ACOFP Blog

By Gail Dudley, DO, CHCQM, MHA, FACOFP

Hospice and Palliative Medicine

As osteopathic physicians, we are schooled in the body/mind/spirit of our patients, and therefore, we know the difference between curing and healing. If you cannot cure the patient, hopefully you can heal them. Nowhere is this perhaps more important than in the care of our patient with end-of-life issues.

So, in selecting hospice care, we hope that when we cannot cure the patient, we can heal them in spirit and mind.

Is Your Patient (and Are You) Ready for Hospice?

The decision to discuss hospice with your patient is not a simple one, involves many facets and would follow discussions about a terminal diagnosis. Is your patient physically, emotionally and spiritually ready for end-of-life discussions? Are you ready to discuss these issues with your patient and their loved ones? Can you give “bad news” and handle family dynamics?

Many who work in medicine have difficulty with the death of a patient. Many doctors feel when a patient dies that they failed their patient. Doctors see their task as saving and curing the patient, but if they talk about hospice, they are taking away hope. The focus of medical education is treating the patient as well as fixing what is broken. But death, like birth, is part of life. We do everything thought possible, but where is the point at which we convert to helping them choose another course of treatment. That being to treat the patient rather than the disease.

Eligibility for Hospice Care

Eligibility is based upon prognosis, not diagnosis. Yet the mantra often is “do they have a diagnosis that, if it ran its normal course, it would take the life of the patient in six months or less?” It is really kind of both. The prognosis is more than just the diagnosis, and often the patients have several factors that create their eligibility. When a patient is initially evaluated for admission to hospice, there are several factors that are considered and standards that must be met. These depend upon the diagnosis used for eligibility, because the terminal prognosis is most often based upon a combination of diagnoses and other comorbid factors, including secondary conditions as a result of their main diagnosis. Basically, we look at it from a subjective judgement, a statistical prognosis and from the clinical condition.

On initial eligibility, there must be two physicians that agree to the eligibility, who will sign a form stating so. One is the hospice medical director and the other is usually the patient’s attending physician who recommended hospice admission. Thereafter, there is only one signature required for re-eligibility: provided by the hospice medical director. Typically, there are two initial 90-day certification periods, followed by an unlimited number of 60-day periods. If a patient leaves hospice, they can be re-admitted at another time.

Eligibility Criteria

So, what makes a patient eligible for hospice care and services? And again, it’s important to remember that certification for hospice is based upon proximity to end-of-life and not on medical necessity. Hospice looks at the diagnosis, any co-morbid, co-exiting, and secondary conditions and their effect on the main diagnosis. What is the affect and effect cycle? What subjective and objective data and medical findings are we seeing? What about symptom burden, disease therapy and illness trajectory? We look at measurable data, which can be monitored for worsening that will help the eligibility.

A patient’s FAST (functional assessment staging) score needs to be in the 7 range. A patient would likely be completely bed-bound, or bed-chair existence. Usually they are incontinent of bowel and bladder (FAST score 6d-e). Usually these patients have limited ability to speak; often 1-5 words a day, or absent all intelligible vocabulary, meaningless vocalizations or understandable words used in an incorrect or meaningless context (FAST score 7a-b). Most often these patients are non-ambulatory; though sometimes when admitted they can self-propel in a wheelchair (considered ambulation), or maybe can stand to pivot, etc. As the patient progresses, they are unable to sit up independently (FAST score 7d), then to being unable to smile (FAST 7e), and lastly unable to hold their head up (FAST 7f). But upon admission they are usually at the FAST score of 7 or at least 6d-e, depending on other criteria.

We also look at the co-morbid and secondary conditions. So, if our patient also had another diagnosis like DM, heart or lung disease that was also declining and adversely affecting the Alzheimer’s such that we are seeing secondary conditions, then that helps the eligibility. If they have DM and are not eating well, this would affect the BS levels. Or they have atrial fibrillation and their heart rate is staying irregular and they are having unstable angina. Or they have COPD and now need oxygen at home—one can see how the secondary conditions affect their overall health and worsen prognosis. What are their pulse ox scores? Are they diminishing from in the 90s to 80s on room air? Is their AF now continuous and not paroxysmal? Are their vital signs no longer stable? Etc., etc. Their prognosis is now affected by the main diagnosis, co-morbidities and secondary conditions. Terminally ill patients will demonstrate disease progression despite optimal assistive care.

Measurable Data

Or—tools of the trade for prognostication. These provide measurable data points that can be followed, but their reliability is only as good as the IRR (inter-rater reliability), and the skill and education of the person performing the measuring. These include scales, tests and other measuring tools. There is not enough room to define all that we use, but below are some examples and state why others are minimally helpful.

ESAS (Edmonton Symptom Assessment System): scale of 1-10. ESAS assess pain, tiredness, nausea, depression, appetite, well-being and SOB.

ECOG (Eastern Cooperative Oncology Group): 0-5 level. ECOG used for assessing function and was devised to select patients for cancer research. It is often used with the KPS.

KPS (Karnofsky Performance Scale): 10-100%. An oncologist developed this to determine how the chemotherapy he ordered was affecting them functionally.

PPS (Palliative Performance Scale): 10-100%. This was developed for hospice use and determines functional capacity based on 5 categories; level of importance flows left to right: ambulation, activity and evidence of disease, self-care, intake, and level of consciousness.

Braden Scale: Predicts pressure sore risk; the lower the score, the higher the risk. This scale uses sensory perception, moisture, activity, mobility, nutrition, and friction and shear.

MAHC: (fall assessment tool) score of 4 or more; uses multiple indictors

FAST (functional assessment staging): This has only been validated in Alzheimer’s patients, but is routinely used in all dementia patients. It grades ability to speak, move and ambulate, incontinence, and ability to sit up and smile.

MUAC (mid upper arm circumference): This is used to determine muscle atrophy. Unfortunately, in chronically ill patients this is not useful. There is acute (or new) muscle atrophy and there is chronic, disuse muscle atrophy. The chronic custodial patients have likely had disuse atrophy, and so these measurements or not useful in that patient population.

MRI (Mortality Risk Index): for end-stage dementia; also uses 7 functional activities of daily living and other factors to determine how long they will live

There are others that include the NYHA and ACC for heart disease, and the Child-Pugh score for liver disease.

Putting It All Together

So, when determining if you patient is ready for hospice, you need to look at many factors in addition to the diagnosis. Check the American Academy of Hospice and Palliative Medicine (AAHPM) website for helpful information. Consider looking at some of the grading scales mentioned above to get an idea. Call your local hospice and speak to someone in admissions who can give you more parameters to check appropriate for the diagnosis.

Hospice care can provide a great deal of assistance as well as spiritual and emotional comfort during your patient’s final journey.