Hospice vs Palliative Care: Key Distinctions
Palliative care can begin at any stage of serious illness and be provided alongside curative treatments, while hospice care is specifically for patients with a terminal prognosis of 6 months or less who agree to forgo curative therapies. 1
Fundamental Differences
Timing and Eligibility
Palliative care should start when a patient becomes symptomatic with serious illness, regardless of prognosis, and continues concurrently with all curative and life-prolonging interventions. 2 The American Thoracic Society explicitly endorses an integrated model where palliative care intensity is adjusted throughout the disease trajectory based on patient needs, not prognosis. 2
Hospice care requires physician certification that the patient has a terminal prognosis—more likely than not less than 6 months to live if the disease follows its expected course. 2 Medicare, Medicaid, and other insurers mandate this 6-month criterion, though patients who survive beyond this period can continue receiving hospice services if they still meet enrollment criteria. 2
Treatment Philosophy
Palliative care allows patients to receive chemotherapy, radiation, dialysis, mechanical ventilation, or any other disease-modifying treatment while simultaneously addressing symptom burden, psychological distress, and quality of life. 2, 3 This represents a fundamental shift from the outdated dichotomous model where patients received either curative or comfort care. 2
Hospice care requires patients to agree in writing that only hospice services (not other Medicare services like curative care) will be used to treat their terminal illness. 2 This means discontinuing disease-directed treatments in favor of pure comfort measures, though patients can withdraw from hospice if their condition unexpectedly improves. 2
Common Clinical Scenarios
The COPD Patient with Frequent Exacerbations
For a patient with severe COPD requiring multiple hospitalizations annually, palliative care consultation should occur immediately to address dyspnea, anxiety, and advance care planning—while the patient continues bronchodilators, steroids, and potentially even BiPAP. 2 Hospice referral becomes appropriate only when the patient meets terminal criteria: disabling dyspnea at rest despite optimal therapy, hypoxemia or hypercapnia on ambient air, right heart failure, and documented functional decline. 4
The Cancer Patient on Active Treatment
A patient newly diagnosed with metastatic lung cancer should receive palliative care consultation at diagnosis to manage pain, dyspnea, and treatment side effects while pursuing chemotherapy or immunotherapy. 1, 5 Hospice becomes appropriate only when the patient decides to stop cancer-directed therapy and focus exclusively on comfort, typically when prognosis shortens to months. 6
Critical Distinctions in Practice
Reimbursement Structure
Palliative care is billed through standard Medicare Part A and B, allowing concurrent curative treatments. 3 Hospice operates under the Medicare Hospice Benefit, which provides comprehensive services but requires forgoing curative care for the terminal diagnosis. 2
Team Composition and Services
Both utilize interdisciplinary teams including physicians, nurses, social workers, and chaplains. 2, 6 However, hospice uniquely provides bereavement services for families up to one year after death. 1 Hospice also includes home health aides and trained volunteers as core team members. 6
DNR Requirements: A Common Misconception
Neither palliative care nor hospice requires a "do not attempt resuscitation" order. 2 It is illegal under the Patient Self-Determination Act for Medicare-funded hospice programs to exclude patients who refuse to forgo CPR, though hospice programs will inform patients they do not provide CPR and will call 911 if requested. 2
Clinical Pitfalls to Avoid
Delaying Palliative Care Until End-of-Life
The most significant error is waiting until a patient is clearly dying to introduce palliative care. 1 Evidence demonstrates that early palliative care improves both quality and duration of life, particularly in cancer patients. 1, 5 Palliative care should be offered at the first sign of symptom burden or serious illness, not reserved for terminal phases. 2
Prognostic Uncertainty as a Barrier to Hospice
Physicians often hesitate to refer to hospice because they cannot guarantee death within 6 months. 2 This misunderstands the requirement: the standard is "more likely than not" less than 6 months, not certainty. 2 For non-cancer lung disease, 53-70% of patients meeting Medicare hospice criteria survive beyond 6 months, yet this does not disqualify them from continued hospice services. 4
Inadequate Communication with COPD Patients
Patients with COPD receive significantly less palliative care in their terminal phase compared to lung cancer patients, largely due to communication barriers, depression, and lack of advance care planning. 2 Address these barriers proactively by initiating goals-of-care discussions early in the disease course. 1
Practical Algorithm for Referral Decisions
For any patient with serious illness and symptoms: Refer to palliative care immediately while continuing all appropriate disease-directed treatments. 2, 1
For patients with terminal prognosis (≤6 months): Discuss hospice if the patient wishes to focus exclusively on comfort rather than life-prolonging interventions. 2, 6
For patients uncertain about prognosis: Palliative care remains appropriate; hospice requires only "more likely than not" ≤6 months, not certainty. 2, 4
For patients improving on hospice: They can be withdrawn from hospice and return to standard care or palliative care. 2