Hospice eligibility guidelines: cancer

Cancer indicators

Read this table together with the general decline indicators and the non-disease-specific baseline (functional status and dependence in activities of daily living) on the eligibility guidelines overview.

How treatment status fits

Hospice under Medicare means the patient chooses comfort-focused care for the terminal illness and waives other Medicare payment for treatment of it. Treatment given to relieve symptoms, such as a short course of radiation for painful bone metastases, can be part of a hospice plan of care when it is palliative in intent. Whether a specific therapy can continue is decided case by case by the hospice physician and interdisciplinary group, who weigh clinical benefit, comfort goals, treatment setting, transport, coordination and payment responsibility before any commitment.

A patient does not have to have exhausted every line of therapy. A patient who understands the options and declines further treatment meets the second indicator. If a patient is still weighing a clinical trial or another line of therapy, palliative care alongside oncology may be the better referral for now.

Supporting documentation

• Primary site, histology, stage, and sites of metastasis, with the most recent imaging or pathology.
• Treatment history and the response to the last line of therapy. The oncologist's note on options going forward.
• The patient's decision about further disease-directed therapy, in their own words where possible.
• PPS, KPS or ECOG performance status, with earlier scores if available.
• Weight trend, appetite and intake. Albumin if already drawn.
• Complications that shorten prognosis: hypercalcemia, malignant effusions or ascites, brain or leptomeningeal metastases, cord compression, bowel obstruction, venous thromboembolism, cachexia, recurrent infection.
• Symptom burden and current medicines, including opioid doses.
• Hospitalizations and emergency visits in the past six months.

Comorbidities

The LCD guidance also weighs comorbidities. The presence and severity of conditions such as chronic obstructive pulmonary disease, congestive heart failure, ischemic heart disease, diabetes, neurologic disease (stroke, ALS, multiple sclerosis, Parkinson's disease), renal failure, liver disease, malignancy, AIDS and dementia can support a prognosis of six months or less even when the primary diagnosis alone does not. Document each one with its current severity and how it limits the patient.

In hematologic malignancies, transfusion dependence and the patient's goals around it are often the central question. Raise it at referral so it can be addressed honestly before the patient elects hospice.

Not sure? Call

Decline in cancer is often the most predictable of any diagnosis, yet many patients are referred in the last days of life. Prognosis is rarely clear cut. If you are weighing a referral, call and talk the case through with a hospice nurse, or ask for a physician-to-physician conversation with our medical director. A call is not a referral and does not commit the patient to anything.

If the patient is not hospice eligible now, we will say so and tell you what we would watch for. Some patients are better served by palliative care first. When you are ready, use Refer a patient. The hospice medical director, with the attending physician if there is one, makes the certification decision under 42 CFR 418.22.

A page you can share with the family

Families often ask the same questions you are weighing, in different words. Our family guide, hospice care for cancer, explains in plain language what hospice does for this illness, what signs are worth raising with a doctor or nurse, and how care is paid for. It does not give an eligibility verdict. You are welcome to share it before or after a goals-of-care conversation.