Ok- so this is an odd follow-up to my blog on aging well, but hey, this is the scope of what we see in geriatrics- from the robust older adult to the frail older adult, many times all in the span of a day.

In these past few weeks, I've had several patients and families consult me about hospice and some end-of-life care planning.  These encounters along with what I've seen over my years of practice highlight how much confusion and misunderstanding there is about hospice.  

So, I decided to write down the conversations I've had with patients & families to clarify a couple of things & clear up some common myths.  These are the questions & concerns I've heard most frequently so I hope they can help you as you navigate this option. 

#1 Hospice is a model of care along with a philosophy of care.  Its aim is to provide symptom control, peace, comfort, & dignity to a patient who is experiencing an illness with a limited life expectancy.  

#2 Hospice is a benefit under Medicare Part A.  Once a patient transitions into hospice care, they tap into their Medicare Part A Hospice benefit to provide coverage for the care.

#3 Yes, a physician does need to certify that a patient's life expectancy is 6 months or less, BUT THAT DOES NOT MEAN THAT "THIS IS IT."  The way I look at it as a physician is asking myself if I would I be surprised if the patient in front of me passed away in the next 6 months.  If I say, "yes" to myself (yet another instance of me talking to myself, but that's another topic), then perhaps this patient is not ready or appropriate for hospice care yet.  If I say "no" to myself, then maybe this is a path to explore further.  All this being said, 6 months is not a time stamped or carved in stone.  Many patients enrolled in hospice, especially at home or in a facility, have been on the hospice program for much longer, sometimes a year or two.  Basically, what you're certifying is that the patient in front of you has a diagnosis that is life limiting and you are expecting a trajectory of decline.  In face of this situation, the patient/family has elected to aggressively pursue care that prioritizes their comfort, pain & symptom control, dignity, & peace.  

#4 Routine labs, x-rays/imaging, diagnostic studies, physical therapy, etc. usually will not be covered under the hospice benefit.  Remember, the goal is comfort, peace, & symptom control.  If a patient is experiencing something causing him/her discomfort, treatments are provided to help them with this.  We're not looking for the cause, but for a way to provide them comfort.  Similarly, therapies are usually not covered.  The only exceptions may be for a very limited number of visits focused on a goal that might make the patient more comfortable- e.g working with the caregivers to understand mobilizing them out of bed into a wheelchair to spend time in a different location during the day.

#5 Medications are covered under the hospice benefit, but mainly the ones related to the qualifying diagnosis and those aimed to provide comfort or symptom control.  Upon enrollment, the hospice team will review the medications with the patient & family and let them know which ones would be covered and which ones will not.  Again, remember, the goal on hospice is not curative or prevention, but to optimize symptom control, peace, comfort, & dignity.  

#6 All hospice agencies have social workers, chaplains, & bereavement specialists to work with the patient & family.  These individuals are extremely helpful for things like logistics, planning, & most importantly, how to have certain delicate conversations or navigate spiritual care.  For example if  a patient has young children or younger adults involved, these individuals can help them understand what's going on- at their level.  Hospice also provided bereavement support for the 1st year after a patient's death. 

#7 Hospice care can be provided at home, in a facility (assisted living/skilled nursing), or (less frequently these days) in a hospital.  

• At home, hospice will provide nursing care & supervision, an aide, medications, equipment, oxygen, & other providers (social workers, chaplains, etc.) to support the patient's care there.  It will not provide 24/7 aide care though. The aide from hospice is usually there for 1-2 hours about 4-6 days per week.  The family/caregiver is responsible for the remainder of the time, & hospice at home requires family/caregivers/aides to be present 24/7 who are willing & able to assess the patient's situation and provide certain treatments if needed.  The hospice aide can help with some basic care & companionship, but cannot clinically triage patients or administer medications.  Additionally, The patient's care giver team must be able to arrange this level of care for hospice to be appropriate for the home situation.

• In an assisted living or skilled nursing (nursing home) environment, hospice services can be provided as at home.  However, because the patient is in a facility, aides & sometimes nursing care can be provided.  The key thing to remember is that in a facility, the care provided by hospice is covered by Medicare Part A Hospice benefit, BUT, the patient/family is responsible for paying room & board privately.  

• Hospice in an "inpatient hospice facility" is becoming more rare, but many hospice agencies have agreements with local hospitals to provide inpatient care when/if needed.  There are a few big caveats to this that you need to be aware of when it comes to "inpatient hospice."  Inpatient hospice is really meant for critical situations- when a patient's symptoms cannot be controlled at home and needs more aggressive interventions (e.g. intravenous dosing of medications, very frequent adjustments of medication regimens with nursing oversight).  Alternatively, this can apply if a patient has already been admitted to hospital for some illness and decides to transition their care to hospice.  In both situations, hospice usually expects care to last in the hospital for 3-5 days.  In that time span, if the patient stabilizes or can be controlled on a regimen that can be managed at home or in a facility, the plan would be to transition him/her there.  Naturally, the other outcome in those 3-5 days would be death.  Inpatient hospice is not meant to be a long-term option for hospice care. 

• All sites of hospice care are managed by the hospice agency's team and a nurse will be on-call 24/7 to help with any questions or concerns.  Many times, at home or in a facility, if a concern comes up during the "after hours," the nurse will make an effort to come see the patient as soon as possible the next day to reassess the situation.  All hospice teams also have a physician who helps oversee the care and provide guidance.  

  
  

#8 Hospice can be a a very helpful, comforting, & pleasant way to face a terminal illness or condition. The earlier the hospice team is involved in the care, the better it is for all as they have the time to get to know the patient and their loved ones and vice-versa.  Quite often, patients/families go crashing into hospice at very rapid speed and this can be overwhelming and discombobulating (one of my favorite words, again, another topic).  

Geriatrics Planning & Solutions, Inc. is happy to help you navigate these discussions and approach these decisions to see if it's right for you or your loved one.  Call us today for a consult and get started.