#247

Initiating a Hospice Referral From the Emergency Department

  • Sangeeta Lamba MD
  • Tammie E Quest MD
  • David E Weissman MD

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Background     Patients with an end-stage illness often present to the Emergency Department (ED) with a crisis event (1).  This Fast Fact provides information for ED providers on how to refer a patient to hospice care directly from the ED (2). Fast Fact #246 suggests strategies for caring for patients receiving hospice care who present to the ED; Fast Fact #298 covers Palliative Care consultation in the ED.

1.  Assess Medicare Hospice Benefit eligibility (see Fast Fact #82).  Fundamentally, this means the patient has a prognosis that is 6 months or less if his/her disease runs its expected course, and the patient’s care goals are compatible with hospice (see #3 below).  Broad guidelines for many cancer and non-cancer related conditions exist (3, 4, 5, 6).  A useful starting point is to ask yourself, Would I be surprised if this patient died within the next 6 months?  For disease specific prognostic information, see Fast Facts #13, 99, 124, 125, 141, 143, 150, 189, 191, 213.

2.   Discuss hospice as a disposition plan with the patient’s physician.   Contact the patient’s personal physician: discuss the current condition, prognosis, and prior goals of care conversations.  If you are considering hospice care, ask if the physician is willing to be the following physician for hospice services.

3.   Assess whether the patient‘s goals are consistent with hospice care.  Generally this means a patient wants medical treatments and other support aimed at alleviating symptoms and maintaining quality of life, without life-prolongation.  Patients may enroll in hospice care if their preeminent care goal is symptom relief, even if they are not entirely sure they want to completely discontinue life-prolonging therapies, as long as the hospice agency indicates they can accommodate those wishes.  These four questions will help you get the discussion started to elicit if the patient and family are psychologically ready to accept hospice care (see also Fast Facts #222-227).

  • “What have you been told about the status of your illness and what the future holds?”
  • “Has anyone talked to you about your prognosis; how much time you likely have?”
  • “Are there plans for new treatments designed to help you extend your life?”
  • “Has anyone discussed with you hospice services? What do you know about Hospice?”

4.  Introduce hospice to the patient and family/surrogates.  

  • Discuss the core aspects of hospice care and how these features can help the patient and family (e.g. 24/7 on-call assistance, home visits for symptom management, coordinated care with the patient’s physician, emotional and chaplaincy support).
  • Address concerns and clarify misconceptions.  
  • Phrase your recommendation for hospice care in positive language, grounded in the patient’s own care goals.  “I think the best way to help you stay at home, avoid the hospital, and stay as fit as possible for whatever time you have left is to receive hospice care at your home….”
  • Discuss location of hospice care:  usually this is the patient’s residence such as a private home or long-term care facility.  Direct admissions to hospice facilities can occur depending on bed availability and ability of local hospice agencies to arrange an immediate, direct facility admission.  This is not available in all communities and requires a discussion with the hospice agency.

5.  Make a referral and write orders (see Fast Fact #139). 

Call a hospice agency; anticipate these questions:  

  • What is the terminal illness? Who will be the following physician? (Step 2)
  • What equipment will be needed immediately (e.g. home oxygen)? Is there a caregiver at home?
  • Code status (patients cannot be denied hospice enrollment if ‘full code’, however the hospice team will need to know if code status needs to be addressed further.)

Questions you may need to ask the hospice agency:

  • How soon can you make an intake visit to the patient’s home? Can you visit the patient immediately, even in the ED (this is available in some communities)?
  • How should I coordinate filling of new prescriptions I want the patient to have?

Example of ED Initiated Hospice Referral Orders:

  • Evaluate and Admit/Enroll in hospice care
  • Terminal Diagnosis: __________.
  • Expected Prognosis: Terminal illness with less than 6 month survival likely if disease runs its normal expected course [or more specific if indicated].
  • Physician who will follow patient: _________.

6.  Ensure patient/surrogate understanding and secure the plan.   Communicate the plan following ED discharge; provide the name and contact number for the hospice agency.

7.  What if hospice enrollment is appropriate, but cannot be arranged in a timely manner?  If the patient can be cared for at home safely for 1-2 days without extra services, send her or him home with appropriate prescriptions and care instructions.  In most communities, patients can be enrolled in hospice care within 24-48 hours, even on weekends.  If they cannot be cared for safely at home, observation vs inpatient admission is likely necessary until a safe discharge plan can be established. 

Summary     Patient-centered care for hospice-eligible, terminally-ill patients may be enhanced by emergency clinicians who acquire skills to make early appropriate hospice referrals from the ED.  

References

  1. Lamba S, Quest TE. Hospice care and the emergency department: rules, regulations and referrals. Ann Emerg Med. 2011; 57:282-290.
  2. Education in Palliative and End-of-Life Care-Emergency Medicine Project, Trainers Guide. Module 5. Emanuel LL, Quest TE, eds.  Chicago, IL: Northwestern University; 2008.
  3. Stuart B, et al. Medical Guidelines for determining prognosis in selected non-cancer diseases. 2nd ed. Alexandria, VA: National Hospice Organization; 1996.
  4. Centers for Medicare and Medicaid Services, Medicare Coverage Database. LCD (Local Coverage Determination) for hospice: determining terminal status (L25678). Available at: http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=25678
  5. Gazelle G. Understanding hospice – an underutilized option for life’s final chapter. New Engl J Med. 2007; 357(4):321-4.
  6. Lynn J. Perspectives on care at the close of life. Serving patients who may die soon and their families: the role of hospice and other services. JAMA.  2001; 285(7):925-32.

Author Affiliations:  University of Medicine and Dentistry of New Jersey, Newark, New Jersey (SL); Department of Veterans Affairs, Emory University School of Medicine, Atlanta, GA (TEQ); Medical College of Wisconsin, Milwaukee, WI (DEW). 

Version History: Originally published September 2011; Copy-re-edited August 2015.