Congratulations You’ve Graduated Hospice

Yes, people can actually graduate from hospice. Most other hospice’s  call it “being discharged”, but I always try to put a positive spin on things. The reason why I decided to write about this topic is that some patients and families come into hospice “kicking and screaming” (figuratively speaking) because they aren’t sure this is what they want, then when they graduate hospice they graduate “kicking and screaming” because they experienced the comprehensive care of hospice and don’t want it to end. So how does one “graduate” from hospice? It usually occurs with non-cancer diagnosis such as End Stage COPD, End Stage CHF and End Stage Dementia. It is much more challenging to predict prognosis with these diagnosis than with cancer. As long as two physicians feel that the patient has less than 6 months, if the disease were to run its normal course, then patients are eligible for hospice. Once they start hospice they have nursing supervision in addition to the home health aides, social worker, chaplain, volunteers, massage, heart touch therapy and physician visits. With close follow up by the team two things happen. We can symptom manage better and sooner (since we are in the home all the time) rather than the patient waiting until the symptom gets really bad and going to the ED, and we can better assess compliance. For example, I have a 72 y/o male with End Stage CHF who was spending 1 week in the hospital, 2-3 weeks out, 1 week in, 2-3 weeks out etc etc. This went on for months before we had a Goals of Care conference with the patient in the hospital and he agreed to hospice care. His cardiologist was baffled as to why he kept coming back when he was “optimized on his diuretics.” The only way he could explain this phenomena was that the patient must not be absorbing the Lasix in his GI tract. During my first home visit, I reviewed his medications, guess what, NO LASIX in the home and no where to be found. It turns out that he had not been taking his medication and didn’t even have Lasix in the house!!!! I ordered Lasix and it has now been 3 months without an admission! This is probably one of the reasons that a new study showed that patients on hospice lived an average of 29 days longer than patients with the same diagnosis not on hospice (The link is below). This is also a common occurrence with End Stage Dementia patients as many patients plateau for an unknown period of time at any stage of the illness (prior to actively dying). If the patients don’t show decline over several months, then any hospice has the obligation to “graduate” a patient if the doctor feels the prognosis has changed. To be honest, this is probably the hardest part of my job, as I’ve seen people who are up, active and talking with their families, die a few days later and one patient with End Stage Dementia I graduated (I’m still following as the attending), over a year ago, is cachectic, contracted, non-verbal, minimally conscious and unable to follow commands but continues to live despite being on hospice for at least two years prior to graduation. Many times I scratch my head but what many patients tell me rings true, “Physicians are not God.” Contrary to popular belief Hospice is not a death sentence and I don’t think I’ve met a patient (or family) that was happy they (or their loved one) was “Graduating” from Hospice.

http://www.nhpco.org/i4a/pages/index.cfm?pageid=5145

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5 thoughts on “Congratulations You’ve Graduated Hospice

    • Thank-you for reading my blog. Would you care to elaborate about what made this entry interesting. I appreciate feed back whether it be good or bad but most people don’t leave comments. Thanks again.

  1. I had Googled “graduating from hospice” because that’s what a nurse (not hospice) was telling my family should happen to my mother and we were confused by the term. She’s in a nursing home with Alzheimer’s and has Congestive Heart Failure. She’s been in hospice for 6 months, pretty much on a liquid diet of Ensure now. We have found the hospice staff to be wonderful.

    • I hope my entry was able to help with what “graduating” means. Although, I’m sure the nurse (not hospice) was well meaning, it’s better if the hospice nurse(s) assess the situation and make that call. There is a different approach sometimes between staff in a nursing home and hospice staff, however as long as someone is on hospice, all decisions and discussion should come from hospice. I hope that helps, if you have further questions, please email me directly at palliativecaremd@yahoo.com
      Regards,
      Hospice Physician

  2. I am a hospice volunteer who found your blog via googling, trying to understand why my patient, who’d been in hospice for about 9 months, was graduated out. They were in the home and I was told that they did not meet the criteria for continuing, e.g., not showing proper decline. It was stressful for them (using the plural form to be as anon. as possible) and the family. They passed less than a month of being discharged. I have heard of people being in hospice for 18 mo – 2 years, so I still do not understand why this patient was “graduated out.” Once someone is in hospice IMHO they should stay there unless they are in remission (in the case of cancer) and are getting decidedly better. This patient had no way of getting better. My opinion of hospice has changed. I would not go into it personally until the final, final practically needing vigil support stage. I’d be too worried about “graduating out” if I were not dying on schedule. Hospice provides wonderful support–and losing it once that support is established is traumatic.

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