Hospice Eligibility Guidelines

A patient becomes eligible for hospice when their attending physician and a hospice doctor—either the hospice’s medical director or the director’s designee—agree the patient has a life expectancy of six months or less if their disease runs its normal course. A patient must also decide to forgo curative treatment.

No prediction is certain, and a patient may live longer than six months in hospice. In these cases, the patient can continue receiving hospice care if their six-month prognosis is recertified by their hospice physician every 60 days thereafter.

Clinicians refer patients to hospice based on a specific underlying disease state that is contributing to a prognosis of six months or less. The hospice physician may collaborate with the referring or attending physician, nurse practitioner or physician assistant to determine which diagnosis is most contributing to the terminality of the patient, but the final decision is the responsibility of the hospice team.

Non-specific conditions or symptoms cannot be listed as the primary hospice diagnosis. For example, debility and failure to thrive may contribute to the terminal decline of a patient, but the underlying condition—such as heart failure or chronic obstructive pulmonary disease (COPD)—would be the primary hospice diagnosis.

The National Alliance for Care at Home provides a full list of ICD-10 codes that cannot be used as primary diagnoses when referring patients to hospice.

Clinicians may encounter a variety of obstacles when discussing hospice eligibility with patients and their families, including:

• Uncertainty about timing – Many families wait too long before considering hospice, unsure if their loved one qualifies.
• Misconceptions about hospice – Some believe hospice is only for the final days of life, but it can provide comfort for months along with comprehensive interdisciplinary clinical care.
• Varying medical conditions – Eligibility is based on different criteria depending on the illness. Cancer patients may have different benchmarks than those with heart disease or dementia.
• Emotional barriers – Families may struggle to accept the transition to hospice, fearing it means “giving up.” Family members may also feel they are not ready for their loved one to die or believe hospice will hasten death. However, hospice does not hasten death or extend life. It focuses on what matters most to the patient and family and develops a care plan focused on those goals.
• Lack of knowledge about value of hospice services – Many are unaware that hospice offers pain management, emotional support, spiritual care, as well as physical therapy, respiratory therapy, speech therapy and other treatments which enhance quality of life.

Clinical guidelines combined with medical judgment determine hospice eligibility, although the decision to choose hospice is one only a patient or their family can make. A healthcare professional may recommend hospice, but a referral is not required. A patient or their family can “self-refer,” meaning they can request an evaluation from a hospice provider at no charge.