Fast Fact and Concept #90: Medicare Hospice Benefit Part III: Special Interventions

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Title: Fast Fact and Concept #90: Medicare Hospice Benefit Part III: Special Interventions

Author(s): Robin Turner, MD

This fast fact will discuss the use of interventions in hospice care that are often controversial and confusing. When a patient elects the Medicare Hospice Benefit (MHB), the patient, the doctor and the Hospice team develop a Plan of Care (POC) that lists a) the patient?s goals for care and b) the services needed to achieve these goals. A hospice program is fiscally responsible for all services (no copay except $5 for meds) outlined in the POC either directly, or through contracts with approved providers (e.g. contract with local hospital for radiotherapy). All hospice services and contracted arrangements are paid from the pool of money the hospice program gets from the per diem payment (see Fast Facts # 82, 87).

Note: since there is no Medicare regulation that specifies what treatments are deemed palliative, it is up to the individual hospice agency to determine whether or not they can financially and philosophically provide the interventions listed below. These interventions range from low cost-low tech (hydration via clysis) to high cost-high tech (multi-agent chemotherapy). With the exception of very large hospice agencies that have a substantial financial base, most agencies will not provide high-cost interventions; patients may elect to be discharged from hospice care if they wish to pursue these options.

Indications for use in Hospice Care In general, the interventions listed below are potentially indicated in patients with a) good functional status (up, out of bed > 50% of the time; KPS >50; ECOG 0-2) and/or b) a clear goal to be met (e.g. wedding anniversary in two weeks). These interventions are not indicated solely to assist patients or families psychologically cope with impending death -- to give the impression that ?something? is being done.

Parenteral Fluids Indication: symptomatic dehydration where there is a patient-defined goal (e.g. upcoming family event). Fluids are not indicated to treat dry mouth or solely to reverse dehydration occurring as a normal aspect of the dying process; fluids may be of benefit to treat delirium in selected patients.

Enteral feeding Indication: patient is hungry and there is a reason oral nutrition can?t be given (e.g. GI obstruction from esophageal cancer). See Fast Facts #10 and 84 for complete review and indications/contraindications for tube feeding.

Radiation Therapy Indication: symptom of pain, bleeding or neurologic catastrophe (e.g. acute spinal cord compression) and the patient is expected to live long enough to experience benefit (> 4 weeks) and the potential benefits outweigh logistic burdens (e.g. travel to the XRT site, getting on and off the treatment table). See Fast Facts # 66, 67.

Red Blood Cell Transfusions or Erythropoietin Indication: Symptomatic anemia (dyspnea or fatigue) in ambulatory patients who demonstrate continued functional benefit.

Platelet Transfusions Indication: active bleeding and severe thrombocytopenia (Plt Count< 10K). Note: medication options are also available, see Future Fast.

Chemotherapy Indication: symptoms from the cancer causing distress and likelihood of effectiveness is high (expected Response Rate greater than 25%--see Fast Fact #14) and patient will live long enough to benefit (> 4-8 weeks) and benefit outweighs burden and the patient is ambulatory (ECOG 0-1).

Antibiotics Indication: Oral antibiotics are appropriate to treat simple symptomatic infections (e.g. UTI). Parenteral antibiotics are not indicated unless there is an identified susceptible organism, and there is a clear functional goal to be met and the likelihood of successful treatment is high and the patient is expected to live long enough to achieve benefit.

Total Parenteral Nutrition Indication: TPN is appropriate in hospice when caring for a patient with short-gut syndrome or bowel obstruction and good functional status and a functional goal.

Laboratory/Diagnostic services Indication: to monitor aspects of POC (e.g. warfarin monitoring). Note: Diagnosis of a new problem that does not relate to the terminal illness can be evaluated and treated by the patients primary care provider under usual Medicare (e.g. AMI).

Also see:
Fast Fact #82, Medicare Hospice Benefit Part I: Eligibility and Treatment Plan
Fast Fact #87, Medicare Hospice Benefit Part II: Places of Care and Funding

References Standards of Practice for Hospice Programs. The National Hospice and Palliative Care Organization. 2000. Hospice Manual. Chapter II-Coverage of Services. Online: http://cms.hhs.gov/manuals/21_hospice/hs200.asp.

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing. Turner, R. Fast Facts and Concepts #90 . Medicare Hospice Benefit: Part III Special Interventions. May 2003. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 5/2003

Format: Handouts

Purpose: Instructional Aid, Self-Study Guide, Teaching

Training: Fellows, 3rd/4th Year Medical Students, PGY1 (Interns), PGY2-6, Physicians in Practice
Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN, Ophthalmology, Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery
Non-Physician: Clergy/Chaplains, General Public, Nurses, Social Workers

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Antibiotics, Blood products, Clinical interventions, Discussing hospice care, Hydration, Interventional procedures, Medicare hospice benefit, Negotiating treatment goals, Non-oral feeding, Radiation or chemotherapy, Rehabilitation, Surgery

The Fast Facts series is distributed for educational use only and does not constitute medical advice. For the most current version of Fast Facts visit the EPERC web site at www.eperc.mcw.edu. This mirror version is provided subject to copyright restrictions for educational use within the Inter-Instutional Collaborating Network on End-of-Life Care (IICN).