By Norma J. Hirsch, M.D., F.A.A.P.
This is a more complex question than it seems. And it is really a two part question: “Is the patient hospice eligible?” And secondly “Is the patient hospice appropriate?” We are well advised not to confuse the two questions and to ask and answer the first question before pursing an answer to
the second question.
“Is the patient hospice eligible?” Determining hospice eligibility is often art as well as science, because accurate prognosis is frequently very difficult. The hospice eligibility criteria as originally established were based upon limited clinical data and often do not accurately predict a survival of less than six months. Materials published by the American Academy of Hospice and Palliative Medicine, for example, indicate that given current medical and surgical interventions the National Hospice and Palliative Care Organization’s criteria for end stage heart disease will predict a less than one year survival accurately less than fifty per cent of the time(1).
Nicholas Christakis in his tome entitled Death Foretold: Prophecy and Prognosis in Medical Care (2) suggests that physicians
overestimate survival by two to five times. Clearly, we must continue to carefully study the disease trajectories that impact our patients' lives if we are to be able to more optimally assist the patients and families that we seek to serve. And clearly more evidence based principles will need to be brought to the art and science of predicting length of survival. Hopefully, the Electronic Clinical Record will enhance our skills and tools in prognostication. Even so, prognostication will likely remain part science and part art.
Currently, in order to be hospice eligible, two physicians must independently confirm that they believe that the patient is terminally ill with a life expectancy of six months or less if the terminal disease runs its normal course, state the clinical findings that they believe support this certification, AND attest that their confirmation is based upon their review of the patient’s records.
But beyond hospice eligibility lies the question of hospice ppropriateness. That is, “Does the patient and family embrace the hospice philosophy that is focused on quality of life?” For sure, there are individuals who meet the criteria for hospice eligibility, but who still want to pursue every possible intervention that might increase their length of survival by anything from hours to days to weeks, with seemingly only nominal consideration for the quality of life that will be obtained via this pursuit. In some of these instances the referring physician makes the hospice referral in hopes that the members of the hospice interdisciplinary team will be able to bring comprehensive teaching and intensive support to the patient and family in order to assist them to optimally utilize the remaining time that the patient still has to live. In other instances, the timing of the referral seems to be primarily related to the referring physician's discernment that the patient in all likelihood has less than six months to live given the usual trajectory of his disease. How the
patient is seeing his disease trajectory or the quality of his life may at times be given less weight in the decision making process.
While Medicare hospice eligibility criteria are universal, who is hospice appropriate is in some respects, hospice specific. That is, open access hospices would consider some patients to be hospice appropriate that other hospices would not be in a position to serve. This would include the fact that some hospices offer palliative radiation and palliative chemotherapy while others are not.
Whatever the reason for the referral of a patient that is hospice eligible, but not yet deemed hospice appropriate (by your hospice’s criteria of hospice appropriateness), it is critically important that there be informed consent. The patient (or surrogate decision maker if the patient lacks decision-making capacity) must be given an explanation of the services offered by the hospice program [and those not provided]. This information session should provide clarity regarding what the hospice is responsible for and what the patient and family will need to provide. THEN having understood this explanation, the patient/surrogate signs informed consent. That is, they enroll for services after they have been adequately informed, clearly understand what is being offered, and they have consented to receipt of the services being offered to them via the hospice provider.
In order to optimally respond to referrals to our hospice, we must do due diligence in determining the patient’s hospice eligibility. This is our first obligation and it must be met before enrolling the patient into hospice services. Once having answered the eligibility question YES, and only then are we ready to ask the second question. And we are well advised to ask ourselves this second question: “Is the patient hospice appropriate?” Knowing the answer to this second question will help us optimally offer our services to the patient and family, collaboratively respond to our referring physicians, and maximally utilize our resources.
Norma J. Hirsch, M.D., F.A.A.P. is Chief Medical Officer for Hospice of Central Iowa, Iowa's oldest hospice, now serving patients in 35 of Iowa’s 99 counties. She is board certified in hospice and palliative medicine and is an EPEC trainer. Prior to her entry into hospice and palliative medicine in 2000, she was the director of the Neonatal Intensive Care Unit at Blank Children’s Hospital which served approximately half of the state’s high risk births. Norma can be reached at nhirsch@hospiceofcentralowa.org.
1. Storey, C. Porter, Jr., Stacy Levine, and Joseph W. Shega, Eds., 2008: American Academy of Hospice and
Palliative Medicine, Unipac 9 (Third Edition): The Hospice and Palliative Medicine Approach to Selected
Chronic Illnesses: Dementia, COPD, and CHF, American Academy of Hospice and Palliative Medicine,
Glenview, Illinois.
2 .Christakis, Nicholas A., 1999. Death Foretold: Prophecy and Prognosis in Medical Care, University of
Chicago Press, Chicago, Illinois. |
