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“When should I offer Hospice care?” is a question commonly asked by physicians. One of the most difficult, if not impossible tasks is to predict when patients may be in their last years or months of life. This is particularly true with prognosticating non-cancer diseases that do not follow a typical cancer trajectory. These patients often live in chronically critical states where any episode or exacerbation could result in either a sudden death or return to a chronic state with an overall gradual decline. There are many factors that influence the decision to begin Hospice palliative care including the general physical status of the patient, the patient’s goals for care, concurrent co-morbidities, family care-giving situations, and the response or lack of response to standard medical management.

One of the easiest yet highly predictive ways to determine if a patient could benefit from Hospice care is to ask the following question:

“Would I be surprised if this patient were to die within one year?”

If the answer were “no” you would not be surprised if they died within one year, then it is time to consider Hospice. In addition, the following situations may indicate the need for a Hospice assessment:

If a patient has been to the emergency room or hospitalized twice within the past twelve months

When you begin to get an increase in calls and requests from family caregivers

When family caregivers seem to be overburdened or fatigued with care giving

When the patient’s office visits become more frequent

When there is indication that coming for office visits is burdensome

If a patient is hospitalized, can no longer return to their home & needs placement into a nursing facility

A weight loss of 10% or more within the past six- months

A steady decline in appetite unrelated to any other medical condition.

Over 50% of hospice patients nationally have non-cancer diagnoses, which are more difficult to prognosticate. The National Hospice and Palliative Care Organization’s Medical Guidelines for Determining Prognosis in Selected Non-Cancer Diseases, 2nd ed. offer indicators for prognostication that are universal, and apply to all disease states. These include physical decline, weight loss, multiple co-morbidities, Serum Albumin < 2.5gm/dl, dependence in several ADLs, Karnofsky Score of < 50%, and the desire or will to die.

Preparation is the key to helping patients and families during this time of transition, loss, and change. Your ability to be “present” and connect your patient to services specifically designed to deal with their desires, hopes and wishes may be the most important gift you give to your patient. Among the suggested actions for improving care is a call for expanded use of Hospice, both in homes and in other settings. In the face of what is probably one of the most difficult times for your patient and their family, physicians can compassionately offer hope and comfort by explaining the benefits of Hospice and connecting patients early in their illness experience.

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