Diagnostic Criteria for Admitting COPD Patients to Hospice Care
Patients with COPD qualify for hospice care when they have severe chronic lung disease with disabling dyspnea at rest, evidence of disease progression, and a prognosis of less than 6 months to live as determined by both the treating physician and hospice medical director. 1
Primary Criteria for Hospice Eligibility in COPD
- Patients must have severe COPD with disabling dyspnea at rest that significantly limits activity and is poorly responsive to bronchodilators 2, 1
- Evidence of disease progression must be present, including at least one of the following:
- Frequent exacerbations (two or more per year) despite adequate treatment 2
- Previous hospitalizations for COPD exacerbations, especially those requiring ICU admission 2
- Severe airflow obstruction with FEV1 < 30% predicted despite optimal treatment 2
- Hypoxemia at rest (PaO2 ≤ 55 mmHg or SaO2 ≤ 88%) on ambient air or hypercapnia 2, 1
- Requirement for long-term oxygen therapy (LTOT) 2
Supporting Criteria
- Right heart failure secondary to pulmonary disease (cor pulmonale) 1
- Unintentional progressive weight loss (>10% over last 6 months) 2, 1
- Resting tachycardia >100 beats/min 1
- Rapidly progressive course of disease with decline in FEV1, progressive dyspnea, and decreased exercise tolerance 2
- Need for increasing visits to the emergency department or hospitalizations for respiratory infections and/or respiratory failure 2
"Common Sense" Criteria
Even when specific physiological criteria aren't met, consider hospice referral when:
- Despite optimal treatment, COPD has progressed to the point that the patient may die at any time due to a common intercurrent illness such as bronchitis 2
- The patient has severely distressing symptoms or limited performance status that can be most humanely managed by hospice care 2
- The patient accepts that death is near and wants to avoid needless prolongation of suffering 2
Challenges in Prognostication
- Unlike cancer, COPD has an unpredictable illness trajectory making 6-month prognosis difficult to determine 2, 3
- The BODE index (Body mass index, airflow Obstruction, Dyspnea, and Exercise capacity) provides prognostic information over 12-52 months but has not been validated for determining 6-month mortality needed to qualify for hospice care 2
- Current prognostic criteria for non-cancer illnesses have limitations in accurately predicting 6-month mortality 1, 3
- Many patients with COPD may have a fatal exacerbation within a short time of having fairly good function, so waiting until death is nearly certain may result in missed opportunities for hospice care 2
Process for Hospice Referral
- Certification that the patient's prognosis is terminal (less than 6 months) must be determined by both the treating physician and hospice medical director 1
- Patients must agree in writing that hospice care will be used to treat their terminal illness 1
- A "do not attempt resuscitation" order is not required for enrollment in hospice programs 2, 1
- Patients can be withdrawn from hospice if their condition unexpectedly improves 2
Common Pitfalls to Avoid
- Delaying hospice referral due to prognostic uncertainty - this is a common barrier that deprives patients of valuable palliative services 2, 1
- Waiting for patients to be imminently dying before considering hospice - earlier referral is associated with better outcomes 1, 4
- Focusing exclusively on lung function measurements without considering overall disease burden, symptom severity, and quality of life 3, 5
- Lack of communication about end-of-life care options - pulmonary rehabilitation provides an important opportunity to assist with advance care planning 2, 6
- Assuming that hospice is only for cancer patients - COPD patients have comparable symptom burden and impact on activities of daily living 5, 7
By using these criteria and avoiding common pitfalls, healthcare providers can better identify COPD patients who would benefit from hospice services, improving quality of life in their final months.