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Palliative Care - Hospice Care - Fast Facts | NEJM Resident 360
Definition and Key Aspects of Hospice Care
Hospice care is both a system and a philosophy of care, focused on enhancing quality of life for patients in the final months of life. To qualify for hospice care, a patient must have a life-limiting diagnosis, with an estimated prognosis of six months or less, as certified by the treating physician.
Hospice care is provided by an interdisciplinary team of clinicians (see below) and may be delivered in multiple care settings. Hospice care at home is most common, though services may also be provided in a free-standing hospice facility, a skilled nursing facility, or a hospital setting, varying based on the patient’s care needs and eligibility.
At the time of hospice enrollment, patients typically stop receiving disease-directed therapies, instead receiving care focused on relief of physical, psychological, and spiritual distress.
Hospice care is paid for via Medicare or a patient’s private insurance. For Medicare beneficiaries, the Medicare hospice benefit covers costs related to the life-limiting diagnosis. This includes clinician services, medical equipment (such as wheelchair, walker, hospital bed, commode), and prescription drugs intended to relieve symptoms related to the terminal illness.
Patients may disenroll from hospice care at any time, such as if their health improves and they elect to pursue further disease-directed treatments. They may also reenroll in hospice at a later time.
Distinguishing Hospice Care from Palliative Care
Hospice care is specialized care aimed at relieving suffering in the final months of life, typically delivered by an interdisciplinary team when patients are no longer receiving disease-altering treatments. Palliative care, by contrast, focuses on enhancing quality of life throughout the course of a serious illness. Palliative care may begin at the time of diagnosis and is often delivered concurrently with disease-directed therapies.
The table below provides a useful comparison of hospice care and palliative care:
(Source: Palliative Care for the Seriously Ill. N Engl J Med 2015.)
Levels of Hospice Care
There are four levels of hospice care. Each patient’s symptoms and care needs determine which level is most suitable to his or her situation.
1. Routine home care
This is the most common type of hospice care, usually delivered within the patient’s home. The patient’s loved ones are the primary caregivers, supported by visits from hospice nurses and interdisciplinary staff (social worker, spiritual care professionals, home health aids, volunteers, and others). Hospice agency staff may visit a few times weekly or as often as daily, depending on the patient’s care needs. Staff give the patient and loved ones guidance regarding medications for symptom management, as well as emotional and spiritual support. The patient and family are also provided with a phone number, at which they can call the hospice agency with concerns 24 hours per day. This often becomes an alternative to calling 911, in an effort to support the goal of remaining at home.
It is a common misconception that hospice services provide 24-hour nursing care at home. That occurs only in the context of continuous home care (see below). Some families may elect to hire private nursing services to augment the support from the hospice agency, though this can be very costly.
2. Continuous home care
Continuous home care refers to around-the-clock nursing services provided in the home for a patient who is having active symptoms requiring ongoing management. Hospice staff remain in the patient’s home for multiple hours, until the symptoms are controlled. This is a temporary service, and the need for continuous home care is reevaluated by the hospice agency at a defined interval (e.g., every 24 hours). If the symptoms cannot be adequately controlled in the home, the patient may require transfer to a facility for general inpatient care (see below).
3. General inpatient care
General inpatient care (GIP) is provided to patients with active symptoms that cannot be managed in a home setting. Such patients often require intravenous medications for symptom control. GIP hospice care is typically provided in a free-standing hospice facility owned by the hospice agency or in a hospice unit within a hospital. In these settings, patients receive around-the-clock nursing care as well as support from other interdisciplinary staff.
4. Respite care
Respite care is short-term care provided in a facility setting in order to give loved ones a necessary reprieve from caregiving. Respite care is typically provided in a free-standing hospice facility, a nursing home, or a hospital setting. Patients and loved ones are eligible for a limited number of respite care days on an occasional basis, as defined by their insurance plan.
Evidence-Based Benefits of Hospice Care
Hospice care has been associated with numerous benefits to the patient, family, and health care system. Patients who die at home with hospice care demonstrate increased quality of life (including increased physical comfort and psychological well-being) compared with patients who die in the hospital or intensive care unit (ICU). Hospice care has also been associated with improved bereavement outcomes for caregivers. Additionally, patients enrolled in hospice caredemonstrate decreased health care utilization and costs near the end of life.