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When Is It Time to Call Hospice? Signs that it's Time for Hospice Care

 July 7, 2021

A Comprehensive Breakdown of the Clinical Signs for When Hospice Care is Appropriate

Hospice Care: Making the Decision

holding and elderly hand

What is Hospice Care?

Hospice care is a holistic approach to treatment that focuses on the patient and family which addresses the physical, mental, emotional, and spiritual needs of the patient and family.

At Connecticut Hospice, we understand that it is a highly personal decision to begin receiving hospice care and we value the choices and goals of each patient and family. We are here to help you make the decision of when it's time for hospice care.

Medicare Health Insurance Card

What Does the Hospice Benefit Cover?

Medicare Hospice Benefit Eligibility

  1. Medicare Part A
  2. Physician certified six months or less prognosis if the terminal illness runs its natural course
  3. The individual is willing to forgo curative therapy for the terminal illness, elect the hospice benefit, and waive all rights to Medicare payments for the terminal illness and related conditions

Centers for Medicare and Medicaid Services, 2021

Hospice Documentation of Decline

A computer keyboard with a stethoscope draped over it.

Patients are considered to have a life expectancy of six months or less if there is documented decline in clinical status.

  • Presumes assessments are done over time
  • Baseline and follow up data must be reported
  • Other clinical variables that may support this prognosis should also be included

End-of-Life Physical Signs 

  • Frequent or recurring infections
  • Rapid decline in health despite aggressive medical treatment
  • Frequent hospitalizations or emergency room visits
  • Uncontrolled pain, nausea, or vomiting
  • Increase in the amount of time sleeping
  • Loss of urinary or bowel control
  • Chest congestion and/or rapid breathing
  • Decrease in food and fluid intake; weight loss
  • Changes in body temperature (fever or feeling cool to the touch)
  • Restlessness or repetitive motions
  • Decreasing ability to perform daily tasks without assistance

End-of-Life Mental And Emotional Signs

  • Withdrawal from family, friends, and loved ones
  • Making statements or requests that seem out of character • Giving away personal belongings
  • Making funeral plans
  • Experiencing visions or hallucinations
  • Making apologies or saying goodbye
  • Expressing a desire to no longer seek medical interventions, hospitalizations, treatment

Painting the Picture of the Decline of a Terminal Patient

measuring tape

Weight Loss:

The patient is unable to be weighed on scales due to bed-bound status. MAC is 18cm to the right upper arm. During the interview with the daughter, who has been caring for the patient over the past year, she said that her mother has lost weight in the past 3 months but unable to state how much. The daughter states that she has been wearing clothing in a size 16 women’s but now she had to get mother new clothing gradually over the past few months due to her clothing “falling off of her”. The patient is now able to wear size 10 women's clothing.

Loss of Appetite:

The patient has been eating 4-6 child-size meals per day but has only eaten about 25% of each meal. This consists of 2 slices of bacon, 3 bits of grits for breakfast. She had a 1/3 of an Ensure supplement, then for lunch, she had a few bites of homemade soup and a popsicle.

Nurse Hold walker for hospice patient getting out of bed

Decline in Functional Status:

The patient requires assistance of one for bathing at the sink, dressing his lower body and now uses a walker for all ambulation inside and outside of his room. The patient was completely independent with all ADL’s and driving and working every day until 3 months ago when he was diagnosed.

Hospice Patient Sleeping with wife at his bedside

Sleeping:

The Nurses Aide describes the patient is sleeping 8-10 hours at night and then takes a 3-4 hour nap during the day. When the patient is up in the chair for more than an hour, she is frequently dosing off. This is a change from just 2 months ago when the patient was not even sleeping during the night and was having agitation in the evening and sleeping a few hours during the day only

A Clinical Break Down of End-of-Life Signs

Patient is Unresponsive to Therapies:

  • Pain requiring increasing doses of analgesics
  • Persistent nausea despite multiple drug (Compazine, Phenergan, Zofran, Reglan)or non-pharmacological interventions (diet, aromatherapy)
  • Dyspnea and persistent cough with increasing respiratory rate
  • Diarrhea

Progressive Weight Loss:

  • Weight loss of at least 10% of body weight in the previous 6 months (not related to reversible causes; diuretic, depression)
  • Decreasing anthropogenic measures (mid-arm circumference, abdominal girth)
  • Observation of ill-fitting clothes, decreased skin turgor, increasing skin folds
  • Other observation to demonstrate loss of weight in a patient that can not be weighed on a scale

