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Hospice Referral and Care: Practical Guidance for Clinicians

  • Authors: Author: Perry Fine, MD
    Medical Writer: Clarinda Mac Low
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Target Audience and Goal Statement

This activity is intended for primary care and specialty physicians, nurse practitioners, registered nurses, physician assistants, and other healthcare professionals with an interest in hospice and end-of-life care.

The goal of this activity is to provide readers with a current and comprehensive overview of hospice referral and care, offering guidance and resources to practicing clinicians.

Upon completion of this activity, participants will be able to:

  1. Describe indications for hospice referral.
  2. Define the provisions of the Medicare Hospice Benefit for Medicare beneficiaries and their families.
  3. Review the patient assessment variables needed to determine the optimum time for hospice referral.
  4. Describe how and when to initiate discussions with patients regarding end-of-life care planning and directives.


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    For Physicians

  • Medscape, LLC is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

    Medscape designates this educational activity for a maximum of 2.0 category 1 credit(s) toward the AMA Physician's Recognition Award. Each physician should claim only those credits that reflect the time he/she actually spent in the activity.

    This program offers 2.0 hours towards the Texas requirement for CME in ethics or professional responsibility.

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    For Nurses

  • Approved for 2.2 contact hour(s) of continuing education for RNs, LPNs, LVNs and NPs. This activity is cosponsored with Medical Education Collaborative, Inc. (MEC) and Medscape. MEC is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

    Provider approved by the California Board of Registered Nursing, Provider Number CEP 12990, for 2.2 contact hour(s).

    Approved by the Florida Board of Nursing, Provider Number FBN 2773.

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Hospice Referral and Care: Practical Guidance for Clinicians


What Should You Expect From a Quality Hospice Program?

A quality hospice program provides an interdisciplinary team of experts that deals with all aspects of the dying process -- physical, social, practical, spiritual, and interpersonal. This team is usually mobile and works with the patient and the primary caregivers (if they have them) wherever the patient lives. It is important to note that in hospice, there are no arbitrary limitations to admission based on the patient's circumstances other than having a life expectancy of < 6 months if the disease runs its expected course.

Care Settings

Hospice is not a place but an applied approach to care, provided in the patient's home, nursing homes, and other facilities. A 2004 compilation by the National Hospice and Palliative Care Organization found that about 58% of patients who died under hospice care died at home, and about 22% died in a nursing facility. The remaining 20% of the patients were in hospitals, hospice-operated inpatient facilities, free-standing hospice units, and residential care settings.[4]

All hospices must provide an inpatient level of care. Hospice programs may have their own inpatient facilities or arrangements with freestanding hospice houses, hospitals, or residential centers to care for patients who have higher acuity care needs. Some hospice providers also have residential centers for patients whose social circumstances preclude care in a private residence. A significant proportion of Americans spend their last months to years in long-term care facilities. There can be some tensions between the philosophies, capabilities, and imperatives of the nursing home staff and the goals of care enumerated by the hospice staff in concert with the patient's (or proxy's) wishes. There are ongoing efforts to reconcile seemingly contradictory regulations and to facilitate improved communications and coordination among all parties involved in caring for this rapidly growing, and highly vulnerable, segment of our population.

Interdisciplinary Team

Modern hospice care requires professionals with expertise in pain and symptom management as well as knowledge of the intra- and interpersonal dynamics at this unique time in the human life cycle. It is a team effort, with a typical interdisciplinary team consisting of medical providers (physician, nurse, nursing assistant), psychosocial care providers (social worker), spiritual care providers (chaplain), and other supportive care professionals as needed (nutritionist, physical therapist, pharmacist, speech therapist, etc.).

Comprehensive Services

Besides professional support, hospice provides support for material needs such as medications for managing symptoms related to the terminal illness, durable medical equipment, and medical supplies. Current hospice care also involves volunteers who provide visitation, companionship, housekeeping help, assistance with errands, and other support. Volunteer involvement is integral to the hospice concept and is a requirement under the provisions of the MHB.