I don't thnk these patients are appropriate

Specialties Hospice

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Specializes in hospice.

I see a number of patients who have mid-stage Alzheimer's. Some are pleasantly confused Some have behaviors. Some are sundowners. When they are ambulatory, able to feed themselves, continent on and off, memory impaired but still able to hold a conversation and appear just a wee bit forgetful to people who don't know them well, I just don't see them as hospice appropriate. I have no trouble with the Alzheimer's patient with a sporifice vocabulary who has lost the ability to feed themselves and forgets to eat. These patients are sliding into death, whether it takes 6 months or 6 years. The patient I have trouble thinking of as hospice appropriate are the ones who are still finding some joy in life; still able to do things for themselves, still able to recognize loved ones (even if a daughter become "that lady who takes care of me"). I look at these patients and I don't see a dying person. I see a person living with chronic illness.

What do the rest of you think? When is a person with Alzheimer's truly appropriate for hospice? I have my own ideas but I want to hear from seasoned hospice nurses.

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Specializes in Hospice.

Check out CMS criteria for dementia as a hospice diagnosis. As I remember, they're really quite specific.

If your concern is the ethics of having the patients you describe on "comfort measures only" - separate from admission to hospice - I think that's perfectly fine. Why force them through invasive and frightening treatment so they'll live to decline even further?

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There are specific criteria for Alzheimer Dementia, see this link for further information:

http://geriatrics.uthscsa.edu/tools/Hospice_elegibility_card__Ross_and_Sanchez_Reilly_2008.pdf

The FAST criteria in addition to weight loss do not apply the same way to other dementia - they are meant for Alzheimer Dementia.

There are different problems with Alzheimer Dementia and hospice:

1. Facilities may ask for hospice screen because they would like to get a broda chair, hoyer lift and the additional CNA through hospice - perhaps they also care about the comfort and the support that hospice offers. But often the referral is motivated by the need for equipment and CNA hours.

There were times when people with Alzheimer got admitted to hospice and stayed on for years. That is not ok and Medicare has become stricter about it.

A patient need sto fulfill certain criteria including a certain level on the FAST scale and documented weight loss and some other problems for example recurrent UTI, pneumonia and so on.

Granted - the hospice medical director has the last word when it comes to admitting a patient.

Personally, I would not recommend admission to hospice is the pat has Alzheimer as the potential hospice dx but is still functional to a higher degree than level 7c.

It is a different story if a person has Alzheimer but is looking for admission to hospice for let's say end stage cancer.

2. How early is too early for hospice?

If a patient with Alzheimer fulfills the criteria it is definitely not too early for hospice. They benefit for the CNA who does not need to rush through personal care (which also reduces aggression from pat who can not deal with being rushed). The benefit from low airloss mattress and being out of the room in a broda chair definitely enhances quality of life. The hospice team helps the pat to be comfortable and supports the family in many ways.

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Specializes in Hospice.

Totally OT: having worked both sides of the hospice-LTC equation, let's not get snotty about who "cares" more about the residents.

In the market where I live, LTC residents are beloved by hospice providers because they collect routine home care reimbursements while providing nothing but the odd bit of DME. There's two sides to every story...

End of De-rail ... carry on ... :D

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Totally OT: having worked both sides of the hospice-LTC equation, let's not get snotty about who "cares" more about the residents.

In the market where I live, LTC residents are beloved by hospice providers because they collect routine home care reimbursements while providing nothing but the odd bit of DME. There's two sides to every story...

End of De-rail ... carry on ... :D

That is bad practice all around but there are hospice company that specialize in those clients because they usually live a bit longer, do not require crisis visits and generate steady income. There is low on call volume as well because the staff in LTC takes good care of their patients.

Hospice and LTC need to collaborate ...

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Specializes in hospice.
There are specific criteria for Alzheimer Dementia, see this link for further information:

http://geriatrics.uthscsa.edu/tools/Hospice_elegibility_card__Ross_and_Sanchez_Reilly_2008.pdf

This is the crux of my problem. I am asked to evaluate patients (and have a few patients on my case load) who have not made it as far as 7a on the fast scale. These are both facility and home patients. Yes, hospice services are beneficial to them, but I honestly don't think they are eligible for hospice under the CMS criteria. I think they would benefit from nursing services and extra attention from a CNA devoted to them only, but if they are talking up a storm (even if it is a confused storm) they are not eligible for the Medicaid benefit paid by the government. We keep getting these referrals. I just wish the MDs would take the CMS criteria under consideration when making referrals.

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Specializes in hospice.

If your concern is the ethics of having the patients you describe on "comfort measures only" - separate from admission to hospice - I think that's perfectly fine. Why force them through invasive and frightening treatment so they'll live to decline even further?

I'm not at all concerned about putting patients on comfort care and I think it's a crime against nature to insert a feeding tube in an 80 year old woman with advanced dementia. My concern is about the legality of accepting hospice patients who don't fit the criteria for eligibility. I think some of the nurses at my agency admit patients just because their is a referral from an MD, and the MDs don't take the CMS criteria into account.

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Specializes in Hospice.
I'm not at all concerned about putting patients on comfort care and I think it's a crime against nature to insert a feeding tube in an 80 year old woman with advanced dementia. My concern is about the legality of accepting hospice patients who don't fit the criteria for eligibility. I think some of the nurses at my agency admit patients just because their is a referral from an MD, and the MDs don't take the CMS criteria into account.

What kind of grief do those nurses get when they don't admit? As I implied in my previous post, census = profit. Inappropriate admissions and levels of care have been prime system-gaming strategies for many hospice companies.

I've been out of the field for 5 years, so my info is dated. But I think I heard recently that CMS is clawing back payments when an admission is shown to be inappropriate. If so, you might see some decline in this particular scam over time.

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Specializes in Hospice.
That is bad practice all around but there are hospice company that specialize in those clients because they usually live a bit longer, do not require crisis visits and generate steady income. There is low on call volume as well because the staff in LTC takes good care of their patients.

Hospice and LTC need to collaborate ...

I totally agree with your last statement. I also agree that specializing in providing hospice resources to LTC residents is a perfectly ethical business model. Brainstorming what that collaboration might look like would be a fascinating topic for another thread.

Meanwhile, the CMS criteria for dementia admissions are pretty clear, I think. What's missing is the middle ground - palliative care. The best hospice in my town is part of a hospital system that uses its certified hospice docs as palliative care consultants, available before pts are appropriate for hospice. How that could be provided or funded through hospice organizations is a puzzle.

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Specializes in hospice.
What's missing is the middle ground - palliative care. The best hospice in my town is part of a hospital system that uses its certified hospice docs as palliative care consultants, available before pts are appropriate for hospice. How that could be provided or funded through hospice organizations is a puzzle.

Yes! Who pays for it?

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Specializes in hospice.

I think some of the nurses at my agency admit patients just because their is a referral from an MD, and the MDs don't take the CMS criteria into account.

My use of "their" instead of "there" is humiliating and now I can't correct it.

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Specializes in Hospice.
My use of "their" instead of "there" is humiliating and now I can't correct it.

No worries ... we promise to not go all grammar nazi on you:D

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