Hospice Care

Initiate primary or specialty palliative care when serious illness produces uncontrolled physical or emotional symptoms, psychosocial or spiritual distress, or difficult tradeoffs about treatment, discharge location, or future care. Palliative care provides symptom management, psychosocial support, and shared decision-making and may continue alongside disease-directed or life-prolonging therapy. Wolters Kluwer+1Wolters KluwerProviding Quality Wound Care at the End of Life : Journal of Hospice & Palliative NursingACCPalliative Care Consultation and the Transition to Hospice for Patients with End-Stage CVD - American College of Cardiology

Offer hospice when the patient’s informed goals favor comfort-focused care rather than further disease-modifying treatment and the certifying clinicians judge survival is more likely to be 6 months or less. Hospice is an interdisciplinary model centered on comfort and quality of life rather than cure. BMJ+2BMJHospice and palliative care utilization in 16 004 232 medicare claims: comparing trauma to surgical and medical inpatients | Trauma Surgery & Acute Care OpenJAMAEvaluation of Prognostic Criteria for Determining Hospice Eligibility ...ScienceDirectHospice Underutilization in the U.S.: The Misalignment of Regulatory Policy and Clinical Reality - ScienceDirect

Frame referral as an active care transition rather than treatment withdrawal: hospice addresses pain and other distressing symptoms and includes emotional, psychosocial, and spiritual support. An informational visit is a reasonable next step when a potentially eligible patient is not ready to enroll during hospitalization or at home. annemergmed+1annemergmedHospice Care and the Emergency Department: Rules, Regulations ...annemergmedUnited States Best Practice Guidelines for... : Annals of Emergency ...

Document the prognosis as a clinical synthesis rather than as a single-score result: underlying disease trajectory, recurrent acute deterioration, functional decline, treatment intolerance or lack of remaining acceptable disease-modifying options, current symptom burden, and the patient’s stated goals. Medicare hospice access depends on a prognosis of 6 months or less; at admission, two physicians must judge that death within 6 months is more likely than survival beyond that interval. JAMA+1JAMAEvaluation of Prognostic Criteria for Determining Hospice Eligibility ...ScienceDirectHospice Underutilization in the U.S.: The Misalignment of Regulatory Policy and Clinical Reality - ScienceDirect

Avoid using disease-specific hospice criteria as if they reliably predict a 6-month outcome in noncancer illness. In COPD, suggested criteria for initiating palliative care based on poor short- or medium-term prognosis have not shown sufficient reliability; in advanced dementia, FAST-based 6-month mortality prediction has also been unreliable. Variable trajectories, multimorbidity, and overlapping symptoms limit discrimination and calibration across noncancer conditions. BMJBMJPrognostic models and factors identifying end-of-life in non-cancer chronic diseases: a systematic review

When prognosis remains uncertain but needs are substantial, refer for palliative care and revisit hospice after each hospitalization, major functional decline, treatment-limiting complication, or explicit change in goals. Prognostic uncertainty should prompt iterative reassessment, not deferral of symptom management or advance care planning. BMJ+2BMJPrognostic models and factors identifying end-of-life in non-cancer chronic diseases: a systematic reviewScienceDirectHospice Underutilization in the U.S.: The Misalignment of Regulatory Policy and Clinical Reality - ScienceDirectWolters KluwerProviding Quality Wound Care at the End of Life : Journal of Hospice & Palliative Nursing

In advanced heart failure, involve palliative care particularly for stage D disease because patients face high cardiac and noncardiac symptom burden and complex choices about therapies and future care. A randomized U.S. study of patients hospitalized for heart failure within the prior year and with ESCAPE score 4 or greater found that an interdisciplinary nurse practitioner-led palliative intervention improved 6-month Kansas City Cardiomyopathy Questionnaire score by 9.49 points and FACIT-Pal score by 11.77 points compared with usual care. jacc+1jaccPalliative Care in Heart Failure: Rationale, Evidence, and Future PrioritiesACCPalliative Care Consultation and the Transition to Hospice for Patients with End-Stage CVD - American College of Cardiology

