Is Pulmonary Disease an appropriate diagnosis to qualify for Medicare hospice guidelines?

Yes, Pulmonary Disease is an Appropriate Diagnosis for Medicare Hospice Eligibility

Pulmonary disease qualifies for Medicare hospice if the patient meets specific clinical criteria demonstrating terminal-stage disease with a life expectancy of 6 months or less. 1

Medicare Eligibility Criteria for Advanced Lung Disease

To qualify for hospice with pulmonary disease, the following criteria must be met:

Required Core Criteria (Both Must Be Present)

Criterion 1: Severe chronic lung disease documented by BOTH:

• Disabling dyspnea at rest that is poorly or unresponsive to bronchodilators, resulting in decreased functional capacity (bed-to-chair existence), fatigue, and cough 1
• Progression of end-stage pulmonary disease evidenced by increasing emergency department visits, hospitalizations for pulmonary infections/respiratory failure, or increasing physician home visits 1

Criterion 2: Gas exchange abnormalities (either):

• Hypoxemia at rest on ambient air: PO₂ ≤55 mmHg OR oxygen saturation ≤88% on supplemental oxygen 1
• OR hypercapnia: PCO₂ >50 mmHg 1

Supporting Documentation (Strengthens Eligibility)

While not absolutely required, these additional findings provide strong supporting evidence:

• Right heart failure secondary to pulmonary disease (cor pulmonale) 1
• Unintentional progressive weight loss >10% of body weight over preceding 6 months 1
• Resting tachycardia >100/minute 1

Important Clinical Considerations

Prognostic Limitations

The current Medicare criteria have significant limitations in accurately predicting 6-month mortality for non-cancer lung disease patients. 2, 3 Studies show that 53-70% of patients meeting these criteria survive longer than 6 months, depending on which combination of criteria are used. 3 However, this prognostic uncertainty should not prevent appropriate hospice referral when patients meet clinical criteria and desire comfort-focused care. 2

Alternative "Common Sense" Criteria

Beyond the formal Medicare criteria, hospice referral is appropriate when: 1

• Despite optimal treatment, the chronic respiratory disease has progressed to where the patient may die at any time from common intercurrent illness (e.g., bronchitis) 1
• The patient has severely distressing symptoms or limited performance status best managed by hospice care 1
• The patient accepts that death is near and wants to avoid needless prolongation of suffering 1

Common Pitfalls to Avoid

Many physicians are unaware of hospice eligibility criteria for non-cancer patients, leading to delayed or missed referrals. 1, 2 The American Thoracic Society emphasizes that pulmonary disease patients face particular difficulties accessing hospice due to:

• Physician reluctance to discuss hospice due to lack of communication skills about approaching death 1
• Unawareness of hospice availability for non-cancer diagnoses 1
• Prognostic uncertainty serving as an inappropriate barrier to referral 2

Do not require FEV₁ documentation - while FEV₁ <30% predicted provides objective evidence of disabling dyspnea, it is explicitly not necessary to obtain for hospice certification. 1

Do not delay referral waiting for the patient to be actively dying - earlier hospice referral is associated with better outcomes, yet the average hospice stay is only 17-19 days, with one-third dying within 7 days of enrollment. 4

Certification Process

Both the treating physician and hospice medical director must certify that the patient's prognosis is terminal (likely <6 months). 4, 2 The patient must also agree in writing that hospice care (not curative care) will be used to treat their terminal illness. 4

Patients do not need a "do not resuscitate" order to enroll in hospice - this is a common misconception. 4, 2