hospice care

**Definition & eligibility (US/Medicare hospice benefit)** - Patient has a terminal illness with life expectancy ≤6 months if the disease follows its expected course. Two physicians (the attending and the hospice medical director) must certify this. - Patient (or surrogate) elects hospice and agrees to forgo curative or disease-modifying treatment for the terminal diagnosis. - Prognosis is not a fixed cutoff. Patients can be recertified in benefit periods (two 90-day periods, then unlimited 60-day periods) if they remain eligible. Patients can revoke hospice at any time and return to curative care. - Common diagnoses: cancer, end-stage heart failure, COPD, dementia (e.g., FAST stage 7), ESLD/cirrhosis, ESRD (if dialysis is stopped), ALS and other neurodegenerative disease.

**Hospice vs. palliative care (high-yield distinction)** - *Palliative care*: Given at any stage of serious illness, alongside curative or life-prolonging therapy, and has no prognosis requirement. - *Hospice*: Given only near the end of life, replaces curative intent, and requires a prognosis of ≤6 months. - All hospice is palliative, but not all palliative care is hospice.

**Interdisciplinary team** - Physician, nurse, social worker, chaplain, home health aide, volunteers, and bereavement counselors. - Care is delivered in the home (most common), nursing facility, inpatient hospice unit, or hospital. - Levels of care: routine home care, continuous home care (crisis), general inpatient care (symptoms uncontrolled at home), and respite care (up to 5 days to relieve caregivers). - Family bereavement support continues for about 13 months after death.

**Symptom management** - Pain/dyspnea: Opioids (morphine) are first-line for both. Titrate to comfort; there is no ceiling dose. The principle of *double effect* applies: the intent is symptom relief, not hastening death, and this is ethically and legally acceptable. Add a bowel regimen (senna ± polyethylene glycol) whenever opioids are started. - Nausea: Haloperidol, metoclopramide, ondansetron. - Terminal secretions ("death rattle"): Glycopyrrolate, scopolamine, or atropine. - Anxiety/agitation/delirium: Benzodiazepines, haloperidol. - Anorexia/cachexia: Focus on comfort feeding. Artificial nutrition/hydration is generally not beneficial in advanced dementia or at end of life. - Interventions are limited to those that improve comfort. Stop unnecessary meds (e.g., statins) and routine labs/monitoring.

**Ethics/communication (Step 2 CK/Step 3 favorites)** - Hospice is not "giving up" or euthanasia. It is not physician-assisted suicide. - Discuss goals of care using a structured approach (e.g., SPIKES for delivering bad news). - Respect patient autonomy. Honor advance directives, DNR/DNI, and POLST. The healthcare proxy decides if the patient lacks capacity. - Patients can be enrolled in hospice with a DNR order, but DNR is *not* required for hospice enrollment. - Hospice covers medications, equipment, and services related to the terminal diagnosis. Room and board in a facility is generally not covered. - Timely referral matters. Late referral (<7 days before death) limits the benefit to patient and family.

**Exam pearls** - Prognosis ≤6 months and focus on comfort = hospice. - A patient who wants chemotherapy or dialysis for the terminal diagnosis is generally not eligible for hospice, but palliative care is appropriate. - Opioids for dyspnea at end of life do not hasten death when titrated appropriately. - Do not withhold opioids out of fear of respiratory depression or addiction in terminal illness.