I understand that navigating the healthcare system, especially when dealing with a terminal illness, can be overwhelming for both patients and their families. It’s essential to have a clear understanding of how diagnoses related to terminal illness and unrelated diagnoses can impact the medications and services covered by a hospice provider in the United States. Let’s delve into this topic and shed some light on these crucial aspects.

The Basics of Hospice Care

is a comprehensive and holistic program that focuses on the care, comfort, and quality of life for individuals with serious illnesses approaching the end of their lives. It provides physical, emotional, and spiritual support for the patient and their loved ones. aims to manage pain and symptoms, enhance the patient’s well-being, and ensure a peaceful transition.

Qualifying for Hospice Care

To qualify for hospice care in the United States, individuals must meet specific criteria primarily set by Medicare. Here are the general requirements:

  • Terminal Illness: The patient’s physician and the hospice physician certify that the individual’s life expectancy will be six months or less if the illness runs its natural course.
  • Treatment Choices: The patient chooses (palliative care) instead of seeking treatment to cure or control the illness. This decision may arise when the treatment is unlikely to be effective or becomes too burdensome.
  • Physician Certification: The patient’s attending physician (if available) and the hospice physician must certify the patient as terminally ill.

Impact of Diagnoses on Medications and Services

The specific diagnoses related to the terminal illness, as well as unrelated diagnoses, play a significant role in determining the medications and services covered by a hospice provider.

Here’s how these diagnoses can impact hospice care:

Diagnoses directly related to the terminal illness are the primary factors considered when developing the hospice plan of care. These diagnoses the selection of medications, treatments, and interventions to manage symptoms and enhance the patient’s comfort. Here are some key points to understand:

  • Covered Medications: Hospice providers typically cover medications directly related to the terminal illness, including , symptom control, and emotional support.
  • Treatment and Services: The hospice team focuses on providing services and interventions specifically tailored to address the symptoms and needs associated with the terminal illness.
  • Important Consideration: The patient cannot receive any medication or treatment considered curative or aggressive for the terminal or related .

Unrelated Diagnoses

Unrelated diagnoses refer to medical conditions or illnesses not directly connected to the terminal illness. While these diagnoses may not be the primary focus of hospice care, they can still impact the overall plan of care. Consider the following:

  • Medication Coverage: Hospice providers do not cover medications unrelated to the terminal illness, such as those for chronic diseases, preventive care, or cosmetic purposes. The patient and family must pay for these medications or use other insurance plans.
  • Specialized Care: The hospice team does not provide services or interventions for unrelated diagnoses unless necessary for the patient’s comfort or safety. The patient can still receive treatment and services for unrelated diagnoses from other providers if they do not interfere with hospice care.
  • Important Consideration: The patient can choose to receive any medication or treatment considered curative or aggressive for unrelated diagnoses as long as they understand the risks and benefits and inform the hospice team of their decision.

Tips for Hospice Nurses and Families

Before and during the admission, care should be taken to evaluate the impact of related vs. unrelated and the effect on the patient related to their comfort, wishes, and desire for a good death. Sometimes, the nurse and family need to advocate for an unrelated code to be changed to related for services and medications to be covered, and there are times when a related diagnosis can significantly interfere with the patient’s journey to die the way they want to die as part of dying a . Let’s explore the most common areas where care must be taken to do the right thing for the patient!

  • The patient desires to continue dialysis until they can no longer attend sessions when the primary terminal diagnosis is not End-Stage Renal Disease (ESRD). ESRD and CKD (chronic kidney disease), as well as any diagnosis mentioning renal or kidney, should be made unrelated to this writer’s experience and opinion to allow the patient to continue to go to dialysis with the understanding that the dialysis service will not be paid for by hospice.
  • The patient has gastric reflux disease (GERD), where the initial thought is to have this diagnosis unrelated. The patient takes an effective medication, but the patient and family cannot bear the cost of the medication. In this writer’s opinion, a review should examine the impact on comfort and the logic that might be used to defend a decision to relate the diagnosis. For example, many cancers are at elevated risk for GI bleeds. Therefore, the patient should be on medications that reduce that risk, improving the patient’s overall comfort.
  • The patient is going to be admitted to hospice for a terminal diagnosis other than heart failure and takes one of the three most common diuretics (furosemide, bumetanide, torsemide) for lower extremity edema with good effect. The patient/family cannot afford to continue to use the diuretic if not covered by hospice. Like the GERD issue above, discussion should occur about the “fluid overload” can cause the patient to see if the diagnosis can be related.

Please keep in mind that these tips have pros and cons. For example, relating a diagnosis to help with medication costs also means the family will get billed separately if they go to a specialist for that diagnosis/disease. Or if you unrelate something such as ESRD, the patient and family still must bear the cost of whatever they are pursuing in that area.

Conclusion

It’s important to communicate openly and honestly with the hospice team about any unrelated diagnoses and medications the patient may require. The hospice team can work alongside the patient and their family to coordinate care effectively and ensure that all aspects of the patient’s well-being are addressed.

Resources

Determining Relatedness to the Terminal Prognosis Process Flow

Diagnosis Coding in Hospice

Hospice Coverage

Hospice Appropriate Diagnoses

Frequently Asked Questions About Hospice Care

Top 30 FAQs About Hospice: Everything You Need to Know

Understanding Hospice Care: Is it Too Early to Start Hospice?

What’s the process of getting your loved one on hospice service?

Picking a hospice agency to provide hospice services

National Hospice Locator and Medicare Hospice Compare

Providing Comfort During the Last Days of Life with Barbara Karnes RN (YouTube Video)

Preparing the patient, family, and caregivers for a “Good Death.”

Velocity of Changes in Condition as an Indicator of Approaching Death (often helpful to answer how soon? or when?)

The Dying Process and the End of Life

The Last Hours of Life

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Gone from My Sight: The Dying Experience

The Eleventh Hour: A Caring Guideline for the Hours to Minutes Before Death

By Your Side, A Guide for Caring for the Dying at Home

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