Pearl 2: How Do I Know a Patient is a Good Candidate to Receive Hospice Support?

A patient should meet two criteria to be a good candidate for receiving hospice support.

1.  Does the patient meet medical eligibility criteria for receiving hospice support? 

Are you as the clinician able to make the statement, "I would not be surprised if this patient were to die within the next year if their overall health condition or disease were to follow their natural course"?

This could be, for example,

-  the patient with worsening dementia, who is now no longer walking and perhaps pocketing food in their mouth instead of swallowing

-  the patient with chronic kidney disease stage 5, who is now symptomatic with confusion, chest pain, and nausea

-  the patient with metastatic colon cancer, who has been admitted twice recently for dehydration and difficulty walking due to severe lymphedema while undergoing third line cancer therapy

-  the patient with previously compensated cirrhosis, who is now requiring recurrent hospitalizations for encephalopathy, bloody emesis, and severe abdominal distention requiring paracentesis every couple weeks

For many of our frail patients - regardless if the underlying disease is advanced cancer, advanced congestive heart failure, severe lung issues, severe cirrhosis, end stage kidney failure, or end stage dementia - allowing their health condition to follow their natural course would likely result in a prognosis of months rather than years. Allowing disease and/or underlying health conditions to follow their natural course refers to no more hospitalizations, IV medications, nor ICU level of breathing support. 

These patients would likely meet medical eligibility criteria to receive hospice support.

Sometimes, a patient who is still early in their devastating diagnosis, such as stage 4 pancreatic cancer, may still have strength and energy to perform day to day activities such as drive to the grocery store or take a shower on their own without help.  Because of the “terminal” nature of the disease itself - where average prognosis would be months if we were to allow the disease to follow their natural course - these patients, who may not yet be frail, would also meet medical eligibility criteria for receiving hospice support.

2.  Are the patient’s goals and values in line with that of the hospice philosophy (that is, focusing on comfort and quality of life with home level of care)?

Many patients meet criteria #1, but do not meet criteria #2 because they are not emotionally nor mentally ready to let go of clinic visits, disease treatments, ER visits, nor hospitalizations with hospital level of care, including diagnostics (such as X-rays, labs, EKGs), IV medications such as IV antibiotics, and as needed ICU level of breathing support and “life support” medications such as pressor support (vasopressors).

It requires a huge mindset shift, often related to significant change in quality of life and disappearing ability to independently perform day-to-day activities we often take for granted such as being able to use the toilet on our own or rinse the shampoo out of our hair without a family member hovering a foot away, to transition from saying

“If I have chest pain, I want to go to the ER to find out what’s happening!  I want the EKG, the labs, the chest CT, the xray, the EGD - whatever is necessary to figure out what’s causing this symptom!”

to

“If I have chest pain, I'm at a point where going to the hospital would be a much bigger burden than benefit.  I wouldn’t need to know what’s going on. Just get rid of the chest pain as fast as possible – with ‘home level of medical support' such as breathing treatments, oral antibiotics, oral steroids, reflux medication, nitroglycerin, morphine, oxygen, whatever you think would help! - and keep me comfortable in my own home, where I can feel secure and at ease.”

Sometimes, we as clinicians have to meet a patient (and family) where they are at, meaning we may have to support them in their endeavors to “get stronger” even when we know they will likely not “get stronger.”

The best we may be able to do at that time in their serious illness journey is inform them that if/when they are ready, they can change their healthcare priorities towards comfort and relief of symptoms, rather than treating the disease or attempting to prolong life with recurrent hospitalizations. Any any time from home, they can call local hospice agencies to “interview” (that is, request an evaluation to receive hospice support), even without a referral. They do have to feel "trapped" following the same medical path if that path is no longer in line with their values.

I hope understanding these two criteria will make it easier to

a)      identify declining patients who may benefit from hospice medical support and

b)      introduce to patients hospice support as a potential medical treatment path.