Considerations of Care — Related and Unrelated Diagnoses for a Terminally ill Patient Receiving Hospice Services

Published on December 22, 2023

Updated on December 22, 2023

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 important to have a clear understanding of how diagnoses related to the terminal illness, as well as 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 who are approaching the end of their lives. It provides physical, emotional, and spiritual support for both the patient and their loved ones. is aimed at managing pain and symptoms, enhancing the patient's overall well-being, and ensuring a peaceful transition.

Qualifying for Hospice Care

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

  • Terminal Illness: The patient's physician, along with the hospice physician, certifies that the individual has a life expectancy of six months or less if the illness runs its natural course.
  • Treatment Choices: The patient chooses () instead of seeking treatment to cure or control the illness. This decision may arise when the treatment is unlikely to be effective or when it 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.

Determination of medication coverage in hospice

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 those for , 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 diagnosis itself as well as any related diagnosis.

Unrelated Diagnoses

Unrelated diagnoses refer to medical conditions or illnesses that are 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/or family have to pay for these medications themselves or use other insurance plans.
  • Specialized Care: The hospice team does not provide services or interventions for the unrelated diagnoses, unless they are necessary for the patient's comfort or safety. The patient can still receive treatment and services for the unrelated diagnoses from other providers, as long as they do not interfere with the hospice care.
  • Important Consideration: The patient can choose to receive any medication or treatment considered curative or aggressive for the 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

Prior to and during the admission, care should be taken to evaluate the impact of related vs. unrelated to the impact 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 diagnosis code to be changed to related in order 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 go to dialysis sessions when the primary terminal diagnosis is not End Stage Renal Disease (). and CKD (chronic kidney disease) as well as any diagnosis mentioning renal, or kidney should be made unrelated in this writer's experience and opinion to allow the patient to continue to go to dialysis with the understanding 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, yet the patient takes a medication that is effective, yet the patient and family cannot bear the cost of the medication. In this writer's opinion, a should be done examining both the impact on comfort as well as 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, and therefore the patient should be on medications that reduce that risk which improve the overall comfort of the patient.
  • 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, and the patient/family cannot afford to continue to use the diuretic if not covered by hospice. Like the GERD issue above, discussion should take place as to the “fluid overload” can cause the patient to see if the diagnosis can be related.

Please keep in mind there are pros and cons to these tips such that 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 have open and honest communication 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

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

Medicare — Find and compare hospice providers

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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