What are the criteria for hospice care?

Criteria for Hospice Care

The primary criterion for hospice eligibility is a physician's determination that the patient has a life expectancy of 6 months or less if the illness follows its expected course. 1, 2, 3

General Eligibility Requirements

Hospice care is designed for patients at the end of life and requires:

1. Terminal prognosis: Physician certification of life expectancy ≤6 months 1
2. Patient agreement: Patient must agree to forego insurance coverage for treatments aimed at curing their terminal illness 1
3. Focus on comfort: Care shifts to symptom management and quality of life rather than curative treatment 2

Disease-Specific Criteria

For Advanced Lung Disease 1

Patients must meet criteria 1 and 2, with criteria 3-5 providing supporting documentation:

1. Severe chronic lung disease with:

   • Disabling dyspnea at rest, poorly responsive to bronchodilators
   • Decreased functional capacity (bed-to-chair existence)
   • FEV1 <30% of predicted (documentation helpful but not required)

2. Hypoxemia with either:

   • PO2 ≤55 mm Hg on room air, OR
   • O2 saturation ≤88% on supplemental oxygen, OR
   • Hypercapnia with PCO2 >50 mm Hg

3. Right heart failure (cor pulmonale) secondary to pulmonary disease

4. Unintentional weight loss >10% over preceding 6 months

5. Resting tachycardia >100/minute

For Heart Failure 1

While specific criteria aren't fully detailed in the evidence, patients with end-stage heart failure may qualify when:

• Symptoms persist at rest despite maximal medical management
• Multiple hospitalizations for heart failure exacerbations
• Poor functional status with limited activity

For Other Conditions

Disease-specific criteria exist for various conditions but generally follow similar patterns of demonstrating end-stage disease with poor prognosis 1.

"Common Sense" Criteria 1

Additional considerations for hospice referral include:

• Despite optimal treatment, disease has progressed to where the patient may die from any common intercurrent illness
• Severely distressing symptoms or limited performance status that can be best managed by hospice
• Patient acceptance that death is near and desire to avoid needless prolongation of suffering

Important Considerations

• Accuracy challenges: Studies show that prognostic criteria often overestimate mortality, with many patients living longer than 6 months 4
• No DNR requirement: Patients do not need a "do not attempt resuscitation" order to enroll in hospice 1
• Continued eligibility: If a patient survives beyond 6 months, Medicare and other insurers will continue coverage if they still meet criteria 1
• Early referral benefits: Evidence suggests that earlier hospice referral (80-90 days before death) provides optimal support for patients and families 1
• Survival benefit: Some studies indicate hospice care may actually extend survival by approximately 29 days, particularly for certain conditions including lung cancer 1

Screening for Hospice Appropriateness 1

The NCCN recommends screening all patients at every visit for:

• Unmanaged symptoms
• Moderate to severe distress related to diagnosis and therapy
• Serious comorbid conditions
• Life expectancy ≤6 months
• Metastatic solid tumors
• Patient/family concerns about disease course and decision-making
• Patient/family requests for palliative care

Common Pitfalls

• Late referrals: Nearly 30% of hospice patients enroll in the last week of life, limiting benefits 1
• Misperception of "giving up": Both physicians and patients may incorrectly view hospice as "giving up" or "hastening death" 1
• Prognostic uncertainty: Physicians often overestimate survival time, delaying appropriate hospice referrals 1, 4
• Disease-specific barriers: Non-cancer conditions like COPD, heart failure, and neurological diseases have less predictable trajectories, making 6-month prognosis difficult 1, 4

By understanding these criteria and addressing common barriers to hospice referral, physicians can help ensure patients receive appropriate end-of-life care that prioritizes quality of life, symptom management, and support for both patients and families.