Hospice and Palliative Care Diagnosis: Ensuring Quality End-of-Life Care

Hospice care represents a vital medical service dedicated to providing holistic, high-quality end-of-life care. At its core is an interprofessional team, often guided by a physician medical director, ensuring comprehensive patient management. Many physicians in this field pursue specialized fellowship training and board certification in hospice and palliative medicine, demonstrating a deep commitment to this area of healthcare.

The foundation of hospice lies in delivering palliative and complex symptom management for individuals with a life expectancy of six months or less. Identifying appropriate candidates involves a nuanced evaluation process. While numerous conditions might qualify a patient for hospice, it’s crucial to differentiate between chronic, stable conditions with minimal impact on prognosis and those that truly signify a terminal stage. Treatments effective for chronic illnesses may become detrimental or non-palliative during the terminal phase, necessitating a shift in focus towards comfort and quality of life. Therefore, a thorough assessment of all patient conditions and treatment plans is paramount when considering hospice eligibility.

Research consistently highlights the positive impact of hospice care on patients’ quality of life. However, statistics reveal a concerning trend: hospice patients, on average, live only about 2.5 months after receiving a six-month prognosis and enrolling in services. This data point, rather than suggesting hospice hastens death, underscores a critical issue – delayed hospice referrals. Patients often become eligible for hospice much earlier than when they actually receive these services. This delay means individuals miss out on the extensive benefits a comprehensive hospice program can offer during their final months. Further investigation is needed to understand the reasons behind this delay, but it’s clear that earlier access to hospice is essential to maximize patient well-being.

Initiating hospice care is not simply about a physician’s six-month prognosis. It involves a detailed and meticulous evaluation, along with thorough documentation, to ensure a smooth transition. The evolving landscape of healthcare, with updated guidelines, revised standards, and new ICD codes, continually shapes the interpretation and application of hospice diagnoses and regulations. Furthermore, the Centers for Medicare and Medicaid Services (CMS) consistently updates its expectations regarding billing and coding practices within hospice care.

Navigating hospice diagnoses can be complex, especially for healthcare providers who don’t specialize in this area. Hospice physicians and organizations play a crucial role in providing clarity and guidance. These organizations can assist in determining patient eligibility and facilitate sensitive conversations with patients and families about the advantages of hospice services. Given the intricate nature of the approval process, early referral to hospice after a terminal diagnosis is generally recommended. This proactive approach ensures the integration of excellent, continuous care. Ultimately, the hospice agency bears the responsibility for ensuring that all patients under their care meet hospice eligibility criteria and that the services provided are medically necessary.

CMS’s approach to hospice-appropriate diagnoses has evolved. The current focus extends beyond a single primary diagnosis to encompass all relevant conditions, related or unrelated, that influence prognosis or the underlying terminal illness. The Uniform Hospital Discharge Data Set defines the principal diagnosis as the “condition after study chiefly responsible for causing admission of the patient to the hospital.” In hospice care, this translates to the diagnosis considered most significant in contributing to the patient’s six-month prognosis. If multiple diagnoses equally contribute to a poor prognosis, all should be documented as principal diagnoses, without a required sequence.

Diagnoses in hospice care are not static. They can and should change as a patient’s condition progresses through the terminal stages. Regular updates and documentation, including additions and deletions, are essential. Maintaining static diagnoses over time might inaccurately portray a stable condition, potentially leading to a reevaluation of the patient’s continued hospice appropriateness.

Determining a terminal prognosis of six months or less often involves considering multiple hospice-appropriate diagnoses. All diagnoses must be confirmed by a physician or legally accountable provider, emphasizing the importance of expert medical judgment in this process.[¹][²][³][⁴]

Key Concerns in Hospice Diagnosis

Many concerns surrounding hospice-appropriate diagnoses center on securing and maintaining approvals, as well as navigating billing and coding complexities. Common challenges include the effective use of symptom codes, combination codes, and accurately coding diagnoses not explicitly listed in manuals. Emerging areas of concern involve specific conditions such as dementia, determining fractures as primary diagnoses, correctly sequencing primary versus secondary neoplasms, and precisely documenting cerebrovascular diagnoses, distinguishing between acute and late-effect codes.[⁵][⁶]

Clinical Importance of Accurate Hospice Diagnosis

Each hospice patient is unique, with diverse diagnoses and conditions influencing their end-of-life journey. Documentation must be comprehensive, clear, and factual, reflecting the patient’s individual circumstances and the impact of their diagnoses on their prognosis. Regular re-evaluation of a patient’s hospice appropriateness is crucial, considering their physical, mental, social, and spiritual needs. CMS guidelines require the coding of all current diagnoses in patient documentation. Conversely, past diagnoses with no bearing on the patient’s current status or prognosis (history codes) should be removed according to coding guidelines. Hospice claims can accommodate up to twenty-five diagnoses. Conditions lacking specific codes or that cannot be included in the diagnoses section can be addressed in the narrative portion of the care plan documentation. Overall, accurate hospice diagnosis and enrollment demand critical thinking from physicians, including maintaining an updated list of conditions and removing irrelevant history codes.

For practical guidance, the Centers for Medicare and Medicaid Services provides assessment criteria for disease progression and non-disease baseline guidelines. An abridged version of these criteria is outlined below:

Part 1: Guidelines for Decline in Clinical Status

A. Disease Progression: Evidenced by worsening status, symptoms, signs, and laboratory results:

• Clinical Status:

  • Refractory or recurring infections
  • Progressive inanition, indicated by measures like 10% weight loss, decreased albumin, and dysphagia leading to aspiration.

• Symptoms:

  • Include nausea and vomiting, dyspnea, persistent cough, fatigue, cognitive decline, diarrhea, and escalating pain.

• Signs:

  • Encompass hypotension, edema, ascites, progressive weakness, new altered mental status, among others.

• Laboratory Results:

  • Include worsening pCO2/pO2/SaO2 values, deteriorating liver function tests, increasing tumor markers, and unstable sodium and potassium levels.

B. Progressive disease leading to a decline in Karnofsky Performance Status or Palliative Performance Score.[⁷]

C. Worsened functional assessment staging of diagnosed dementia.

D. Increased need for assistance with Activities of Daily Living (ADLs).

E. Worsening refractory stage 3 to stage 4 pressure ulcers despite wound care.

F. Increased healthcare utilization such as emergency room visits, hospital admissions, and physician appointments related to the primary hospice diagnosis prior to hospice enrollment.

Part 2: Non-Disease Specific Baseline Guidelines (Both A and B must be met)

A. Physiologic impairment of functional status as indicated by a Karnofsky Performance Status or Palliative Performance Score of less than 70%.

B. Need for assistance with two or more ADLs: ambulation, transfer, dressing, feeding, continence, and bathing.

C. Comorbidities: When a condition is not the primary hospice diagnosis, significant comorbidities contributing to a prognosis of six months or less should be considered. Examples include:[⁸][⁹][¹⁰][¹¹]

• Chronic obstructive pulmonary disease (COPD)
• Congestive heart failure (CHF)
• Ischemic heart disease
• Diabetes mellitus
• Neurologic diseases (cerebrovascular accident, Parkinson’s disease, multiple sclerosis, amyotrophic lateral sclerosis)
• Renal failure
• Liver disease
• Neoplasia
• Acquired immune deficiency syndrome/HIV
• Dementia
• Refractory severe autoimmune diseases (e.g., lupus or rheumatoid arthritis)
• Recurrent sepsis

Review Questions

(Original review questions are assumed to be available in the source context, but not provided for rewriting in this prompt.)

References

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3. Wang X, Knight LS, Evans A, Wang J, Smith TJ. Variations Among Physicians in Hospice Referrals of Patients With Advanced Cancer. J Oncol Pract. 2017 May;13(5):e496-e504. PMC free article: PMC5455161 PubMed: 28221897
4. Cheraghlou S, Gahbauer EA, Leo-Summers L, Stabenau HF, Chaudhry SI, Gill TM. Restricting Symptoms Before and After Admission to Hospice. Am J Med. 2016 Jul;129(7):754.e7-754.e15. PMC free article: PMC4914433 PubMed: 26968471
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6. Cherlin EJ, Brewster AL, Curry LA, Canavan ME, Hurzeler R, Bradley EH. Interventions for Reducing Hospital Readmission Rates: The Role of Hospice and Palliative Care. Am J Hosp Palliat Care. 2017 Sep;34(8):748-753. PubMed: 27443281
7. Mehta A, Chai E, Berglund K, Rizzo E, Moreno J, Gelfman LP. Using Admission Karnofsky Performance Status as a Guide for Palliative Care Discharge Needs. J Palliat Med. 2021 Jun;24(6):910-913. PMC free article: PMC8336248 PubMed: 33524302
8. Jones BW. Evidence-based practice in hospice: is qualitative more appropriate than quantitative? Home Healthc Nurse. 2013 Apr;31(4):184-8. PubMed: 23549249
9. Kaufman BG, Klemish D, Kassner CT, Reiter JP, Li F, Harker M, O’Brien EC, Taylor DH, Bhavsar NA. Predicting Length of Hospice Stay: An Application of Quantile Regression. J Palliat Med. 2018 Aug;21(8):1131-1136. PubMed: 29762075
10. Goy ER, Bohlig A, Carter J, Ganzini L. Identifying predictors of hospice eligibility in patients with Parkinson disease. Am J Hosp Palliat Care. 2015 Feb;32(1):29-33. PubMed: 23975684
11. Wladkowski SP, Wallace CL. Current Practices of Live Discharge from Hospice: Social Work Perspectives. Health Soc Work. 2019 Feb 01;44(1):30-38. PubMed: 30561640

Disclosure: Dac Teoli declares no relevant financial relationships with ineligible companies.

Disclosure: Abhishek Bhardwaj declares no relevant financial relationships with ineligible companies.