Fast Fact and Concept #090: Medicare Hospice Benefit Part III: Special Interventions

2nd Edition

Author(s): Robin Turner, MD & Drew Rosielle, MD

This Fast Fact will discuss the use of interventions in hospice care that can be controversial due to high cost and/or uncertainty whether they constitute ‘palliative’ interventions. 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 outlined in the POC, and these services are paid for from the pool of money the hospice program gets from per diem payments (physician fees are billed separately – see Fast Fact #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. Most hospice agencies are not able to provide high-cost interventions due to financial limitations; patients may elect to be discharged from hospice care if they wish to pursue these options. Hospices with a large number of enrolled patients have greater financial resources and thus are better able to provide high-cost treatments. Recently, some hospices have introduced ‘open-access’ programs which more freely provide costly and even life-prolonging therapies to dying patients who would otherwise benefit from hospice services. The hope is that the increased costs will be covered by increased revenue from enrolling more patients earlier in the course of their illness.

Indications for use in Hospice Care In general, the interventions listed below are potentially indicated in patients with a) a good functional status (up, out of bed > 50% of the time; Karnofsky Performance Status >50; ECOG ≤ 2 – see Fast Facts #13, #124), 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 (see Fast Fact #133).

Enteral feeding Indication: patient is hungry and there is a reason oral nutrition can’t be given (e.g. upper GI obstruction from esophageal cancer). See Fast Facts #10 and #84 for a complete review of the indications/contraindications for tube feeding.

Total Parenteral Nutrition Indication: patient has short-gut syndrome or bowel obstruction and good functional status and a functional goal. See Fast Fact #190 for further discussion.

Radiation Therapy Indication: symptoms of pain, bleeding, or neurological catastrophe (e.g. acute spinal cord compression) and thepatient is expected to live long enough to experience benefit (> 4 weeks) and the potential benefits outweigh logistic burdens (e.g. travel to the radiotherapy 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 continuedfunctional benefit from treatment.

Platelet Transfusions Indication: active bleeding and severe thrombocytopenia (Platelet count < 10K).

Chemotherapy Indication: symptoms from the cancer are causing distress and thelikelihood of effectiveness is high (expected Response Rate greater than 25% - see Fast Facts #14, #99) and patient will live long enough to benefit (> 4-8 weeks, ECOG 0-2) and benefits outweigh burdens.

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.

Laboratory/Diagnostic services Indication: to monitor aspects of POC (e.g. warfarin monitoring) or as part of a diagnostic evaluation for a new symptom for which the testing is likely to substantially alter patient management. Note: diagnosis of a new problem that does not relate to the terminal illness can be evaluated and treated by the patient’s primary care provider under usual Medicare billing (e.g. acute myocardial infarction).

References

1. The Hospice Manual. Centers for Medicare & Medicaid Services. Available at: http://www.cms.hhs.gov/manuals/downloads/pub_21.zip. Accessed November 1, 2007.
2. Wright AA, Katz IT. Letting go of the rope – aggressive treatment, hospice care, and open access. NEJM. 2007; 357:324-327.
3. Marantz Henig R. Will we ever arrive at the good death? New York Times. August 7, 2005. Available at: http://www.nytimes.com/2005/08/07/magazine/07DYINGL.html. Accessed November 2, 2007.

Fast Facts are edited by Drew A. Rosielle MD, Palliative Care Center, Medical College of Wisconsin. For comments/questions write to: drosiell@mcw.edu. The complete set of Fast Facts is available at EPERC: www.eperc.mcw.edu.

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Turner R, Rosielle D. Fast Fact and Concept #90. Medicare Hospice Benefit, Part III: Special Interventions. 2nd Edition. November 2007. End-of-Life/Palliative 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: 1/2008

Purpose: Instructional Aid, Self-Study Guide, Teaching

Audience(s)

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Ethics, law, policy, health systems