What are the criteria for a hospice diagnosis in a patient refusing treatment for sepsis?

Hospice Eligibility for Patients Refusing Sepsis Treatment

A patient refusing treatment for sepsis can qualify for hospice if a physician and hospice medical director certify that the patient's prognosis is terminal (more likely than not to have less than 6 months to live), and the patient agrees in writing to receive only hospice care rather than curative treatment for their terminal illness. 1

Core Eligibility Requirements

The fundamental criteria for hospice enrollment apply regardless of the underlying diagnosis:

• Prognostic certification: Both the treating physician and hospice medical director must certify that the patient has a terminal prognosis—defined as more likely than not having less than 6 months of life remaining 1, 2
• Patient agreement: The patient must agree in writing that only hospice care (not curative Medicare services) will be used to treat their terminal illness 1
• No resuscitation requirement: Patients do NOT need a "do not attempt resuscitation" order to enroll in hospice—this is a common misconception and it is actually illegal under the Patient Self-Determination Act for Medicare-funded hospice programs to exclude patients who don't agree to forgo CPR 1

Sepsis as a Terminal Condition

When a patient refuses treatment for sepsis, the clinical trajectory becomes critical for hospice eligibility:

• Untreated sepsis progression: Sepsis represents a life-threatening organ dysfunction caused by an unregulated host response to infection 3. Without treatment, severe sepsis and septic shock are often fatal 4
• Rapid deterioration: Sepsis can become self-perpetuating if not treated early, particularly in elderly persons who are at greater risk of death 4
• Mortality risk: Septicemia and sepsis are leading causes of death, and despite aggressive treatment, they are often fatal 5

Documentation and Assessment

For a patient refusing sepsis treatment to qualify for hospice:

• Establish terminal prognosis: The physician must document that without treatment, the patient's sepsis will likely result in death within 6 months 1, 2
• Verify informed refusal: Ensure the patient (or surrogate decision-maker) understands the consequences of refusing treatment and that this decision is consistent with their goals of care 1
• Goals of care discussion: The Surviving Sepsis Campaign recommends discussing goals of care and prognosis with patients and families, incorporating these into treatment and end-of-life care planning using palliative care principles 1
• Timing: Goals of care should be addressed as early as feasible, but no later than within 72 hours of ICU admission 1

Important Considerations

Prognostic certainty: The physician certifying hospice eligibility does not "guarantee" death within 6 months—if the patient survives beyond 6 months, Medicare and other reimbursement organizations will continue coverage if enrollment criteria are still met 1

Reversibility: Patients can be withdrawn from hospice programs if their condition unexpectedly improves (for example, if they change their mind and accept treatment) 1, 2

Common pitfalls to avoid:

• Many physicians are unaware that patients refusing life-sustaining treatment can qualify for hospice 1
• Prognostic uncertainty should not serve as a barrier to hospice referral when a patient is refusing treatment for a life-threatening condition 2
• 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

Clinical Context

The American Thoracic Society emphasizes that establishing realistic treatment goals is important in promoting patient-centered care, and discussing prognosis for achieving goals of care has been identified as an important component of surrogate decision-making 1. When a patient with sepsis refuses treatment, this represents a clear decision to forgo curative care in favor of comfort-focused care, which aligns directly with the hospice model 6.