Consider hospice for heart failure when the patient has been optimally treated or is not a candidate for surgery or other interventions and has NYHA class IV symptoms at rest despite medical therapy. Supporting clinical features include symptomatic or refractory ventricular arrhythmias, prior cardiac arrest, syncope, or embolic stroke. These findings support the overall prognosis assessment; they do not replace discussion of whether the patient wants further disease-modifying treatment. ACCACCPalliative Care Consultation and the Transition to Hospice for Patients with End-Stage CVD - American College of Cardiology

Patients considered for destination ventricular assist device therapy require palliative care specialist participation. Use that consultation to address symptom burden, expected tradeoffs, advance care planning, and contingency planning for later clinical deterioration or a transition away from device-directed care. ACCACCPalliative Care Consultation and the Transition to Hospice for Patients with End-Stage CVD - American College of Cardiology

Conduct a structured goals-of-care discussion before referral: establish the patient’s understanding of illness and expected trajectory; identify priorities such as comfort, time at home, function, or life prolongation; ask which interventions would become unacceptable if decline continues; and identify the surrogate decision-maker. Hospice and palliative care consultations commonly address symptoms, goals, desired post-treatment location, advance care planning, and spiritual concerns. jacc+1jaccPalliative Care in Heart Failure: Rationale, Evidence, and Future PrioritiesACCPalliative Care Consultation and the Transition to Hospice for Patients with End-Stage CVD - American College of Cardiology

Include caregivers directly, with the patient’s permission, because advance care planning interventions improve patient-caregiver congruence for end-of-life preferences (standardized mean difference 0.73; 95% CI, 0.42 to 1.05). Effects on congruence decline over time, so revisit documented preferences after major changes in health status or care goals. ACP also improved decisional conflict in two trials and showed evidence of improved bereavement outcomes and satisfaction with communication. BMJBMJAdvance care planning and caregiver outcomes: intervention efficacy – systematic review | BMJ Supportive & Palliative Care

When discussing hospice, distinguish an informational visit from enrollment, state that symptom management remains active medical care, and clarify whether ongoing disease-directed treatments fit the patient’s goals and the intended hospice plan. For patients who decline enrollment, document the conversation, continue palliative care, and schedule reassessment at the next clinical inflection point. Wolters Kluwer+2Wolters KluwerProviding Quality Wound Care at the End of Life : Journal of Hospice & Palliative NursingannemergmedHospice Care and the Emergency Department: Rules, Regulations ...annemergmedUnited States Best Practice Guidelines for... : Annals of Emergency ...

At transition, define the immediate plan around the patient’s priority symptoms, preferred location of care, caregiver needs, and communication pathway for new distress. In palliative wound care, goals are stabilization of existing wounds, prevention of new wounds when feasible, and symptom management to improve comfort and well-being; the same goal-oriented approach prevents default pursuit of low-value healing or disease-control endpoints when they conflict with comfort. Wolters KluwerWolters KluwerProviding Quality Wound Care at the End of Life : Journal of Hospice & Palliative Nursing

For advanced heart failure, clinically meaningful palliative-care outcomes include documentation of goals of care, hospice utilization with attention to stays shorter than 7 days or longer than 180 days, pain control, days at home during the last 6 months of life, and family experience. Use these measures to identify late referral, unresolved symptoms, or a mismatch between documented goals and delivered care. jaccjaccPalliative Care Across the Spectrum of Heart Failure

Perform a medication review when hospice begins, prioritizing medications that improve current comfort or function and reconsidering agents whose harms or burdens outweigh quality-of-life benefit. Hospice nurses report that deprescribing discussions are more acceptable to caregivers and prescribers when framed around medication harms and their effects on quality of life. Wolters KluwerWolters KluwerNurses’ Perspectives on Family Caregiver... : Journal of Hospice & Palliative Nursing