When is hospice care appropriate for an older adult patient with a terminal diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and a history of smoking, with comorbidities such as heart disease or diabetes?

Hospice Eligibility Criteria for Terminal COPD

Hospice care is appropriate for COPD patients when they have severe airflow obstruction (FEV1 <30% predicted post-bronchodilator), disabling dyspnea at rest poorly responsive to bronchodilators, and progressive disease documented by recurrent hospitalizations or emergency visits, along with either hypoxemia (PaO2 ≤55 mmHg or SaO2 ≤88% on supplemental oxygen) or hypercapnia (PaCO2 ≥50 mmHg), or cor pulmonale. 1

Core Clinical Indicators

The Medicare hospice eligibility framework requires certification that life expectancy is 6 months or less if the disease follows its natural course, though this does not guarantee death within that timeframe—rather, it certifies the prognosis is more likely than not less than 6 months. 1 The American Thoracic Society acknowledges that predicting 6-month mortality in COPD is inherently challenging due to the unpredictable disease trajectory, and Medicare will continue coverage beyond 6 months if patients still meet enrollment criteria. 1

Required Objective Criteria

• Severe airflow obstruction: FEV1 <30% of predicted value after bronchodilator administration 1
• Gas exchange abnormalities: Either hypoxemia at rest on supplemental oxygen (PaO2 ≤55 mmHg or oxygen saturation ≤88%) or hypercapnia (PaCO2 ≥50 mmHg) 1
• Progressive disease: Documented by increasing emergency department visits or hospitalizations for pulmonary infections and/or respiratory failure 1
• Cardiac complications: Right heart failure secondary to pulmonary disease (cor pulmonale) 1

Required Subjective Criteria

• Disabling dyspnea at rest that is poorly responsive to bronchodilators and results in decreased functional capacity 1
• Functional impairment: Inability to perform activities of daily living due to breathlessness 2
• Symptom burden: Including anxiety associated with dyspnea, depression, and other distressing symptoms 2

Timing of Referral

Refer to hospice when prognosis is months to weeks, not days to hours. 3 A critical pitfall is delaying referral until death is imminent—the average hospice stay for patients with chronic lung disease is only 17-19 days, with one-third dying within 7 days of enrollment, representing a failure to refer early enough. 3 Earlier referral (at 80-90 days) is associated with better outcomes and allows hospice services to reach their full impact. 3

The unpredictable COPD trajectory makes it difficult to determine the precise appropriate time for palliative care, but do not delay palliative interventions while waiting for absolute certainty of 6-month prognosis. 1 Primary care teams should be trained in general palliative care requirements for critically ill COPD patients. 4

Comorbidity Considerations

Patients with heart disease or diabetes as comorbidities should be evaluated using the same COPD-specific criteria above. 1 The presence of comorbidities may support hospice eligibility but does not change the core respiratory criteria. Unintentional progressive weight loss serves as an additional objective finding that supports terminal prognosis. 2

What Hospice Does NOT Require

Common misconceptions that create barriers to appropriate referral:

• Hospice does NOT require withdrawing all medical treatments—patients can continue comfort-oriented medications and interventions including supplemental oxygen, bronchodilators, and other symptom management therapies. 3
• Hospice does NOT require a "do not attempt resuscitation" (DNR) order. 3
• Hospice is NOT only for the last hours to days of life. 3
• Patients are NOT required to withdraw all medical treatments, but rather focus on comfort-oriented care rather than curative treatments. 3

Advance Care Planning Requirements

During stable periods, initiate discussions about end-of-life care to prepare patients for life-threatening exacerbations while assisting them to continue living and enjoying life. 4 Pulmonary rehabilitation provides an important opportunity for advance care planning, as educational programs within rehabilitation increase adoption rates for advance directives and patient-physician discussions about end-of-life care. 4

Essential documentation includes:

• Confirming DNR/DNI status (though not required for enrollment) 1
• Discussing preferences for management of future exacerbations 1
• Clarifying that patient understands hospice provides comfort care only 1
• Documenting patient/family understanding of terminal prognosis and goals of care 2

Recertification Criteria

For hospice recertification beyond the initial 6-month period, document:

• Continued terminal prognosis with joint certification by treating physician and hospice medical director 2
• Evidence of continued decline through progressive symptoms, functional deterioration, increasing healthcare utilization, or new complications 2
• Comparison with previous assessments showing worsening symptoms, functional status, or new complications 2
• Ongoing symptom management plan prioritizing quality of life 2

Symptom Management in Hospice

Continue bronchodilators for symptom relief. 1 Use opioids as first-line treatment for refractory dyspnea, with careful consideration of dose and frequency. 1 Address anxiety and depression, which are common and treatable in advanced COPD patients—do not overlook these conditions. 1 Continue supplemental oxygen for comfort, not to prolong life. 1

Non-invasive ventilation (NIV) can be used as a palliative intervention to reduce symptoms of dyspnea, but ensure it does not lead to more side effects and does not unnecessarily prolong a dying process. 4 The potential benefit must be critically weighed against possible adverse effects such as respiratory dehydration or worsening of dyspnea. 4

Evidence Supporting Earlier Referral

Contrary to common fears, hospice enrollment is associated with longer survival, not shorter. A retrospective analysis of 4,493 Medicare patients found those referred to hospice had mean survival 29 days longer than those not referred, particularly for patients with lung cancer and congestive heart failure. 3 Patients avoid complications and burdens of futile aggressive treatments that may actually shorten life through adverse effects, infections, and treatment-related morbidity. 3