Criteria for Progressive Decline to Qualify for Hospice Care
The primary criterion for hospice eligibility is certification that the patient has a terminal prognosis with a life expectancy of 6 months or less, as determined by both the treating physician and hospice medical director. 1, 2
General Eligibility Requirements
- Medicare, Medicaid, and most insurers require certification that the patient's prognosis is terminal—meaning more likely than not to have less than 6 months of life remaining 1
- Patients must agree in writing that hospice care (not other Medicare services like curative care) will be used to treat their terminal illness 1, 2
- Patients do not need a "do not attempt resuscitation" order to be enrolled in hospice programs 1, 2
- Patients can be withdrawn from hospice programs if their condition unexpectedly improves 1
Disease-Specific Progressive Decline Criteria
For Advanced Lung Disease
Patients with advanced lung disease qualify for hospice if they meet the following criteria:
Severe chronic lung disease as documented by both:
- Disabling dyspnea at rest, poorly responsive to bronchodilators, resulting in decreased functional capacity (bed-to-chair existence), fatigue, and cough 1
- Evidence of disease progression through increasing emergency department visits, hospitalizations for pulmonary infections/respiratory failure, or increasing physician home visits 1
Hypoxemia at rest on ambient air (PO₂ ≤55 mm Hg or oxygen saturation ≤88%) OR hypercapnia (PCO₂ >50 mm Hg) 1
Supporting criteria include:
For Non-Cancer Diagnoses
For patients with non-cancer diagnoses (e.g., COPD, heart failure, dementia), additional "common sense" criteria include:
- Despite optimal treatment, the chronic disease has progressed to where the patient may die at any time due to common intercurrent illness 1
- Severely distressing symptoms or limited performance status that can be most humanely managed by hospice care 1
- Patient acceptance that death is near and desire to avoid needless prolongation of suffering 1
Challenges in Prognostication
- Current prognostic criteria for non-cancer illnesses have limitations in accurately predicting 6-month mortality 3, 4
- The BODE index (body mass index, airflow obstruction, dyspnea, exercise capacity) provides prognostic information for COPD but has not been validated for determining 6-month mortality 1
- Studies show that recommended clinical prediction criteria for serious non-cancer illnesses (COPD, heart failure, liver disease) are not effective in identifying a population with a survival prognosis of 6 months or less 4
Alternative Assessment Approaches
- The "surprise question" ("Would you be surprised if the patient dies within a defined short time interval?") can help identify patients who would benefit from palliative care measures 1
- Consider functional decline, increasing symptom burden, and increasing healthcare utilization as indicators of progressive decline 3, 5
- For patients with chronic illness, consider one of three typical end-of-life trajectories:
Common Pitfalls and Caveats
- Many physicians are unaware of hospice eligibility criteria for non-cancer patients, leading to delayed referrals 1, 2
- Prognostic uncertainty often serves as a barrier to timely hospice referral 3
- Physicians may be reluctant to discuss hospice due to lack of skill in communicating that death is near 1
- There is a misconception that hospice is only for the last hours to days of life, when earlier referral is associated with better outcomes 2
- Patients with non-cancer diagnoses often receive less timely referrals to hospice despite potential benefits 2
Remember that the physician who certifies hospice eligibility does not "guarantee" death within 6 months, and Medicare will continue to reimburse for extended periods if patients still meet enrollment criteria 1.