Should hospice arrangements be made for a hospitalized patient with ongoing concerns with oral feeding if the family is preferring hospice?

Should Hospice Arrangements Be Made Now?

Yes, hospice arrangements should be initiated now for this hospitalized patient with ongoing oral feeding concerns when the family is preferring hospice care. The decision to transition to hospice should not be delayed when the patient has persistent symptoms despite optimal treatment and the family has expressed a preference for comfort-focused care.

Key Decision-Making Framework

When to Initiate Hospice Discussions

Healthcare professionals trained in providing palliative care should be involved when hospitalized patients have persistent symptoms and concerns despite optimal disease treatment 1. The presence of ongoing oral feeding difficulties that cannot be adequately managed represents exactly this scenario—a persistent concern requiring a shift in care goals.

• The American Thoracic Society confirms that hospice eligibility requires certification by a treating physician and hospice medical director that the patient's prognosis is terminal (more likely than not having less than 6 months of life) 1.
• Importantly, if a patient survives beyond 6 months in hospice, Medicare and other reimbursement organizations will continue coverage if patients still meet enrollment criteria 1.
• Patients do not need a "do not attempt resuscitation" order to enroll in hospice programs 1.

Addressing the Oral Feeding Concerns

In end-of-life situations, older persons with low nutritional intake in the terminal phase should be offered comfort feeding instead of enteral nutrition 1. This is a critical distinction:

• Enteral nutrition (tube feeding) is fundamentally a life-prolonging procedure 1.
• When prolongation of life is no longer the primary goal, the patient's quality of life should be considered exclusively 1.
• Comfort feeding means offering whatever the patient likes to eat and drink orally, in whatever amount they desire, with covering nutritional requirements being entirely irrelevant 1.

The ESPEN guidelines explicitly state that voluntary cessation of nutrition and hydration is a legally and medically acceptable decision of a competent patient when chosen in disease conditions with frustrating prognosis and at the end of life 1. There is no compelling evidence that dehydration or forgoing nutrition in the dying patient leads to significant suffering 1.

Practical Steps for Discharge Planning

Immediate Actions

Hospice care can be provided in multiple settings dependent on the patient's and family's needs and preferences 1:

• Most patients prefer to die at home, though this may not always be possible 1.
• Achievement of the preferred place of death is accepted as a quality indicator of good end-of-life care 1.
• Home hospice requires adaptations to facilitate a "hospital at home" arrangement with increased reliance on primary care physicians and community-based nurses 1.

Anticipatory Prescribing for Home Discharge

If discharging home with hospice, anticipatory prescribing should be implemented immediately 1. This means writing prescriptions for medications that might be needed urgently, including:

• Opioids (morphine, oxycodone) for shortness of breath or pain 1
• Antiemetics (metoclopramide, ondansetron) for nausea/vomiting 1
• Diuretics (furosemide, bumetanide) for congestion 1
• Benzodiazepines (lorazepam, clonazepam) for anxiety 1
• Midazolam for potential palliative sedation 1

Having these medications readily accessible at home with detailed instructions empowers patients and caregivers in self-management until professional supervision is available 1.

Medication Deprescribing

Medication deprescribing should be undertaken as a proactive, patient-centered approach 1:

• Medications inconsistent with or irrelevant to the goal of patient comfort can be discontinued 1.
• Medications for symptom palliation should be continued unless ineffective or causing distressing side-effects 1.
• This revision should consider the patient's changing goals of care, values, preferences, and perceived life expectancy 1.

Common Pitfalls to Avoid

Delaying Hospice Referral

Physicians may be reluctant to discuss hospice due to lack of skill in acknowledging or communicating that death is near 1. This represents a significant barrier that must be overcome:

• The prognosis of non-cancer patients may be more difficult to determine, but this should not prevent hospice referral when appropriate 1.
• Physicians may be unaware of hospice availability or eligibility criteria for non-cancer patients 1.
• Family members and loved ones should be invited and supported to visit the dying patient, with bereavement support offered after death 1.

Misunderstanding Hospice Requirements

Medicare requires patients to agree in writing that only hospice care (not curative care) can be used to treat their terminal illness 1. However:

• Patients can be withdrawn from hospice programs if their condition unexpectedly improves 1.
• The physician certifying hospice eligibility does not "guarantee" death within 6 months 1.

Artificial Nutrition Misconceptions

Withholding or withdrawing nutrition is ethically permissible and may improve some symptoms in the dying patient 1:

• There are risks associated with artificial nutrition and hydration, including fluid overload, infection, and potentially hastened death 1.
• Symptoms like dry mouth should be treated with local measures (mouth care, small amounts of liquids) 1.
• The absence of hunger and thirst is normal in the dying patient 1.

Family Communication Strategy

Advance care planning should be routinely conducted or reviewed by clinicians with patients and their loved ones 1. In this case:

• The family has already expressed a preference for hospice, indicating alignment with comfort-focused goals 1.
• Family members often need repeated reassurance that other methods have been tried and that hospice is unlikely to shorten the patient's life 1.
• They should be kept informed about the patient's well-being and what to expect 1.
• After discharge, the family should be offered bereavement support and resources 1, 2.

The care team must provide supportive care to family members, including listening to their concerns, attention to grief and physical/psychological burdens, and awareness of any perceived feelings of guilt 1.