Hospice & Home-Based Palliative Care

The family asks when their mother is going to get better. The hospice nurse knows the patient is not going to get better — and helping this family understand that truth, gently and clearly, is the most important nursing intervention of the day.

Hospice care provides comfort-focused, interdisciplinary care for individuals with a terminal illness and a life expectancy of 6 months or less if the disease follows its expected course. Medicare Hospice Benefit covers hospice services when the patient elects hospice and agrees to forgo curative treatment for the terminal diagnosis (they can still receive treatment for unrelated conditions). Hospice is most commonly provided in the home, though it can also be delivered in residential hospice facilities, long-term care, or hospitals. The interdisciplinary hospice team includes the physician, nurse, social worker, chaplain, home health aide, bereavement counselor, and trained volunteers. The hospice nurse's role in the community includes symptom management (pain, dyspnea, nausea, anxiety, agitation), medication management focused on comfort (converting to subcutaneous or sublingual routes when the patient can no longer swallow), family and caregiver education (what to expect during the dying process, medication administration, when to call hospice rather than 911), psychosocial and spiritual support, coordination with the interdisciplinary team, and pronouncement of death (in most states, the hospice nurse can pronounce death in the home). Palliative care differs from hospice — palliative care can begin at any point during a serious illness, does not require a terminal prognosis, and can be provided alongside curative treatment. The nurse educates families on the differences. Bereavement support extends to the family for at least 13 months after the patient's death under the Medicare Hospice Benefit.

Key Distinctions

Hospice requires a terminal prognosis of 6 months or less AND an election to forgo curative treatment for the terminal condition. Palliative care has no prognosis requirement and does not require giving up curative treatment. Students frequently confuse these — palliative care is appropriate at diagnosis of any serious illness, not just at end of life. Hospice is structured in Medicare benefit periods — two initial 90-day periods followed by unlimited 60-day periods, with physician recertification required at the start of each period. Patients are not locked in and can revoke hospice to pursue curative treatment at any time. If a hospice patient calls 911 for a terminal-diagnosis-related emergency, EMS may initiate aggressive treatment that contradicts the hospice plan of care. The nurse teaches families to call the hospice number first, not 911. DNR status is separate from hospice election — not all hospice patients are DNR, though most are.

Clinical Pearl

Hospice is not giving up. It is choosing to live as well as possible for as long as possible. The nurse who frames it that way gets the family to hear it.