What are the primary recommendations for a patient with panlobular emphysema being considered for hospice admission?

Hospice Admission Criteria for Panlobular Emphysema

Patients with panlobular emphysema qualify for hospice admission when they have severe disease with disabling dyspnea at rest, documented disease progression (including frequent exacerbations or hospitalizations), and a physician-certified prognosis of less than 6 months. 1

Primary Eligibility Criteria

The following criteria must be present for hospice admission:

• Disabling dyspnea at rest that significantly limits activity and responds poorly to bronchodilators 1, 2
• Physician certification by both the treating physician and hospice medical director that prognosis is terminal (less than 6 months) 1, 2
• Evidence of disease progression including at least one of the following:
  • Two or more exacerbations per year despite adequate treatment 1
  • Previous hospitalizations for exacerbations, especially requiring ICU admission 1
  • Severe airflow obstruction with significant lung function impairment despite optimal treatment 1
  • Hypoxemia at rest or hypercapnia on ambient air 1, 2

Supporting Criteria That Strengthen Eligibility

Additional factors that support hospice admission include:

• Cor pulmonale (right heart failure secondary to pulmonary disease) 1, 2
• Unintentional progressive weight loss greater than 10% over the last 6 months 1, 2
• Resting tachycardia greater than 100 beats per minute 1
• Requirement for long-term oxygen therapy (LTOT) 1
• Rapidly progressive disease course with declining lung function, progressive dyspnea, and decreased exercise tolerance 1
• Increasing emergency department visits or hospitalizations for respiratory infections and/or respiratory failure 1

Admission Process Requirements

For formal hospice enrollment:

• Written patient agreement to use hospice care for terminal illness treatment is required 1, 2
• A "do not resuscitate" order is NOT required for hospice enrollment—this is a common misconception 1, 2
• Patients can be withdrawn from hospice if their condition unexpectedly improves 1, 2

Critical Pitfalls to Avoid

Delayed referral is the most common error. Many physicians are unaware of hospice eligibility criteria for non-cancer patients, leading to late referrals when patients have only hours to days remaining rather than weeks to months. 2 Earlier hospice referral is associated with better outcomes and improved quality of life. 2

Prognostic uncertainty should not be a barrier. While the unpredictable course of advanced lung disease makes 6-month prognosis challenging, the "surprise question" ("Would I be surprised if this patient died in the next 6 months?") can help identify appropriate candidates. 2, 3 Current prognostic criteria have limitations, but clinical judgment combined with the criteria above should guide decision-making. 2

Misconceptions about hospice timing: Hospice is not only for the last hours to days of life—it provides comprehensive symptom management, psychosocial support, and practical assistance that benefits patients and families throughout the terminal phase. 2, 3

Symptom Management Focus in Hospice

Once admitted, palliative interventions should prioritize:

• Dyspnea management with opioids (morphine 2.5-10 mg PO every 2 hours as needed if opioid-naive), oxygen therapy for symptomatic hypoxia, fans, and positioning 4, 5
• Anxiety control with benzodiazepines (lorazepam 0.5-1 mg PO every 4 hours as needed if benzodiazepine-naive) when dyspnea is associated with anxiety 4
• Secretion management with anticholinergics as death approaches 4
• Non-invasive ventilation may be considered for symptom reduction but should not prolong the dying process 4

Open communication about death and preferred place of dying should be part of routine medical consultation with patients who have advanced pulmonary disease. 4 Discussions about advance care planning should occur when reduced respiratory reserve is first identified, not delayed until an acute crisis. 4