What are the recommendations for managing patients who require hospitalization while on hospice care?

Managing Patients Who Require Hospitalization While on Hospice Care

Patients on hospice care who require hospitalization should be managed with a coordinated approach that prioritizes their goals of care, with continued hospice involvement during the hospital stay to maintain continuity and ensure alignment with the patient's end-of-life preferences. 1

Understanding Hospice Care in the Hospital Setting

Hospice is a specialized model of end-of-life palliative care for patients with a prognosis of less than 6 months, covered by Medicare and other third-party payers 1. When a hospice patient requires hospitalization, several key considerations must be addressed:

Key Principles for Managing Hospitalized Hospice Patients

1. Maintain Goals of Care

   • Review the patient's advance directives and hospice care plan immediately upon admission
   • Document code status and treatment limitations clearly in hospital records
   • Ensure hospital staff understand the patient remains on hospice services

2. Coordination Between Teams

   • Establish immediate communication between hospital staff and hospice team
   • Determine who will be the primary decision-maker during hospitalization
   • Schedule regular updates between hospice and hospital teams

3. Symptom Management Priorities

   • Focus on aggressive symptom control rather than disease-modifying treatments
   • Prioritize comfort measures over diagnostic testing when appropriate
   • Continue hospice medication regimens when possible to maintain symptom control

Clinical Decision Algorithm for Hospitalized Hospice Patients

Step 1: Assess Reason for Hospitalization

• Symptom crisis (pain, dyspnea, agitation) requiring intensive management
• Caregiver breakdown requiring respite
• Acute event (fall, fracture) requiring specific intervention
• Family request despite hospice recommendation

Step 2: Determine Appropriate Level of Intervention

• Review hospice enrollment documentation for previously established limits
• Consult with hospice medical director regarding appropriate interventions
• Avoid unnecessary diagnostic testing that won't change management approach

Step 3: Implement Hospital-Based Care Plan

• For symptom management:

  • Initiate aggressive symptom control measures
  • Consider palliative sedation for refractory symptoms if aligned with goals

• For acute events:

  • Provide targeted interventions that improve comfort
  • Avoid interventions solely aimed at prolonging life

Step 4: Plan for Discharge

• Coordinate early with hospice team for transition back to home or facility
• Ensure continuity of medication regimens between settings
• Address any new care needs identified during hospitalization

Special Considerations

Heart Failure Patients on Hospice

For heart failure patients on hospice who require hospitalization, the American College of Cardiology Foundation/American Heart Association guidelines recommend:

• Assessment of volume status and adjustment of heart failure therapy as appropriate
• Management of comorbid conditions
• Reinforcement of heart failure education and self-care 1

Avoiding Common Pitfalls

1. Discontinuing hospice enrollment unnecessarily

   • Many acute symptoms can be managed while maintaining hospice status
   • Temporary revocation of hospice should be a last resort

2. Excessive diagnostic testing

   • Limit tests to those that will directly impact comfort-focused management
   • Avoid routine labs and imaging that won't change the care approach

3. Communication breakdowns

   • Designate a specific hospital provider to liaise with hospice team
   • Document all discussions about goals of care prominently in the chart

4. Medication disruptions

   • Be aware that many hospice patients may miss critical medications during hospitalization
   • Studies show that even antidepressants are often disrupted in the final days 2

Impact of Hospice Care on Hospitalizations

Research demonstrates that hospice enrollment reduces hospitalization risk and healthcare costs at the end of life. A matched cohort study of 86,851 patients with cancer showed hospice care was associated with significantly lower hospitalization rates, fewer ICU admissions, and fewer invasive procedures 1.

Additionally, nursing facilities with higher hospice penetration show reduced hospitalization risk for both hospice and non-hospice residents, suggesting broader benefits of hospice presence 3.

Conclusion for Clinical Practice

When managing hospitalized hospice patients, the primary focus should remain on comfort and quality of life rather than extending life at all costs. Early and frequent communication between hospice and hospital teams is essential to maintain continuity of care and respect the patient's established goals.