Young and old hands
by Joseph Shega

As health care professionals, we innately want what’s best for patients. Of course, in order to determine the best possible treatment path, we must work together—not just with the full health care team, but with patients and their loved ones as well. Defining the goals of care requires deeply personal decision-making, and it’s our responsibility to help patients and their families understand their choices, and to honor their wishes with compassion
and respect.

For some patients with serious illness, especially those requiring home health care, there may come a time over the course of their health care journey when curative and restorative treatment no longer aligns with their values and end-of-life priorities. For these patients, hospice can provide tremendous relief and the kind of support they need at the right time.

To be clear, entering hospice is not about losing hope—it’s about giving patients a renewed sense of hope for
how they’ll be able to spend their final chapter of life.

Understanding the Benefits of Hospice Care
First, it’s important to distinguish the differences between home health and hospice care. The two modalities of care certainly share some similarities: Both are aimed at improving quality of life, allowing the patient to remain at home and receive important physical and psychosocial care while also helping prevent or reduce the need for hospitalization. However, each approach is meant to address distinct patient populations with unique needs
and goals.

Unlike home health care, which is intended to help patients recover from injury or illness or progress toward improved functionality, hospice care is for those with advanced illness for whom curative treatments are no longer effective or preferred. Patients are eligible when they have a prognosis of six months or less if their disease or illness runs its natural course, as certified by a physician; this approach to care is squarely focused on improving quality of life and prioritizing patients’ and families’ wishes during whatever time they have left.

Routine hospice care takes place wherever the patient calls home—a private residence, nursing home, assisted living community or residential care facility. Daily care is provided by a family caregiver, friend or private duty caregiver who is supported by an interdisciplinary team of hospice experts, including nurses, aides, physicians, chaplains, social workers, volunteers and bereavement specialists, all of whom specialize in compassionate end-of-life care.

Common hospice services include the delivery of medications, equipment and supplies necessary to manage the patient’s diagnosis. Covered by the Medicare Home Health Benefit, these services are— importantly—provided at no cost to the patient or family. Medicare also covers continuous, inpatient and respite care for hospice patients. In fact, hospice is the only Medicare benefit designed to titrate whatever care the patient needs in order to keep them in their setting of choice.

Home health services, on the other hand, do not cover inpatient stays if symptoms become unmanageable at home. Caregivers of those in hospice also receive access to additional layers of psychosocial support. Simply put, hospice care gives patients and their loved ones the peace of mind that comes with knowing their final days will be filled with specialized support and comprehensive, round-the-clock comfort care, without undue economic burden.

Identifying Hospice-Eligible Patients
Home health is ideal for patients who are stable or improving, but when a home health patient declines or fails to achieve therapy goals, it can take a significant emotional and financial toll on the individual and
the family.

Identifying hospice-eligible patients earlier in the progression of their illness can have a measurable impact on their quality of life and medical expenses. A 2020 Trella Health study found that hospice patients overall benefitted from significantly fewer unnecessary hospitalizations and reduced health care costs compared to patients who did not receive hospice.

This was especially true for patients who were referred to hospice earlier in their disease course (receiving at least three months of care) compared to late hospice patients (receiving fewer than two weeks of care). Patients who received early hospice care were 10 times less likely to be admitted to the hospital during their final month of life than their nonhospice peers, and emergency room visits were five times more likely for late hospice patients compared to early hospice patients.

That means earlier identification of hospice eligibility can actually help patients remain in their preferred care setting, which plays a large role in quality of life. After all, no one wants to spend more time in emergency departments and hospital rooms than they have to.

If you’re wondering whether a patient may be ready to transition to hospice care, consulting VITAS Healthcare’s hospice eligibility guidelines is a great first step. It may also help to keep these significant predictors of declining prognosis in mind:

  • Reliance on others for help with three or more activities of daily living, such as bathing, dressing, urine or bowel control, moving from one place to another, walking and feeding
  • Shortness of breath or fatigue at rest or minimal exertion
  • Emergency department visits or hospitalizations
  • 10% weight loss within six months or 5% in one month
  • Recurrent falls with injury
  • Decreased tolerance of physical activity
  • Complications related to Alzheimer’s disease/dementia, cardiac or lung disease, cancer or sepsis/post-sepsis syndrome

When a patient and their caregivers are struggling with these issues, it may be time to consider the transition to hospice.

Facilitating the Transition
For hospice-eligible patients, goals-of-care discussions are so important, yet many home health care professionals may feel ill-equipped to initiate these conversations. As advocates for patients’ well-being, it is incumbent upon us to speak up and present them with their care options. Keep in mind that an informed patient armed with choices and an understanding of their current health status ultimately feels more in control.   

It’s important to take an approach that’s informative, but also empathetic and open to hearing the patients’ wishes and concerns. This should be a compassionate two-way dialogue. You may wish to broach the subject with open-ended questions, such as, “How has your health changed over the last year?” or, “What are your most important goals for your care?”

At VITAS Healthcare, we recommend the ‘SPIKES’ approach to ensure goals-of-care discussions are as patient-centered as possible and firmly rooted in respect:

  • Setting: Choose a private, comfortable and non-threatening atmosphere
  • Perception: Uncover what the patient and family think is happening
  • Invitation: Ask the patient what they would like to know
  • Knowledge: Explain the disease and care options in plain language
  • Emotion: Respect feelings and respond with empathy
  • Summarize: Recap and decide next steps

Home health care professionals who care for patients with advanced illness are uniquely positioned to shape patients’ end-of-life experience by helping them get the right care at the right time in their disease course.

Joseph Shega, MD, is executive vice president and chief medical officer for VITAS Healthcare, a leading provider of end-of-life care. He is board-certified in geriatric and hospice and palliative medicine and has been caring for, studying and teaching about geriatric patients and end-of-life care since 1999. Visit