What are the criteria for determining hospice eligibility in patients with terminal illnesses?

Criteria for Determining Hospice Eligibility in Terminal Illnesses

Hospice eligibility primarily requires certification that a patient has a terminal prognosis with life expectancy of less than 6 months, though patients can remain in hospice beyond this timeframe if they continue to meet eligibility criteria. 1

General Eligibility Requirements

Medicare/Medicaid Requirements

• A treating physician and hospice medical director must certify the patient's prognosis is terminal—defined as more likely than not having less than 6 months to live 1
• Patient must agree in writing that hospice care (not curative treatments) will be used to treat their terminal illness 1
• Patient does NOT need a "do not attempt resuscitation" order to enroll in hospice 1

Clinical Indicators of Terminal Prognosis

1. Disease Progression

   • Evidence of progressive decline despite optimal medical treatment
   • Increasing symptom burden
   • Declining functional status
   • Weight loss and nutritional decline

2. Functional Assessment

   • Declining performance status (e.g., using BODE index for COPD patients, though this has limitations for 6-month prognosis) 1
   • Increasing dependence in activities of daily living
   • Reduced mobility and increasing time spent in bed/chair

Disease-Specific Criteria

The National Hospice Foundation published criteria for non-cancer conditions that Medicare and other insurers have incorporated into their enrollment requirements 1. However, research shows these criteria don't accurately predict 6-month mortality 2.

For Advanced Lung Disease

• Severe airflow obstruction
• Oxygen dependence
• Multiple hospitalizations for respiratory exacerbations
• Right heart failure secondary to pulmonary disease
• Unintentional weight loss >10%
• Resting tachycardia

For Heart Failure

• NYHA Class IV symptoms despite optimal treatment
• Ejection fraction <20%
• Multiple hospitalizations for heart failure
• Resistant dysrhythmias or syncope
• History of cardiac arrest or resuscitation
• Embolic complications

For End-Stage Liver Disease

• Advanced cirrhosis with complications (ascites, encephalopathy, variceal bleeding)
• Ineligibility for liver transplantation
• Hepatorenal syndrome
• Progressive malnutrition and muscle wasting 3

For Dementia

• Inability to ambulate, dress, or bathe independently
• Urinary and fecal incontinence
• Minimal verbal communication
• Recent aspiration pneumonia, pyelonephritis, or pressure ulcers 4

"Common Sense" Criteria

When disease-specific criteria are unclear, these additional considerations may help determine hospice appropriateness 1:

1. Despite optimal treatment, disease has progressed to where patient may die from any common intercurrent illness
2. Patient has severely distressing symptoms or limited performance status best managed by hospice care
3. Patient accepts that death is near and wants to avoid needless prolongation of suffering

Important Considerations and Pitfalls

Challenges in Prognosis

• Non-cancer conditions have less predictable trajectories than cancer 5
• Research shows current criteria have limited accuracy in identifying patients with ≤6 months to live 2
• Patients with dementia or debility are more likely to remain in hospice beyond 6 months 6

Common Barriers to Hospice Referral

• Difficulty determining prognosis in non-cancer conditions 1
• Physician discomfort discussing end-of-life care 1
• Lack of awareness about hospice availability for non-cancer patients 1
• Uncertainty about eligibility criteria for non-cancer patients 1

Important Notes

• If patients survive beyond 6 months, Medicare will continue coverage if they still meet eligibility criteria 1
• Patients can be withdrawn from hospice if their condition unexpectedly improves 1
• Hospice care can be provided in multiple settings (home, facility, inpatient) 1
• Respite care is available to support family caregivers 1

Decision Algorithm for Hospice Referral

1. Assess if patient has a terminal condition with prognosis ≤6 months
2. Apply disease-specific criteria when available
3. Consider "common sense" criteria when disease-specific criteria are unclear
4. Discuss goals of care with patient/family
5. If appropriate, obtain certification from treating physician and hospice medical director
6. Have patient agree in writing to hospice care approach

Remember that while the 6-month prognosis is required for initial eligibility, patients can remain in hospice beyond this timeframe if they continue to meet criteria for terminal illness.