When to refer patients for hospice care

August 19, 2014

What happens to patients once they reach the maximum benefit of traditional curative treatment? For many, hospice should be considered. A point on the healthcare continuum, hospice offers a comfort-focused approach to care when aggressive treatment would create more burden than benefit for the patient. The National Hospice and Palliative Care Organization (NHPCO) estimates that in 2013, more than 1.1 million patients died in hospice programs in the United States.

Many people link hospice with a cancer diagnosis—yet cancer diagnoses accounts for only about one-third of hospice admissions. Hospice may be appropriate not just for cancer patients but for others at the end stage of a chronic debilitating disease. Statistics show a growth in hospice referrals; most referrals are initiated less than 3 weeks before the patient’s death.

Hospice care specializes in managing symptoms and providing psychosocial, spiritual, and emotional support while preparing the patient and family for the final days. Initiating a hospice referral early gives the hospice team time to:

  • develop an end-of-life plan of care with the patient and family
  • discuss advanced directives, if these aren’t already in place
  • review the goals of care.

As a nurse, you’re ethically obligated to ensure patients’ and families’ right to self-determination in making healthcare choices, especially when it comes to end-of-life care. Early hospice referral can increase family functioning and caregiver satisfaction, reduce hospitalizations, and promote bereavement adjustment. This article examines a scenario similar to those encountered by nurses in many healthcare settings.

Identifying a high-risk patient

Marvin Grant, age 85, is admitted to the hospital for treatment for a urinary tract infection and dehydration. He has a history of dementia (diagnosed 10 years ago) and heart failure (HF). Three months ago, he was treated for aspiration pneumonia, which necessitated placement of a percutaneous endoscopic gastrostomy (PEG) tube. His body mass index (BMI) is 18, indicating he’s slightly underweight, and he has a stage 2 pressure ulcer on his coccyx. He’s becoming more dependent for care and is unable to ambulate. Although oriented to self, he verbalizes only two or three words. This is his third hospitalization this year, and he remains a full code.

Mr. Grant doesn’t have a living will. His son, who has power of attorney, hopes tube feedings will help his father regain strength and return to his baseline status.

You might encounter patients like Mr. Grant in virtually any healthcare setting, including a nursing home, home care, or acute care. In each setting, care providers have the opportunity to assess such patients for hospice referral and initiate a discussion with the interdisciplinary healthcare team. When a hospice consult is ordered, the provider making the referral order must agree that the patient’s prognosis is less than 6 months and aggressive therapy is no longer beneficial. For hospice admission, Medicare requires that the attending physician and hospice medical director certify the patient is terminally ill with a life expectancy of 6 months or less.

Indicators for hospice referral

When faced with a patient like Mr. Grant, ask yourself, “Would I be surprised if this person died within the next 6 months?” Although chronic illnesses can take a relatively unpredictable progression, the following factors indicate a poorer prognosis:

  • poor performance status
  • declining cognitive status
  • advanced age
  • poor nutritional status
  • pressure ulcers
  • comorbidities
  • previous hospital admissions for acute decompensation.

Poor performance and cognitive status

Declining performance and cognitive status predict a poor prognosis. Ask yourself, “Can the patient perform activities of daily living (ADL) or carry on a meaningful conversation?”

To assess performance and functional status, you can use several scales, such as the Palliative Performance Scale (PPS) or the Reisberg Functional Assessment Staging (FAST) Scale. PPS evaluates five areas—ambulation, activity and evidence of disease, self-care, intake, and level of consciousness. It grades each activity on a scale of 0% to 100%; the lower the score, the poorer the performance.

More specific for dementia patients, FAST is designed to evaluate cognitive and functional status. A score of 7C indicates loss of independent ambulation, loss of verbal capacity, and dependence on others for ADLs. The FAST score is one of Medicare’s criteria for hospice appropriateness for dementia patients.

Both PPS and FAST are useful in documenting disease progression. Obtaining a PPS score on admission to an acute or long-term facility allows comparison with later scores to assess for a decline over time. In our example, Mr. Grant is becoming more dependent in his ADLs and therefore has a relatively low performance rating on both scales.

Advanced age

Mr. Grant’s advanced age makes it less likely he will regain the ability to become independent.

Poor nutritional status

Assess the patient for malnutrition, use of artificial nutrition, BMI below 18.5, progressive loss of 10% of baseline weight, and serum albumin level below 3 g/dL. For patients with dementia, enteral feeding hasn’t been shown to improve survival significantly. Mr. Grant is receiving artificial nutrition and has a low BMI; caregivers should continue to evaluate him over time for progressive weight loss.

Pressure ulcers

Presence of at least one pressure ulcer suggests a poor prognosis. Mr. Grant has a stage 2 ulcer.


Mr. Grant’s medical history includes dementia and HF. A combination of chronic comorbid conditions increases symptom burden. A hospice nurse may conduct a formal evaluation to see if Mr. Grant meets hospice criteria for these chronic diseases based on Medicare guidelines. Given the combination of physical indicators, Mr. Grant most likely is appropriate for hospice care.

Previous hospital admissions for acute decompensation

This is Mr. Grant’s third hospital admission in 6 months.

Framework for discussion

Because nurses spend more time with patients than other healthcare team members do, we may be more aware of the need to discuss advanced care planning and hospice. We’re often present to answer questions and help the patient and family fully understand the information the physician has provided.

If the patient has an advanced directive, it should be part of the health record so all healthcare team members can review it. If the patient doesn’t have one, ask about his or her wishes regarding health care. If the patient can’t participate in this discussion, as with Mr. Grant, urge the family to focus on what their loved one would want—not what they want for their loved one. (See SPIKES: A framework for difficult discussions.)

Nurses have the opportunity to evaluate their patients and promote hospice referral through thoughtful, planned interdisciplinary collaboration and, most important, by communicating with the patient and family. Many clinical indicators can point to the need for a hospice referral. Using these indicators as triggers for a discussion about a hospice referral can help prevent aggressive treatments that won’t improve survival. Using the information in this article, you can help answer the all-important question, “Is it time?” O


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Elizabeth Puffenbarger is a liaison for the Center for Connected Care at the Cleveland Clinic Hospice and Palliative Medicine at Home in Independence, Ohio.