What are the criteria and goals for hospice care in an adult patient with a terminal illness, such as cancer, heart disease, or dementia, and limited life expectancy?

Hospice Care for Terminal Illness

Hospice care should be initiated when a physician certifies a terminal prognosis with life expectancy of 6 months or less if the disease follows its expected course, with the primary goal of maximizing quality of life through comprehensive symptom management and support rather than curative treatment. 1, 2

Core Eligibility Criteria

Traditional hospice enrollment requires:

• Physician certification (both treating physician and hospice medical director) that prognosis is terminal with likely survival less than 6 months 1, 3
• Patient agreement in writing to receive hospice care rather than curative treatment for the terminal illness 1
• Important caveat: Patients do NOT need a "do not resuscitate" order to qualify for hospice—this is a common misconception 1, 4

Primary Goals of Hospice Care

The fundamental objectives prioritize quality of life over life extension:

• Relief of distressing symptoms including pain, dyspnea, anxiety, and other physical suffering 5, 1
• Psychological, social, and spiritual support for patients and families 5, 6
• Maintenance of dignity and comfort during the dying process 7
• Support for achieving patient-defined end-of-life goals 8

Disease-Specific Considerations

Heart Failure

For advanced heart failure patients, hospice focuses on symptom relief rather than traditional cardiac interventions:

• Frequent IV diuretics and continuous inotropic infusions may be appropriate for breathlessness management, not just analgesics 5
• Anxiolytics, sleeping medications, and narcotics should be prescribed for distress in final days 5
• Critical challenge: Predicting 6-month mortality is particularly difficult in heart failure due to unpredictable disease trajectory with periods of stability followed by sudden death 5

Advanced Lung Disease

Specific criteria for pulmonary disease patients include:

• Severe chronic lung disease with disabling dyspnea at rest 4, 3
• Evidence of disease progression with hypoxemia at rest on ambient air or hypercapnia 4, 3
• Supporting features: right heart failure, unintentional progressive weight loss, resting tachycardia 4, 3
• Important limitation: Current Medicare criteria have poor predictive accuracy, with 53-70% of patients meeting criteria surviving beyond 6 months 3

Cancer and Dementia

These patients typically have more predictable trajectories, though early referral remains underutilized:

• Average hospice stay for cancer patients is only 17-19 days, with one-third dying within 7 days of enrollment—indicating systematic late referrals 1
• Optimal timing is when prognosis is months to weeks, not days 1

What Hospice Does NOT Require

Critical misconceptions to address with patients and families:

• Patients need not withdraw ALL medical treatments—only those aimed at curing the terminal illness 1
• Comfort-oriented medications, supplemental oxygen, and symptom control interventions continue and often intensify 1
• Hospital admission is appropriate when symptom control cannot be achieved in current setting 1
• Patients can refuse specific treatments while continuing others based on their goals 1

Timing and Prognostic Challenges

The 6-month criterion presents practical difficulties:

• Healthcare providers generally cannot accurately predict end of life, particularly in non-cancer illnesses 5
• In one large ICU study, majority of patients meeting broad hospice criteria survived beyond 6 months despite contrary predictions 5
• Recommendation: Use the "surprise question" ("Would I be surprised if this patient died in the next 6-12 months?") to identify candidates for palliative care discussions 4
• Patients can be withdrawn from hospice if condition unexpectedly improves 4, 3

Evidence Supporting Earlier Referral

Contrary to fears that hospice hastens death, evidence shows the opposite:

• Medicare patients referred to hospice survived mean of 29 days longer than those not referred, particularly for CHF, lung cancer, and pancreatic cancer 1
• Positive correlation exists between length of hospice stay and survival (0.8 days longer survival per day in hospice) 1
• Patients avoid complications and burdens of futile aggressive treatments that may shorten life through adverse effects 1
• Earlier referral (80-90 days) allows hospice to reach full impact on grief preparation and acceptance 1

Advance Care Planning Requirements

When initiating hospice discussions (prognosis of months to weeks):

• Complete MOLST/POLST documentation 1
• Document patient values, preferences, and decisions in medical record 1
• Designate healthcare proxy or power of attorney for when patient cannot participate in decisions 5
• Confirm patient's preferred place of death (most cancer patients prefer home; ICU death associated with higher caregiver distress) 1
• Consider deactivation of implanted defibrillator life-saving functions 5

Interdisciplinary Team Approach

Hospice care delivery involves coordinated services:

• Physicians (treating and hospice medical director), nurses, social workers, counselors, home health aides, trained volunteers 2, 6
• Care can be delivered in patient's home, long-term care facilities, dedicated hospice facilities, or hospitals when needed 1, 2
• Palliative care specialists should be consulted for situations beyond primary clinician's competence 5

Communication Framework

Effective hospice discussions require:

• Realistic expectations for survival communicated accurately to patients and families 5
• Realistic recommendations avoiding procedures that add neither hope of recovery nor quality of life improvement 5
• Ongoing candid discussions about treatment goals starting early in serious illness, not when death is imminent 1
• Coordination with same team for outpatient, inpatient, and crisis management to reduce fragmented care 5

Common Barriers to Appropriate Referral

Systemic issues preventing timely hospice enrollment:

• Many physicians unaware of hospice eligibility criteria for non-cancer patients 4, 8
• Prognostic uncertainty serves as barrier despite evidence that earlier referral improves outcomes 4
• Misconception that hospice is only for last hours to days of life 1, 4
• Lack of physician skill in communicating that death is near 4
• Solution: Counsel patients and families that hospice enrollment is associated with longer survival, not shorter 1