Medicare Requirements for Hospice Nurse Admission Authority
Under Medicare regulations, a hospice nurse cannot independently sign and legally admit a patient to inpatient hospice—this requires physician certification by both the patient's attending physician and the hospice medical director certifying a terminal prognosis of less than 6 months. 1, 2
Physician Certification Requirements
Medicare mandates dual physician certification for hospice admission:
- Both the treating physician and the hospice medical director must certify in writing that the patient has a terminal prognosis, meaning life expectancy is more likely than not less than 6 months if the disease follows its expected course 1, 2
- The patient must agree in writing that hospice care (not curative care) will be used to treat their terminal illness 1
- This certification requirement applies to all levels of hospice care, including inpatient hospice 1
Role of the Hospice Nurse in Admission
The hospice nurse serves as the initial contact and assessment coordinator, but lacks legal authority to certify admission:
- The hospice nurse ideally makes the preliminary assessment and completes demographic data, phasing, problem areas, and suggested strategies 3
- Formal in-depth assessment occurs as soon as possible after the nurse's initial contact, with input from medical and paramedical team members 3
- The nurse coordinates information but cannot substitute for the required physician certifications 3
Common Pitfalls to Avoid
Several misconceptions create barriers to appropriate hospice admission:
- Physicians often delay referrals due to prognostic uncertainty, waiting until patients are clearly in the dying process rather than when prognosis is months to weeks 4, 5
- The median hospice length of stay is only 17.4 days, with 36% of patients dying within 7 days of admission—reflecting inappropriately late referrals 5
- There is no requirement for a "do not attempt resuscitation" order for hospice enrollment, and 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, 6
Inpatient Hospice Admission Criteria
Inpatient hospice admission requires specific clinical justification beyond standard hospice eligibility:
- Hospital admission for hospice patients is indicated when satisfactory symptom control cannot be achieved in the current care setting, such as severe dyspnea or pain, acute symptom crises, or need for specialized procedures 1
- The goal remains improving symptom management, not curative treatment 1
- Hospice care can be delivered in multiple locations including hospitals when needed for symptom control, but physician certification requirements remain unchanged 1
Documentation Requirements
Proper documentation must support the terminal prognosis certification:
- For respiratory failure patients, documentation should include disabling dyspnea at rest, functional limitations, disease progression indicators (such as two or more exacerbations per year), and objective findings like hypoxemia or right heart failure 6
- The certifying physicians must explicitly state that the patient meets terminal prognosis criteria despite known limitations of prognostic tools 6
- Prognostic uncertainty should be acknowledged, as expert predictions of life span are imprecise and often overly optimistic by an average of 3.4 weeks 7