Dysphagia

  • Coughing or choking when eating or drinking, persistent drooling of saliva, pocketing of food; being unable to chew food properly, a gurgly, wet-sounding voice when eating or drinking.
  • Leading to recurrent aspiration and/or inadequate oral intake ØDocumented decrease in food portion consumption
  • Documented decrease in food portion consumption 

Decline in Clinical Status

  • Decline in systolic BP to < 90 or progressive postural hypotension
  • Ascites
  • Venous, arterial, lymphatic obstruction due to metastatic disease
  • Edema
  • Pleural or Pericardial effusion 
  • Weakness
  • Change in level of consciousness

Laboratory Values

  • Increasing or Decreasing pCO2
  • Decreasing SaO2
  • Increasing calcium, creatinine, or liver function test ØIncreasing tumor markers
  • Progressively decreasing or increasing serum potassium or sodium

Decline in Clinical Status Guidelines

  • Decrease in Karnofsky and Palliative performance Score due to disease progression
  • Progressive decline in Functional Assessment Staging Test (FAST) for dementia to 7A or greater
  • Progression to dependence on assistance with ADLs
  • Progressive stage 3-4 pressure ulcers despite optima care
  • Increasing ER visits, hospitalizations, or physician visits related to the terminal illness before election of the hospice benefit.

Non-Disease Specific Baseline Guidelines

(HIV Disease, Stroke, and Coma require a lower score to qualify)

Dependence on assistance for two or more of the following ADLS

  • Ambulation 
  • Continence 
  • Transfer 
  • Dressing 
  • Feeding 
  • Bathing

Comorbidities

  • Chronic Obstructive Pulmonary Disease (COPD)
  • Congestive Heart Failure (CHF)
  • Ischemic Heart Disease
  • Diabetes Mellitus (DM)
  • Neurologic Disease (Parkinson, ALS, MS, CVA)
  • Renal Failure
  • Liver disease
  • Neoplasia
  • AIDS/HIV
  • Dementia
  • Refractory Autoimmune disease (Lupus or Rheumatoid Arthritis)

Palliative Performance Score (PPS) below 70%*

Palliative Performance Scale PPS
% Ambulation Activity Level Evidence of Disease Self Care Intake Level of Consciousness Est. Median Survival in Days (a) Est. Median Survival in Days (b) Est. Median Survival in Days (c)
100 Full Normal No Disease Full Normal Full NA NA 108
90 Full Normal Some Disease Full Normal Full NA NA 108
80 Full Normal With Some Effort Some Disease Full Normal Full NA NA 108
70 Reduced Can't do Normal Job or Work Some Disease Full Normal or Reduced Full 145 NA 108
60 Reduced Can't do hobbies or housework Significant Disease Occasional assistance needed Normal or Reduced Full or Confusion 29 4 108
50 Mainly sit/lie Can't do any work Extensive Disease Considerable assistance needed Normal or Reduced Full or Confusion 30 11 41
40 Mainly in bed Can't do any work Extensive Disease Mainly assistance needed Normal or Reduced Full or Drowsy or Confusion 18 8 41
30 Bed Bound Can't do any work Extensive Disease Total Care Reduced Full or Drowsy or Confusion 8 5 41
20 Bed Bound Can't do any work Extensive Disease Total Care Minimal Full or Drowsy or Confusion 4 2 6
10 Bed Bound Can't do any work Extensive Disease Total Care Mouth Care Only Drowsy or Coma 1 1 6
0 Death

Karnofsy Performance Status (KPS) below 70%*

Karnofsky Performance Status Scale Definitions Rating % Criteria
100 Normal no complaints; no evidence of disease
Able to carry on normal work; no special care needed 90 Able to carry on normal activity; minor signs or symptoms of disease
80 Normal activity with effort; some signs or symptoms of disease;
70 Cares for self; unable to carry on normal activity or do active work.
Unable to work; able to live at home and care for most personal needs; varying amount of sassistance needed. 60 Requires occasional assistance; but is abke to care for most personal needs.
50 Requires considerable assistance and frequent medical care.
40 Disabled; requires special care an assistance.
30 Severely disabled; hospital admission necessary; active supportive treatment necessary.
Unable to care for self; requires equivalent of institutional or hospital care; disease may be progressing rapidly. 20 Very Sick; hospital admission necessary; active support treatment necessary.
10 Moribund; fatal processes progressing rapidly.
0 Dead

Download our Free PDF of Hospice Ready Signs

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Do you have a loved one that is ready for Hospice Care?

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