Hospice EligibilityHospice Eligibility

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

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.

Dementia

Stage 7 or higher on the FAST scale– 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.

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

DebilityA study published in American Journal of Hospice and Palliative Medicine

Vol. 13, No. 6, 38-44 (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.

Failure to ThriveHospice 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

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

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

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

Medicare Benefit Policy ManualChapter 11- End Stage Renal Disease

50.6.1.4 Coverage under the Hospice Benefit– (Rev 1.10-01-03)

“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.”

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.

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 $115-120 per day– Statistically hospice patients withdraw from dialysis

within 2 weeks

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

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

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

“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.

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.

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