When it comes to referring patients to hospice, there are many gray areas.
There are, however, explicit black-and-white requirements for hospice admission:
The patient must have six months or less to live.
Two physicians need to certify that the patient is terminally ill.
Documentation showing the pattern of decline, plus an end-stage diagnosis, must be provided.
For everything outside those requirements — the gray areas — the decision should start with the person who matters most: the patient.
“What are the patient’s goals? What do they expect from their treatment if they get aggressive therapy, are the side effects worse than the progression of the disease?” questions Maggie Stockton, Nurse Practitioner for Crossroads Hospice. Referral for hospice admissions “needs to be based on what the patient wants,” Maggie says. Prior to her career in hospice, Maggie worked in oncology, where her perspective on end-of-life care was formed. “As a healthcare professional, there’s always something else we can do,” Maggie says. After seeing the horrible side effects of chemotherapy, Maggie learned the importance of proposing different health care options — from continued treatment to hospice — with a patient. A recent study showed hospice is often used too late to really benefit a patient or the family. That’s why Maggie recommends starting hospice discussions earlier rather than later. A patient is likely to be open to options, but no one will know unless questions like the ones Maggie suggest are asked. “Maybe they’d rather be comfortable with a better way of life,” through hospice care, instead of continuing treatment. The better way of life that comes with hospice care originates with the years of experience behind the care. “We’ve had longevity, and we have more comfort options than ever before,” Maggie says. “We know more about how to improve someone’s quality of life.” When hospice in the United States began in the 1970s, the majority of the patients had terminal cancer, and so most of the care was for those needs. Now, hospice provides care for cancer as well as neurological, cardiac and other conditions. To begin the discussion of hospice care as an option, consider doing one of the following:
Have a conversation with the patient around a durable power of attorney, and then make it official.
Seek advice from a second physician, to discuss the patient's treatment options and rate of decline and to get a second opinion. This physician could go on to provide the second certification for hospice referral, as mandated by law, when it's appropriate for the patient.
- Think about what the patient’s behavior is like outside the hospital or doctor’s office – and that the person you see in the office may be putting on a front, while suffering in the privacy at home. Consider asking a Nurse Practitioner or Physician’s Assistant to meet with the patient one-on-one to get a better understanding of how the patient truly feels about their treatment options.
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