When to Consider Hospice in Cancer

Hospice eligibility is a rule, not a judgment about attitude. Medicare requires the hospice doctor, and the person's regular doctor if they have one, to certify that the illness is terminal. That means a life expectancy of 6 months or less if it runs its normal course.

Two more conditions apply. The patient must have Medicare Part A. The patient must also accept comfort care for the cancer instead of care aimed at cure. Then they sign a Hospice Election Statement.

Nothing in that rule says a person must die within 6 months. The National Cancer Institute notes that hospice goes past 6 months. It continues as long as the patient still qualifies at each review.

Medicare sets hospice up as two 90-day benefit periods. After those come an unlimited number of 60-day periods. At the end of each one, a doctor reviews the case and either recertifies or does not.

People sometimes hear "the 6-month rule" and assume hospice ends at a deadline. It does not. It renews.

Federal rules at 42 CFR 418.302 set out what a hospice can bill. Knowing the names helps a caregiver ask for the right thing during a bad week.

Routine home care. The default. The patient is at home and not receiving continuous care. Home here includes a nursing home or an assisted living apartment.

Continuous home care. For a crisis at home, such as pain out of control, breathlessness, or agitation. The rule requires at least 8 hours of care in a day. Most of that must be nursing care, though aide or homemaker hours can count.

Inpatient respite care. Short-term care in an approved facility so the family can rest. The rule caps it. It may not run more than 5 days in a row.

General inpatient care. For pain control, or for symptoms that cannot be handled in another setting.

If a caregiver is drowning, say the words "we need respite" or "we need continuous care." Those are billing categories with rules behind them, not favors.

Medicare's hospice booklet lists a broad team. It names doctors, nurses or nurse practitioners, counselors, social workers, and pharmacists. It also names physical and occupational therapists, speech-language pathologists, hospice aides, homemakers, and volunteers.

Covered items include prescription drugs for pain and symptom control. They include medical equipment such as wheelchairs or walkers. They include supplies such as bandages and catheters. They also include hospice aide and homemaker services, social worker services, and grief counseling for the family.

That last item matters and is often missed. Bereavement support is part of the benefit, and it continues for the family after the death.

The lines are firm:

• Treatment intended to cure the terminal illness
• Prescription drugs intended to cure it
• Care from a provider the hospice team did not arrange
• Room and board
• Hospital inpatient or outpatient care not arranged by the hospice team

One point is widely misunderstood. Original Medicare keeps covering health problems that are not part of the terminal illness. A hospice patient with lung cancer still has insulin covered for diabetes. They can still be treated for a broken hip.

NCI's summary on end-of-life planning names a pattern worth knowing. More patients now start a new chemotherapy regimen within 30 days of death. More keep getting chemotherapy within 14 days of death. And hospice stays stay short. Among men with prostate cancer, hospice use ran roughly 32 to 60 percent. The share of stays under 7 days rose.

Paperwork lands late too. In one dataset, the median gap between signing a do-not-resuscitate order and death was 0 days for inpatient deaths. For outpatient deaths it was 30 days.

Awareness is the gap. Among 128 patients with advanced lung cancer, only 25 percent said they had been told about palliative care. But 63.5 percent wanted to be told.

Some practical signals should raise the question. The cancer has grown on the current treatment, and the oncologist expects no next line to help. There have been two or more unplanned hospital stays in a few months. Weight loss and weakness keep advancing between visits. Or most of the day is spent in bed or a chair.

NCI is clear on this. Palliative care should begin when the cancer is diagnosed. It runs alongside treatment aimed at the cancer. Hospice shifts fully to easing symptoms and supporting the person at the end of life.

You can ask for palliative care today without giving anything up. Many people who eventually enroll in hospice arrive through a palliative care team.

For covered hospice services from a Medicare-approved hospice, there is generally no charge. Two exceptions are written into the benefit:

• Up to $5 per prescription for outpatient prescription drugs
• 5 percent of the Medicare-approved amount for inpatient respite care

Room and board in a nursing home is not covered by the hospice benefit.

The Medicare booklet is explicit. You may stop hospice care at any time. If someone wants to try a new treatment, or simply changes their mind, they revoke the election. If they still qualify later, they can return.

That is worth saying out loud in a family meeting. Enrolling is not a locked door.

• Which of us is certifying, and when is the next recertification date?
• What is the after-hours number, and who actually answers it at 2 a.m.?
• How fast can you start continuous home care if the pain gets out of control?
• Which of my current medicines will you continue, and which will you stop?
• Which facility do you use for respite, and how far is it?

NCI points to two tools for finding and comparing agencies. One is the National Hospice and Palliative Care Organization provider database. The other is Medicare's Care Compare.

• Call the hospice after-hours line now, at any hour, if pain, breathlessness or agitation has got out of hand at home. Say "we need continuous home care." Under 42 CFR 418.302 that is a defined level of care, requiring at least 8 hours in a day, mostly nursing. If hospice has not started yet, use the oncology team's 24-hour number instead.
• Call the hospice or the oncology team the same day if you as the caregiver cannot safely keep going. "We need respite" is also a billing category, capped at 5 days in a row in an approved facility.
• Raise hospice at the next appointment if the cancer has grown on the current treatment with no next line expected to help, there have been two or more unplanned admissions in a few months, or most of the day is now spent in bed or a chair.

https://www.medicare.gov/coverage/hospice-care

https://www.medicare.gov/publications/02154-medicare-hospice-benefits.pdf

https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-418/subpart-G/section-418.302

https://www.cancer.gov/about-cancer/advanced-cancer/care-choices/hospice-fact-sheet

https://www.cancer.gov/about-cancer/advanced-cancer/planning/end-of-life-hp-pdq