Hospice Transition for Patients Requesting End-of-Life Care
When a patient expresses desire for hospice care, refer immediately to a hospice agency—this should be the first intervention to ensure timely enrollment and prevent the common problem of patients dying within days of referral. 1
Eligibility Criteria
The patient qualifies for hospice when both the treating physician and hospice medical director certify a terminal prognosis with life expectancy likely less than 6 months if the disease follows its expected course. 2, 3
Key requirements:
- Written agreement from the patient to receive hospice care (not curative treatment) for their terminal illness 2
- No requirement for a "do not resuscitate" order—this is a common misconception that delays appropriate referrals 2, 3
- Patients can be withdrawn from hospice if their condition unexpectedly improves 3
Timing of Referral
Critical pitfall: The average hospice stay for cancer patients is only 17-19 days, with one-third dying within 7 days of enrollment—this represents a failure to refer early enough. 1
Optimal timing by prognosis:
- Months to weeks: Actively facilitate hospice referral and complete advance directives 1
- Weeks to days: Hospice should already be engaged; focus shifts to symptom management and family support 1
The panel consensus emphasizes that only 53-54% of cancer patients die in hospice care, primarily because oncologists fail to recommend it early enough. 1
What Patients Can Continue While in Hospice
Major misconception to address: Hospice does not require withdrawing all medical treatments. 2
Treatments that continue:
- Palliative medications for pain, dyspnea, anxiety, and other distressing symptoms (often enhanced) 2
- Supplemental oxygen 2
- Medications for symptom control 2
- Other interventions that improve quality of life 2
What changes: The focus shifts from curative treatments to comfort-oriented care for the terminal illness. 2
Advance Care Planning Documentation
Essential steps when life expectancy is months to weeks:
- Complete MOLST/POLST (Medical Orders for Life-Sustaining Treatment) and ensure accessibility across all care settings 1
- Document patient values, preferences, and decisions in the medical record 1
- Confirm the patient's wishes regarding where they want to die—most cancer patients prefer home, and dying in ICU is associated with higher physical/emotional distress and prolonged grief disorder in caregivers 1
Symptom Management Priorities
For dyspnea (the most common distressing symptom):
- Opioids are first-line treatment 1
- Glycopyrrolate for secretions (preferred over other anticholinergics as it doesn't cross blood-brain barrier and causes less delirium) 1
- Scopolamine subcutaneously or transdermally (note: transdermal patches take 12 hours to work, inappropriate for imminently dying patients) 1
- Benzodiazepines when other options fail (though benefit is small) 1
- Non-pharmacologic: handheld fans directed at face (proven effective in reducing breathlessness) 1
Addressing Common Barriers
Prognostic uncertainty should not delay referral. Current criteria for non-cancer illnesses have limitations in predicting 6-month mortality, but the combination of advanced disease with functional decline provides sufficient evidence. 3, 4
For non-cancer patients (COPD, heart failure): These patients receive less timely referrals despite potential benefits—use the same early referral approach. 2
Conflict resolution: Consider palliative care consultation when patient, family, and medical team disagree on benefit/efficacy of interventions. 1
The Conversation Framework
This is an individualized decision requiring ongoing candid discussions about treatment goals and preferences, balancing risks/benefits of additional therapy with careful assessment of overall clinical status. 1 However, the conversation about integrating supportive care and eventual hospice should start early in the management of any serious illness, not when death is imminent. 1