This consists of 2 slices of bacon, 3 bits of grits for breakfast. She had a 1/3 of an Ensure supplement, then for lunch, she had a few bites of homemade soup and a popsicle.

Decline in Functional Status:

The patient requires assistance of one for bathing at the sink, dressing his lower body and now uses a walker for all ambulation inside and outside of his room. The patient was completely independent with all ADL’s and driving and working every day until 3 months ago when he was diagnosed.

Sleeping:

The Nurses Aide describes the patient is sleeping 8-10 hours at night and then takes a 3-4 hour nap during the day. When the patient is up in the chair for more than an hour, she is frequently dosing off. This is a change from just 2 months ago when the patient was not even sleeping during the night and was having agitation in the evening and sleeping a few hours during the day only

Patient is Unresponsive to Therapies:

• Pain requiring increasing doses of analgesics
• Persistent nausea despite multiple drug (Compazine, Phenergan, Zofran, Reglan)or non-pharmacological interventions (diet, aromatherapy)
• Dyspnea and persistent cough with increasing respiratory rate
• Diarrhea

Progressive Weight Loss:

• Weight loss of at least 10% of body weight in the previous 6 months (not related to reversible causes; diuretic, depression)
• Decreasing anthropogenic measures (mid-arm circumference, abdominal girth)
• Observation of ill-fitting clothes, decreased skin turgor, increasing skin folds
• Other observation to demonstrate loss of weight in a patient that can not be weighed on a scale

Dysphagia

• Coughing or choking when eating or drinking, persistent drooling of saliva, pocketing of food; being unable to chew food properly, a gurgly, wet-sounding voice when eating or drinking.
• Leading to recurrent aspiration and/or inadequate oral intake ØDocumented decrease in food portion consumption
• Documented decrease in food portion consumption 

Decline in Clinical Status

• Decline in systolic BP to < 90 or progressive postural hypotension
• Ascites
• Venous, arterial, lymphatic obstruction due to metastatic disease
• Edema
• Pleural or Pericardial effusion 
• Weakness
• Change in level of consciousness

Laboratory Values

• Increasing or Decreasing pCO2
• Decreasing SaO2
• Increasing calcium, creatinine, or liver function test ØIncreasing tumor markers
• Progressively decreasing or increasing serum potassium or sodium

Decline in Clinical Status Guidelines

• Decrease in Karnofsky and Palliative performance Score due to disease progression
• Progressive decline in Functional Assessment Staging Test (FAST) for dementia to 7A or greater
• Progression to dependence on assistance with ADLs
• Progressive stage 3-4 pressure ulcers despite optima care
• Increasing ER visits, hospitalizations, or physician visits related to the terminal illness before election of the hospice benefit.

Dependence on assistance for two or more of the following ADLS

• Ambulation 
• Continence 
• Transfer 
• Dressing 
• Feeding 
• Bathing

Comorbidities

• Chronic Obstructive Pulmonary Disease (COPD)
• Congestive Heart Failure (CHF)
• Ischemic Heart Disease
• Diabetes Mellitus (DM)
• Neurologic Disease (Parkinson, ALS, MS, CVA)
• Renal Failure
• Liver disease
• Neoplasia
• AIDS/HIV
• Dementia
• Refractory Autoimmune disease (Lupus or Rheumatoid Arthritis)