Hospice Care Protocol for Terminal Illness
Hospice care should be initiated when a physician and hospice medical director jointly certify that the patient has a terminal prognosis (life expectancy ≤6 months if disease follows its expected course), with the patient agreeing in writing to receive hospice care focused on comfort rather than curative treatment. 1, 2
Core Eligibility and Enrollment Requirements
Certification Process:
- Both the treating physician and hospice medical director must certify terminal prognosis (≤6 months life expectancy) 1, 2
- Patient must agree in writing to use hospice care to treat their terminal illness 2, 3
- A DNR order is NOT required for hospice enrollment - it is illegal under the Patient Self-Determination Act for Medicare-funded hospice programs to exclude patients who don't agree to forgo CPR 3
- Patients can be withdrawn from hospice if their condition unexpectedly improves 3
Interdisciplinary Team Composition
The hospice team must include 4:
- Physicians (treating physician and hospice medical director)
- Registered nurses with end-of-life care expertise (available 24/7)
- Medical social workers
- Mental health professionals and counselors
- Chaplains for spiritual support
- Nurse practitioners and physician assistants
- Dietitians
- Home health aides
- Trained hospice volunteers
Care Settings and Service Delivery
Hospice care can be provided in multiple settings 4, 5:
- Patient's home (most common setting)
- Long-term care facilities
- Dedicated hospice facilities
- Hospital settings when needed for acute symptom control
Symptom Management Protocol
Pain Management
Use the WHO Pain Ladder approach systematically 6:
- For opioid-naive patients: morphine 2.5-10 mg PO every 2 hours PRN or 1-3 mg IV every 2 hours PRN 4
- For patients on chronic opioids: increase dose by 25% 4
- For cancer patients: nonsteroidal anti-inflammatory drugs, opioids, and bisphosphonates are proven effective 4
- Titrate analgesics to adequate dosage for complete pain control 4
Dyspnea Management
First-line treatment is opioids for unrelieved dyspnea 4, 1:
- Morphine 2.5-10 mg PO every 2 hours PRN or 1-3 mg IV every 2 hours PRN for opioid-naive patients 4
- Oxygen therapy only if hypoxic and/or subjective relief is reported 4
- Non-pharmacologic interventions: fans, cooler temperatures, positioning 4, 1
- Benzodiazepines for anxiety-associated dyspnea: lorazepam 0.5-1 mg PO every 4 hours PRN 4
- Reduce excessive secretions with scopolamine 0.4 mg subcutaneous every 4 hours PRN, atropine 1% ophthalmic solution 1-2 drops sublingual every 4 hours PRN, or glycopyrrolate 0.2-0.4 mg IV/subcutaneous every 4 hours PRN 4
Depression Management
Treat depression with proven therapies 4:
- Tricyclic antidepressants or selective serotonin reuptake inhibitors
- Mirtazapine 7.5-30 mg at bedtime (also addresses anorexia) 4
- Psychosocial interventions
Anorexia/Cachexia Management
For patients with months to year life expectancy 4:
- Megestrol acetate 400-800 mg/day
- Olanzapine 5 mg/day
- Dexamethasone 2-8 mg/day
- For patients with weeks to days remaining: withholding or withdrawing artificial nutrition is ethically permissible and may improve symptoms 4
- Treat dry mouth with local measures (mouth care, small amounts of liquids) rather than IV hydration 4
Assessment and Communication Requirements
Regular Symptom Screening
Clinicians must routinely and periodically assess 4:
- Pain intensity and characteristics
- Dyspnea severity (use labored breathing or physical signs in noncommunicative patients) 4
- Depression symptoms
- Functional status and activities of daily living 1
Patient and Family Communication
Healthcare providers must 4:
- Respect the dignity of both patients and caregivers
- Be sensitive to and respectful of patients' and families' wishes
- Use measures consistent with patients' choices
- Respect patients' rights to refuse treatment
- Provide realistic expectations for survival and communicate accurately 4
- Offer anticipatory guidance regarding the dying process 4
Advance Care Planning
Documentation must include 4, 1:
- Patient/family understanding of terminal prognosis and goals of care
- Identification of key decision makers
- Care preferences across all settings
- Communication modality for patients with aphasia or dysarthria 4
Recertification Protocol
For hospice recertification, document 1:
- Joint certification by treating physician and hospice medical director that prognosis remains terminal
- Evidence of continued decline through:
- Progressive symptoms
- Functional deterioration
- Increasing healthcare utilization (≥2 exacerbations/year, hospitalizations)
- New complications
- Comparison with previous assessments showing worsening 1
Palliative Sedation for Refractory Symptoms
Reserved for patients with weeks or less to live with intractable symptoms despite optimal palliative care 4:
- Intent is symptom relief, not to produce death (doctrine of double effect)
- Consider when estimated time to death from disease ≤ predicted time to death from sedation-induced dehydration
- Requires careful attention to social, emotional, and existential dimensions of suffering 4
Bereavement Support
Hospice must provide 4:
- Bereavement counseling for the terminally ill patient
- Adjustment-to-death support for family and friends
- Bereavement services up to 1 year after patient's death
Common Pitfalls to Avoid
Delayed referral is the most common error 4, 3:
- Physicians often overestimate survival, limiting timely hospice access 4
- Average hospice enrollment is only 2 months, with 30% arriving in the last week of life 4
- Refer when patients may die at any time from intercurrent illness, have severely distressing symptoms, or limited performance status 2
Misconceptions about hospice 3:
- Hospice is not only for the last hours to days - earlier referral improves outcomes
- Prognostic uncertainty should not delay referral
- Patients refusing life-sustaining treatment can qualify for hospice 3
Inadequate symptom management 4: