Chapter 27: End-of-Life Care

CASE 27.1

A 75-year-old man is admitted to the hospital for a heart failure exacerbation. This is his second admission for heart failure within the last 6 months. His nurse asks if he is an appropriate candidate for hospice care.

Question 27.1.1 Which of the following would qualify your patient for the Medicare hospice benefit?

A) His cardiac ejection fraction is 20%, and he is dyspneic with moderate exertion (NYHA class II heart failure).

B) He agrees to a do not resuscitate (DNR) status in the event of cardiorespiratory failure.

C) He needs assistance with ambulation.

D) His implanted cardiac defibrillator (ICD) has fired once in the past year.

E) He has had escalating cardiac hospitalizations despite optimal medical management.

Answer 27.1.1 The correct answer is "E." If your patient has a terminal disease with declining function, worsening symptoms, worsening laboratory tests, or escalating hospitalizations, he or she probably qualifies for hospice. "A," a low cardiac ejection fraction (typically <20%), is a recommended criterion for heart disease but must be accompanied by dyspnea at rest (class IV heart failure). "B" is incorrect. Despite popular belief, a hospice patient need not agree to a DNR status; however, hospice agencies are permitted to have different admission criteria and some require a DNR status for admission. Check with your local hospice agencies. Regardless, you should have a frank discussion with the patient about the role of aggressive resuscitation and the goals of hospice care. "C" is also incorrect. While a decline in functional status is a strong indication of worsening prognosis, it is not automatically a criterion. Most patients with heart failure need assistance with at least four activities of daily living (ADLs) before having a prognosis of death within 6 months. "D" is incorrect. Patients with ICDs are eligible for hospice, and whether or not it has fired does not impact enrollment decisions. It is important to talk about the ICD, ideally before a patient approaches the final weeks/days of life. Many patients choose to have it disabled once they enroll in hospice. If an ICD is not disabled, it is important that the hospice staff be aware of it and know what to do as it will fire when the patient dies, which can be distressing for both the patient and the family.