What are the criteria and considerations for writing a hospice referral for an End-Stage Renal Disease (ESRD) patient?

Writing a Hospice Referral for ESRD Patients

Core Eligibility Certification

For ESRD patients, hospice referral requires joint certification by both the treating physician and hospice medical director that the patient has a terminal prognosis (life expectancy likely less than 6 months) and written patient agreement to receive hospice care rather than curative treatment for their terminal illness. 1, 2

The patient must agree in writing that hospice care (not other Medicare services like curative care) will be used to treat their terminal illness. 1 Importantly, patients do not need a "do not attempt resuscitation" order to qualify for hospice—this is a common misconception that delays appropriate referrals. 1, 2

Essential Documentation Components

Patient Status and Prognosis

Document explicitly that the patient meets terminal prognosis criteria despite known limitations of prognostic tools. 3 For ESRD patients, this includes:

• Patients who have decided against renal replacement therapy (dialysis or transplantation) or are discontinuing dialysis 4
• Patients with ESRD who are not candidates for transplantation and have progressive decline despite dialysis 4
• Evidence of functional deterioration, increasing healthcare utilization, or new complications 3

Clinical Indicators of Progressive Decline

Document objective findings that support terminal prognosis:

• Unintentional progressive weight loss 3
• Increasing symptom burden despite optimal management (uremia, nausea, pruritus, pain, dyspnea) 5, 6
• Declining functional status with inability to perform activities of daily living 3
• Frequent hospitalizations or emergency department visits 3
• Development of complications (cardiovascular disease, severe electrolyte abnormalities, refractory hypervolemia) 4

Symptom Assessment

Document the patient's symptom burden, which is extensive in ESRD:

• Chronic pain, depression, cognitive impairment, and physical disability 5
• Uremic symptoms (nausea, vomiting, pruritus, altered mental status) 6
• Anxiety and other distressing symptoms 3

Goals of Care Documentation

Document patient/family understanding of terminal prognosis and goals of care. 3 This should include:

• Confirmation that the patient desires comfort-oriented care rather than life-prolonging interventions 7
• Patient's preferred place of death (most patients prefer home; dying in ICU is associated with higher caregiver distress) 1
• Advance directives and MOLST/POLST completion 1

Ongoing Symptom Management Plan

Document the plan for symptom management prioritizing quality of life: 3

• Palliative treatments for pain, dyspnea, nausea, pruritus, and other distressing symptoms continue and are often enhanced 1
• Medications for symptom control and other interventions that improve quality of life can be maintained 1
• Supplemental oxygen, if needed for comfort 1

Critical Timing Considerations

Refer immediately when the patient expresses desire for hospice care to ensure timely enrollment. 1 The average hospice stay is only 17-19 days, with one-third dying within 7 days of enrollment, indicating systematic failure to refer early enough. 1

Optimal timing is when prognosis is months to weeks, not days to hours. 1 Earlier referral is associated with better outcomes, improved symptom control, and lower healthcare costs. 5, 2

Common Pitfalls to Avoid

• Do not delay referral due to prognostic uncertainty—this is the most common barrier to timely hospice referral for ESRD patients. 2
• Do not assume hospice is only for the last hours to days of life—this misconception leads to delayed referrals and missed opportunities for improved quality of life. 2
• Do not require patients to have a DNR order—it is illegal under the Patient Self-Determination Act for Medicare-funded hospice programs to exclude patients who don't agree to forgo CPR. 2
• Do not assume patients must withdraw all medical treatments—hospice focuses on comfort-oriented care, not complete treatment withdrawal. 1

Special Considerations for ESRD

ESRD patients have extensive and unique palliative care needs, often for years before death, yet the vast majority die in acute care facilities without accessing palliative care services. 6 Hospice is particularly underutilized in the ESRD population, even among patients who withdraw from dialysis. 5

For patients deciding against renal replacement therapy or discontinuing dialysis, palliative care and hospice referral are indicated immediately. 4 These patients qualify for hospice based on their decision to forgo life-sustaining treatment combined with their terminal diagnosis. 2