What are the eligibility criteria and enrollment process for hospice care in Ontario?

Hospice Eligibility in Ontario

To qualify for hospice care in Ontario, a patient must have a terminal illness with a prognosis of 6 months or less as certified by a physician, and agree to focus on comfort-oriented care rather than curative treatment for their terminal condition. 1, 2

Core Eligibility Requirements

Prognostic Certification:

• Both the treating physician and hospice medical director must certify that the patient's prognosis is terminal, meaning life expectancy is likely less than 6 months if the disease follows its expected course. 1, 3
• This certification does not guarantee death within 6 months—patients can remain in hospice if eligibility criteria continue to be met, and can be withdrawn if their condition unexpectedly improves. 3

Patient Agreement:

• The patient must agree in writing that hospice care (not curative care) will be used to treat their terminal illness. 1
• Importantly, patients do NOT need a "do not attempt resuscitation" order to qualify for hospice—this is a common misconception. 1, 3

Disease-Specific Criteria for Progressive Decline

For Advanced Lung Disease (COPD):

• Disabling dyspnea at rest that significantly limits activity and responds poorly to bronchodilators. 3, 4
• Evidence of disease progression including at least one of: two or more exacerbations per year despite adequate treatment, previous hospitalizations, severe airflow obstruction despite optimal therapy, or hypoxemia/hypercapnia on ambient air. 3, 4
• Supporting criteria include right heart failure secondary to pulmonary disease, unintentional progressive weight loss, and resting tachycardia. 3

For Heart Failure:

• Patients with advanced heart failure should be considered when optimal guideline-directed management no longer controls symptoms and there is evidence of progressive decline. 5

For Cancer Patients:

• Optimal timing for hospice referral is when prognosis is months to weeks, not days to hours. 1

What Treatments Can Continue

Patients are NOT required to withdraw all medical treatments in hospice: 1

• Palliative treatments for symptom management (pain, dyspnea, anxiety) continue and are often enhanced. 1
• Supplemental oxygen, medications for symptom control, and other interventions that improve quality of life can be maintained. 1
• Patients can refuse specific treatments while continuing others based on their goals of care. 1

Ontario-Specific Context

Service Availability in Ontario:

• Hospice care in Ontario can be provided in multiple settings: patient's home, long-term care facilities, dedicated hospice facilities, and hospitals when needed for symptom control. 6
• There is considerable variability in available services depending on the setting—palliative care units are most likely to provide care for complex procedures and methadone for pain management, while hospices are most likely to provide complementary therapies. 6
• Medical wards in hospitals are the most common location for palliative care overall, particularly in rural areas of Ontario. 6

Critical Pitfalls to Avoid

Timing of Referral:

• Do not wait until the patient is actively dying—earlier referral (at 80-90 days before death) is associated with better outcomes and longer survival. 1
• The average hospice stay is only 17-19 days, with one-third dying within 7 days of enrollment, indicating systematic failure to refer early enough. 1

Prognostic Uncertainty:

• Do not delay referral due to difficulty predicting exact survival time—current prognostic criteria have limitations in accurately predicting 6-month mortality, particularly for non-cancer illnesses. 3, 7
• Prognostic uncertainty should not serve as a barrier to timely hospice referral. 3

Common Misconceptions:

• Hospice does not hasten death—evidence shows patients receiving hospice tend to have longer survival, particularly those with congestive heart failure, lung cancer, and pancreatic cancer. 1
• Hospice is not only for the last hours to days of life. 1, 3
• Patients with non-cancer diagnoses (COPD, heart failure) often receive less timely referrals despite potential benefits. 1

Enrollment Process

Immediate Steps:

• When a patient expresses desire for hospice care, refer immediately to a hospice agency to ensure timely enrollment. 1
• Complete advance directives (MOLST/POLST) and document patient values, preferences, and decisions in the medical record. 1
• Confirm the patient's wishes regarding their place of death. 1

Barriers in Ontario:

• Lack of financial support and human resources are the most frequent perceived barriers to providing quality palliative care in Ontario facilities. 6
• Actual use of hospice care among long-term care facility residents is very poor in Canada (less than 3%), with potential barriers including ageism, rurality, and dementia diagnosis. 8