Deciding when to transition from curative treatment to hospice care is a difficult choice for patients with terminal illnesses and their families. Hospice provides comfort care and pain management for patients expected to have six months or less to live. Doctors base their hospice recommendations on a variety of factors.
When hospice care begins
Hospice care can begin once doctors determine a patient has 6 months or less to live if their disease runs its normal course. This prognosis is based on the doctor’s clinical judgment. Doctors look at:
- The patient’s overall health
- Disease progression and symptoms
- Response to treatments so far
They may use tools like the Karnofsky Performance Status scale to help estimate life expectancy. Patients with scores of 50% or less on this scale often qualify for hospice. Doctors also consider rapid weight loss, recurrent infections, and other signs a patient’s health is declining. However, predicting life expectancy is not an exact science.
Karnofsky Performance Status Scale
| Score | Performance Status |
|---|---|
| 100% | Normal, no complaints, no signs of disease |
| 90% | Capable of normal activity with only minor symptoms |
| 80% | Normal activity with effort, some symptoms |
| 70% | Cares for self, unable to do normal activity |
| 60% | Requires occasional assistance |
| 50% | Requires considerable assistance |
| 40% | Disabled, requires special care |
| 30% | Severely disabled |
| 20% | Very ill, requires hospitalization |
| 10% | Moribund, fatal process progressing rapidly |
| 0% | Deceased |
When to make the transition
There is no single point when doctors definitively recommend hospice. It’s a very individual decision based on the patient’s needs and wishes. Some general guidelines include:
- Patients declining despite disease-directed treatment
- Treatment focused on quality of life rather than a cure
- Patient strongly values comfort care over life-prolonging measures
The transition tends to occur when:
- The patient has advanced, end-stage disease
- Life expectancy is 6 months or less
- Treatment aims to maximize comfort and dignity
Example indicators it may be time for hospice
| Disease | Potential indicators for hospice |
|---|---|
| Cancer |
|
| ALS |
|
| End-stage dementia |
|
However, the choice depends on the individual patient’s values and priorities. Patients can always leave hospice and return to curative treatment if their condition improves or stabilizes. Or they may choose to remain in hospice if it aligns with their care goals, even with a prognosis over 6 months.
Talking with doctors about hospice
Becoming educated about hospice criteria helps patients and families have informed conversations with their doctors. Questions to ask include:
- How do you determine life expectancy for hospice eligibility?
- What clinical signs or test results are you looking at?
- How quickly do you expect my condition to progress?
- How might my quality of life change in the next 3-6 months?
- What factors should I consider when deciding on hospice care?
Doctors make hospice recommendations based on their clinical judgment and knowledge of the patient. Their input, along with the patient’s values, helps guide the transition process. With an understanding of what to expect, patients and families can make informed choices about pursuing hospice care.
Medicare coverage of hospice services
Medicare Part A covers hospice care for terminally ill beneficiaries with a life expectancy of 6 months or less. To qualify, the patient’s hospice doctor and regular doctor must certify the prognosis. Coverage includes:
- Doctor services
- Nursing care
- Medical equipment
- Prescription drugs
- Short-term inpatient care
- Home health aide and homemaker services
- Counseling
- Spiritual support
Patients can receive hospice care for two 90-day benefit periods, followed by an unlimited number of 60-day periods. The care is covered in full as long as doctors recertify life expectancy is 6 months or less at the start of each period. Patients pay a copay of up to $5 per prescription.
Medicare hospice benefit usage
Here is a table showing the percentages of Medicare hospice patients by length of stay in 2018 (latest data available):
| Length of Stay | Percentage of Patients |
|---|---|
| Less than 7 days | 9.6% |
| 7-14 days | 5.7% |
| 15-30 days | 9.8% |
| 31-60 days | 11.5% |
| 61-90 days | 11.3% |
| 91-180 days | 18.8% |
| Over 180 days | 33.3% |
This shows hospice lengths of stay vary widely, with a third of patients receiving care for over 6 months. Doctors recertify these patients as still having a 6-month prognosis based on the expected progression of their condition.
Conclusion
The decision to begin hospice is highly personal based on each patient’s unique situation. Doctors recommend hospice when they estimate a patient has 6 months or less to live if their disease follows its normal course. However, predicting life expectancy is inexact. The most important factors are the patient’s wishes, care goals, and priorities. With hospice, the focus shifts to providing comfort and enhancing quality of life. Through discussions with their doctors, patients with terminal illnesses can determine when it feels right for them to transition to hospice care.