The end-of-life experience can be peaceful and a patient can pass with dignity when provided with appropriate intervention. Hospice staff provide expert care and guidance during this time with:
- Dedicated Hospice Physician Services
- High-Acuity Skilled Nursing Care
- Certified Nurses Aides
- Social Work Services
- Spiritual Counseling
- Durable Medical Equipment
- Medications and Pharmacy Services
- Medical Supplies
Hospice Levels of Care:
Routine Home Care is the primary level of care under the hospice benefit. If a patient resides in a nursing home, it can also be called routine nursing home care and includes:
- Skilled nursing services
- Physician oversight
- Social services
- Certified nurse aide services
- Counseling services, including pastoral, spiritual, bereavement, dietary, and others
- Medications
- Medical equipment
- Medical supplies
- Personal care supplies
- Lab and diagnostic studies related to terminal diagnosis
- Therapy services when deemed palliative and medically necessary
If you have Continuous Home Care, a nurse and/or a home health aide will remain in the patient’s home environment for eight to 24 hours per day. Continuous care is a short-term level of care, and must be reevaluated every 24 hours by a registered nurse.
Qualifying Symptoms for Continuous Home Care
- Unrelieved pain
- Intractable, severe nausea and vomiting
- Severe shortness of breath
- A temporary breakdown in the primary caregiver support system
Some patients have short-term symptoms so severe they cannot get adequate treatment at home, and require treatment at an inpatient facility.
Symptoms requiring inpatient care are the same as those requiring continuous care, only the setting of care may be different. With inpatient care, nurses are available around the clock to administer medications, treatments, and emotional support to help make the patient more comfortable.
Inpatient Facilities
There are several types of facilities that offer inpatient hospice services:
- A free-standing facility owned and operated by a hospice company
- An inpatient hospice unit within a hospital
- A hospice unit in a skilled nursing facility, such as a nursing home
Respite care services are more for the family than for the patient.
If a patient’s family is the primary source of care and cannot meet their loved one’s needs due to caregiver stress or other extenuating circumstances, a patient may temporarily be admitted to an inpatient environment to give the family a needed break or respite.
Most insurance covers five days in respite care. Once that period expires, the patient is discharged and returns home.
Hospice Eligibility:
Determining a primary hospice diagnosis can be challenging when a patient has some, but not all, of the clinical indicators of a specific disease or condition. The following clinical signs often support hospice eligibility in combination with another primary diagnosis.
- Rapid decline over the past three to six months, evidenced by:
- Rapid progression of disease
- Progressive decline in Palliative Performance Score (PPS)
- Weight loss not due to reversible causes and/or declining serum albumin levels
- Dependence on assistance for two or more ADLs: feeding, ambulation, continence, transfer, bathing or dressing
- Dysphagia leading to inadequate nutritional intake or recurrent aspiration
- Decline in systolic blood pressure to below 90 systolic or progressive postural hypotension
- Increasing ER visits, hospitalizations or physician follow-up
- Multiple progressive Stage 3 or Stage 4 pressure ulcers in spite of optimal care
- Frequent falls or increasing problems with balance and weakness
- Increased lethargy/sleepiness
- Uncontrolled pain, shortness of breath, nausea/vomiting, anxiety
- Multiple, recurrent infections
- Patient appears to be “giving up” physically and emotionally
- Must have established AIDS or HIV diagnosis
- Decision has been made to forego antiretroviral, antibacterial, antifungal, chemotherapeutic and prophylactic drug therapy related specifically to the AIDS diagnosis.
