Hospice - Sooner Than Later
By Ruby Bendersky, MD, FACC
CMS has determined that a hospice beneficiary “be determined to have a terminal illness - which is defined as having a prognosis of 6 months or less if the disease or illness runs its normal course.” A patient is eligible for hospice when 1) he has less than six months to live, and 2) he chooses to forego curative treatment.
But the reluctance to turn to hospice sooner in the disease process than later may be due to societal & cultural taboos, patient or family denial, lack of shared Advance Directives, miraculous stories and other barriers from both physicians and their patients/families.
Barriers and benefits of hospice care
Some patients and their families simply do not want to receive hospice care. They may be unwilling to recognize that comfort rather than curative care is a more realistic goal. From the physician perspective, medical care is focused on curing and healing. There is still a strong social stigma within physician circles that hospice requires “giving up” on a patient. On the contrary, the benefits of hospice and palliative care is the true care coordination that occurs in this model. Medication reconciliation/management and care protocols are overseen by the hospice and patient selected physician, as well as an all-inclusive team. This care coordination reduces duplicative medication therapy, improves access to medical oversight and psychosocial needs, while improving the persons quality of life
A cursory list of eligible diagnoses includes ALS, Cancer, CVA/Stroke/Coma, Dementia/Alzheimer’s, Heart Disease, Huntington’s Disease, Lung Disease/COPD,
MS, MD, Parkinson’s, Chronic Renal Failure and other non-specific illnesses.
Some persistent myths
Hospice doesn’t require a physician’s order, but a physician’s recommendation is extremely influential. The burden of fully explaining the hospice benefit can and should be delegated to the hospice of choice. For the physician, ACA/Medicare penalties associated with rehospitalization and mortality are often mitigated or even dismissed by utilizing hospice. Physicians may also choose to continue following their patients on hospice as well.
Finally, perhaps the most common patient-perspective myth is that hospice benefits can be “used up.” Hospice care is available for two 90-day periods followed by an unlimited number of 60-day periods during the remainder of the hospice patient’s lifetime if they continue to meet hospice eligibility. And for the most part, DME and medications related to the diagnosis are provided at no cost, relieving some of the financial burdens often associated with end-of-life.
And hospice care comes with its own version of a guarantee: If the patient or family isn’t satisfied or wants to re-pursue curative measures, a beneficiary may voluntarily terminate (revoke) his or her hospice election period at any time.
Changes in hospice care
With the national average length of stay hovering near 17 days within the last few years, far too many patients and their families are not receiving the care and financial benefits of hospice earlier in their disease process. Technological advances in home care have brought about the use of EMRs, secure texting, even one-button cell phones with GPS and fall-algorithms, connected to quick react clinical teams. These and other advances are helping patients, physicians and hospital systems avoid unnecessary and often further-debilitating ER visits and hospitalization stays. This is especially true within the 30 days of an acute discharge.
The best hospice programs are not ambulance chasers – they’re ambulance avoiders.
No one has a crystal ball when determining the length of the “normal course” of a disease or illness process. As physicians, unless we come to embrace hospice as the best alternative care plan, we deprive both patients and families of realizing what could have been. Atul Gawande, MD, MPH, author of “Being Mortal,” sums it up this way: “Our ultimate goal, after all, is not a good death but a good life to the very end.”
Ruby Bendersky, MD, FACC, is a practicing clinical cardiologist, currently on retainer with OnPointe at Home. She is Medical Director over the specialty cardiac program, which is exclusively offered by OnPointe at Home in ABQ, NM. She can be reached at