Clinical Inquiries

How do we decide when a patient with nonmalignant disease is eligible for hospice care?

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Each hospice has its own policy, but Medicare requires 6 months or less life expectancy for certification of eligibility and reimbursement. Other important criteria include patient and family understanding and wishes.

Evidence-based guidelines for determining prognosis in some noncancer diseases have been developed. However, despite their widespread use, limited data exist to support their accuracy (strength of recommendation: B). Moreover, a high degree of prognostic accuracy may be unattainable given the unpredictable course of common noncancer chronic diseases. Hospice eligibility for patients with nonmalignant disease is based on clinical judgment.


Refer to hospice when goals are focused on quality of life rather than intervention
Nancy Havas, MD
Medical Collage of Wisconsin, Milwaukee

Hospice referral with a nonmalignant diagnosis is challenging but essential to quality patient care. Between episodes of disease exacerbations, we need to take an active role in discussing goals of care, remembering that some patients and families need “permission” to palliative goals rather than continuing with aggressive interventions. My gauge of when to refer to hospice is when the goals of care become focused on quality of life and staying out of the hospital rather than intervention in the disease course. Most patients underuse the benefits that a hospice referral can provide, and while some patients outlive the 6-month criteria for hospice care, this benefit can be renewed if the patient still meets the criteria.

Evidence summary

Hospices have varying admission criteria. However, according to US law, patients must be certified to be “terminally ill” with a prognosis of less than 6 months to live in order to qualify for the Medicare hospice benefit.1 US law and Medicare regulations specify that an attending physician and the accepting hospice medical director must agree to the prognosis for certification of eligibility.

Brickner et al’s survey2 demonstrated that physicians find accurate prognostication difficult. Furthermore, many of the common noncancer diseases have erratic and unpredictable courses, making prognosis even harder. Indeed, patients with noncancer diagnoses are typically admitted to hospices later in their terminal course, 3 resulting in increased inpatient hospital stays4 and ultimately lower patient and family satisfaction. 5 The difficulties inherent in prognostication were underscored by a study that found patients with non-cancer diagnoses to be much more likely to be discharged from hospice alive.6

The National Hospice Organization (NHO) has created guidelines7 for determining prognosis in selected noncancer diseases including heart disease, pulmonary disease, dementia, HIV, liver disease, renal disease, stroke, coma, and amyotrophic lateral sclerosis (ALS). To validate these guidelines, one group identified 2607 patients who meet the NHO guidelines.8 Only 655 (25%) were dead within 6 months. The estimated median survival of these identified patients was 804 days. When every potential prognostic criterion was met (far more than NHO standards) only 19 of the 2607 patients qualified for hospice, and yet 10 of them were still alive at 6 months. Unlike many cancers, in which there is a steady terminal decline, diseases such as chronic obstructive pulmonary disease, congestive heart failure, and liver failure are characterized by a baseline of moderate functioning with intermittent—often life-threatening—exacerbations.

A recent Clinical Inquiry9 addressed the issue of hospice care for patients with late-stage Alzheimer’s disease. That evidence-based answer concluded that criteria superior to the NHO guidelines or clinical judgment had been established for prognosis of Alzheimer’s disease. However, using those improved criteria yielded only marginally more accurate prognostication. At best, 71% of the patients predicted to live less than 6 months did so, but only if the patients had progressed through the disease in an orderly fashion. For the larger subset of patients, those who did not progress through Alzheimer’s in a predictable way, only 30% of the patients actually died within 6 months.

Recommendations from others

The NHO7 provides parameters to help determine a 6-month life expectancy. The “General Guidelines for Determining Prognosis” are summarized in the TABLE. Further details of the “general guidelines” as well as guidelines for prognosis in specific diseases (heart disease, pulmonary disease, dementia, HIV, liver disease, renal disease, stroke, coma, and ALS) are outlined by the NHO.7

Hospice criteria

Patients should meet all of the following criteria:
  1. The patient’s condition is life limiting, and the patient and/or family have been informed of this determination.
  2. The patient and/or family have elected treatment goals directed toward relief of symptoms, rather than cure of the underlying disease.
  3. The patient has either of the following:
    1. Documented clinical progression of disease.
    2. Documented recent impaired nutritional status related to the terminal process.

Evidence-based answers from the Family Physicians Inquiries Network

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