- Chronic, persistent diarrhea
- Significant weight loss of 10% or more in the past three months
- Generalized weakness
- Viral load > 100,000 copies/ml
- CD4 count < 25
- History of frequent opportunistic infections
- Palliative Performance Indicator Score of 50% or less
- CHF at rest
- AIDS dementia complex
- Toxoplasmosis
- Generalized wasting
- Substance Abuse
In order for a dementia patient to meet the hospice eligibility criteria, he or she must have a life expectancy of six months or less if the disease continues in its typical progression. For patients with dementia, it may be time to consider hospice when the patient’s physical condition begins to decline. Some things to look for include:
- A diagnosis of other conditions as COPD, CHF, cancer or congenital heart disease
- An increase in hospitalizations, frequent visits to the doctor and/or trips to the ER
- A diagnosis of pneumonia or sepsis
- Weight loss or dehydration due to challenges in eating/ drinking
Additional criteria lend additional support to terminal status:
- Incontinence
- Inability to communicate meaningfully (1 to 5 words a day)
- Non-ambulatory (unable to ambulate and bear weight)
- All intelligible vocabulary lost
- Unable to sit up independently
- Unable to smile
- Unable to hold head up
- Pathology report reveals evidence of malignancy or metastases
- Decline in condition in spite of therapy, or patient opts out of further disease-directed therapy
- Palliative Performance Score or Karnofsky Score of 70% or less
- Electing to forgo further disease directed curative treatment
- Certain cancer diagnoses are often eligible for hospice without other criteria including small cell lung cancer, pancreatic cancer, and primary CNS malignancy
- Palliative Performance Score or Karnofsky Score of 40% or less
- Mainly bed to chair bound
- Impaired functional status
- Requires assistance with activities of daily living (ADLs)
- Changes in orientation status
- Unable to maintain sufficient fluid and caloric intake
- Progressive weight loss, the patient’s doctor, and often a hospice doctor as well, must determine that the patient is terminally ill, with a life expectancy of six months or less; the decision to treat someone at a higher level of care falls to the hospice physician
- Identification of specific structural/functional impairments
- Ejection fraction <20% (not required, but an important consideration)
- A poor response to diuretics and vasodilators
- Dyspnea, tightness or pain in the chest
- Impaired heart rhythms, contraction force of ventricular muscles and impaired blood supply to the heart
- Changes in appetite, unintentional weight loss
- Impaired sleep functions
- Decline in general physical endurance
- Relevant activity limitations and/or impaired mobility
- Weakness and compromised ability to perform activities of daily living (ADLs)
- Recurrent variceal hemorrhage
- Hepatic encephalopathy
- Prothrombin time prolonged more than five seconds over control or INR > 1.5
- Serum albumin < 2.5 gm/dl
- Peritonitis
- Elevated creatinine and BUN with Oliguria <400 ml/day and urine sodium concentration <10 mEq/l
- Ascites
- Malnutrition
- Muscle wasting
- Asterixis
- May be awaiting liver transplant, but if organ is procured, the patient is no longer eligible
- Creatinine clearance of <10cc/min (<15cc/min for diabetics) AND serum creatinine >8.0 mg/dl (>6.0 mg/dl for diabetics)
- Uremia with obtundation
- Nausea/vomiting
- Patient has chosen not to have renal dialysis
- Intractable hyperkalemia
- Hepatorenal syndrome
- Structural and functional impairments
- Platelet count <25,000
- Comorbid and secondary conditions contribute to terminal prognosis
- Pruritus
- Self-care deficits
- Activity limitations
- Uremic pericarditis
- Anorexia
- Albumin <3.5 gm/dl
- Recent visits to the ER or hospitalization for pulmonary infections or respiratory failure
- Dyspnea or tightness in the chest (FEV1 <30% of predicted)
- Identification of specific structural/functional impairments
- Relevant activity limitations
- Changes in appetite and unintentional progressive weight loss
- Impaired sleep functions
- Decline in general physical endurance
- Impaired mobility
- Requires oxygen some or all of the time
- May require breathing treatments or use of inhalers
- May have difficult eating or carrying on conversations without supplemental oxygen
- Structural/functional impairments
- Impaired mental function
- Impaired sensory function and pain
- Impaired neuromusculoskeletal and movement functions
- Impaired communication
- Impaired mobility
- Self-care deficit
- Activity limitations
Comorbid and secondary conditions also contribute to a terminal prognosis.
Eligibility and Determining Level of Care
In order to qualify for hospice care, the patient’s doctor, and often a hospice doctor as well, must determine that the patient is terminally ill, with a life expectancy of six months or less; the decision to treat someone at a higher level of care falls to the hospice physician.
Additional Services
Our hospice aides provide bathing, and personal care on an intermittent basis. Their visit frequency is determined by the Registered Nurse in accordance with patient need and medicare guidelines. Hospice aide visits generally last 45 minutes to an hour, with a care plan developed by the Registered Nurse. Often, a patient’s needs exceed the family’s ability to manage and fall beyond the scope of hospice services. In these instances, a family may decide to seek additional care in the form of Personal Assistance Services. While Pathway Hospice also maintains a license to provide PAS in the State of Texas, we think it is important to focus on what we do best. To better serve our patients and families, we partner with several excellent PAS agencies and can provide information upon request.
