Hospice decisions can be difficult for patients, families, and physicians to discuss. Choosing hospice care services requires careful consideration because it is a weighty decision. Hospice care is a very personal decision. Although cancer is a common hospice diagnosis, fewer than one-third of hospice patients have been diagnosed with cancer. Moreover, every patient's disease progression and prognosis is different. All of these factors can result in a very different decision-making process for different patients.
Nevertheless, it is possible to identify some characteristics of hospice care and the patients who use it. The National Hospice and Palliative Care Organization (NHPCO) has studied hospice care service providers and their patients. Here are four frequently asked questions, along with answers, about hospice care:
Regardless of the patient's disease or condition, hospice care generally requires a prognosis of six months or less. But how do doctors arrive at this prognosis?
Based on research, scientists have identified certain situations that are correlated with a prognosis appropriate for hospice care. For example, a six-month prognosis may be made based on a rapid progression of the patient's disease or condition over three to six months as established by test results combined with rapid weight loss or a drop in levels of a liver protein called albumin. All of these can signal that the body is struggling to overcome the disease or condition.
A tool known as the Palliative Performance Scale (PPS) has been developed to help determine a patient's suitability for hospice. The PPS assigns a score based on factors such as the patient's ambulation, activity level, evidence of disease, ability to self-care, ability to eat and drink, and level of consciousness. For example, a patient who is confined to bed, cannot work and needs assistance with care may be eligible for hospice, with other supporting signs.
Physicians can also use disease-specific signs that indicate that the patient has a six-month prognosis. One common hospice diagnosis is cancer. When a cancer patient has extensive malignancy, has a score of 70% or lower on the PPS, and declines despite treatment, hospice care may be available. These disease-specific signs are available for each common hospice diagnosis, including heart disease, dementia, kidney disease, stroke, and lung disease.
Hospice patients range widely. According to the NHCPO, about 47% of people in hospice care are over the age of 85 and about 5% of are under the age of 65. Among those between 65 and 85, the number in hospice care increases with age.
About 58% of hospice patients are women. Two reasons explain this. First, women tend to live longer than men, so the age distribution of hospice patients tilts the gender distribution in favor of women. Second, women are more likely to prefer palliative care, while men are more likely to prefer curative treatment even when they have been informed that treatment would be ineffective. This difference is attributed to social factors that define the roles of men and women. Men tend to want to "fight" their disease or condition.
Hospice care usually begins with a discussion between a physician and the patient. This discussion will likely occur when the patient has received a common hospice diagnosis, such as cancer, combined with a prognosis of less than six months.
If the patient desires more information about hospice care, the physician can make a hospice referral. In response to the hospice referral, the patient has a face-to-face meeting with a hospice nurse or hospice physician to discuss hospice services. This meeting is covered for patients insured by Medicare.
Although the prognosis to trigger hospice care is six months or less, about 6.7% of patients are discharged as no longer terminally ill. In fact, research shows that palliative care improves the quality of life and reduces depression in cancer patients. This improvement in mood and outlook resulted in about three months of additional life.
Hospice care is reviewed after six months. If the patient's condition is no longer terminal, the patient can be discharged. If the patient's condition is unchanged, Medicare can authorize payment for additional hospice services.
Hospice care is a difficult decision. However, having reliable information can help.