Hospice Care Continuation for End-Stage Alzheimer's Disease
Yes, this patient absolutely should continue hospice services with comfort-focused care—she meets all clinical criteria for terminal Alzheimer's disease with a prognosis of 6 months or less, and hospice provides the appropriate framework for managing her progressive decline while maximizing comfort and dignity. 1
Hospice Eligibility Confirmation
This patient clearly meets hospice eligibility criteria based on multiple converging indicators:
- Functional Status: Complete ADL dependence (6/6), fully bedbound status, and KPS 30% establish the profound functional decline characteristic of terminal dementia 2, 3
- Cognitive Severity: FAST 7C staging with nonverbal status, disorientation (A&O x0), and minimal interaction document end-stage cognitive impairment 2, 4
- Nutritional Decline: MAC loss of 2 cm (from 17 to 15 cm) with poor oral intake requiring blended diet demonstrates progressive nutritional failure 3, 5
- Medical Complications: Nonhealing pressure ulcers despite active wound care, fragile skin, and chronic constipation requiring intensive bowel regimen reflect the terminal phase complications 6, 3
- Progressive Trajectory: Documented continued global decline across nutritional, physical, and functional domains with increasing care burden 2, 5
The physician certification that prognosis is 6 months or less if the illness follows its expected course is clinically appropriate and does not "guarantee" death within 6 months—Medicare will continue coverage beyond 6 months if eligibility criteria persist. 1
Comfort-Focused Care Plan
Symptom Management Priorities:
- Pain Assessment: Implement behavioral pain scales regularly, as undiagnosed pain commonly manifests as behavioral changes in nonverbal patients and is a frequent cause of care refusal 6, 3
- Pressure Ulcer Care: Continue wound care focused on comfort rather than healing, recognizing that nonhealing wounds are expected in terminal dementia with immobility and poor nutritional status 6, 3
- Bowel Management: Maintain current regimen (lactulose, Miralax, suppositories, episodic enemas) as constipation significantly impacts quality of life and comfort 6, 3
- Skin Protection: Continue repositioning and pressure injury prevention measures, recognizing increasing skin fragility 3
Medication Reassessment:
- Review all current medications for continued benefit versus burden in the context of terminal disease 3
- Discontinue medications that no longer serve comfort goals 2
- Avoid unnecessary interventions including tube feeding, which does not improve outcomes in end-stage dementia and may prolong dying 2
What to Avoid: Critical Errors in Terminal Dementia Care
The European Association for Palliative Care identifies two categories of errors to avoid:
Too Much Intervention (Harmful):
- Tube feeding or aggressive nutritional interventions beyond comfort feeding 6, 2
- Excessive laboratory testing or monitoring 6
- Physical restraints 6
- Hospitalization for complications that could be managed with comfort measures 3
Too Little Intervention (Neglectful):
- Inadequate pain control 6
- Allowing preventable discomfort from dehydration or constipation 6
- Emotional and social neglect of patient and family 6
- Insufficient caregiver support and education 6, 3
Family and Caregiver Support
Essential Education Components:
- Provide comprehensive information about dementia progression, expected complications, and what to expect as death approaches 6, 3
- Discuss the dying process including signs that death is imminent (further decreased consciousness, changing breathing patterns, mottled skin, decreased urine output) 1
- Connect family to support resources including respite services, support groups, and the Alzheimer's Association 2, 3
- Address spiritual needs and facilitate chaplain involvement as appropriate 1, 2
Advance Care Planning:
- Document discussions with the substitute decision-maker regarding preferences for end-of-life care, including decisions to forgo hospitalization, antibiotics for infections, or other aggressive interventions 3
- Ensure DNR orders are in place and family understands the rationale 2
- Reassess goals of care regularly as clinical status changes 1
Continuity of Care Model
Home Hospice Structure:
- Registered nurse coordinates care with onsite visits to evaluate needs 1
- Social worker and chaplain provide essential support to patient and family 1
- Interdisciplinary team (physicians, nurses, social workers, chaplains) develops and implements the care plan 1
- Maintain continuity with a stable care team that knows the patient and family, as this is extremely important 1, 7
Common Pitfall to Avoid:
Families often prefer continuity in care and living arrangements but may find it difficult to accept involvement of a large team of unfamiliar caregivers despite recognizing their complex support needs. 7 Address this by maintaining consistent team members and clearly explaining each person's role in supporting comfort and dignity.
The current plan appropriately focuses on comfort, safety, and dignity while providing comprehensive symptom management and family support—this represents optimal hospice care for terminal Alzheimer's disease. 1, 6