Determining Hospice Eligibility for Dementia
As the disease progresses, people with dementia like Alzheimer's disease have a hard time finding the right words, and they speak with growing reluctance. It becomes more difficult for them to pay attention, to reason, and to understand abstract concepts. As the disease progresses, these patients become increasingly disoriented and unable to care for themselves. Ultimately the patient may require care at a facility. It is only when they reach the final stages that they are eligible and have hospice care.
Survival times vary greatly in patients. Determining when a patient is nearing the end of life and therefore should have hospice care is not an easily question. Hospices rely on physicians to answer that question. The accepted norm is that if a physician determines that the dementia patient has a prognosis of six months or less, to the best of his or her clinical ability, the patient is eligible for hospice care.
To guide physicians in making that determination there are guidelines from a number of organizations such as the National Hospice Organization (NHO) and Medicare. The physician is required to take into consideration the following factors in the decision making process:
- Progression of disease on the FAST (Functional Assessment Staging) Scale
The FAST1 scale was developed by Dr. Barry Reisberg & Associates, from New York University Medical Center's Aging and Dementia Research Center to aid in determining the progression of dementia.
The scale lists seven levels of function that help clinicians determine what "stage" the patient is. Here's an example of how it measures stages of disease progression:
- Levels 1 - 5: Patient experiences increasing forgetfulness, inability to perform complex tasks, and needs assistance with dressing.
- Level 6: Patient needs help with bathing and toileting, and is unable to control bladder or bowels.
- Level 7: Patient experiences inability to form intelligent speech, inability to ambulate without assistance, and requires total care.
- Ability to perform activities of daily living. The tracking of the decline in self care. In the end-of-life stage, the patient is unable to dress, bathe or ambulate without assistance.
- Difficulty with communication
- Weight Loss
- Development of certain health issues
- Urinary or fecal incontinence, intermittent or constant
- Aspiration pneumonia
- Cardiac issues
- Diabetes
- Pyelonephritis or other upper UTI
- Septicemia
- Multiple stage 3 or 4 decubitus ulcers
- Fever that recurs after antibiotic therapy
- Inability to maintain sufficient fluid and calorie intake, with 10 percent weight loss during the previous six months or serum albumin level less than 2.5 g per dL (25 g per L)
Changes in behavior
There is no simple laboratory test to answer the question. The physician has to take into consideration the history of the patient and recent health issues the patient has. Sometimes after referral to hospice care, some of these issues go away, probably from the patient getting more attention and care. Hospice may determine that the patient no longer qualifies for hospice services and would need to withdraw services. The physician would be notified of the findings and would then have to make a revision of his prognosis.
When medical insurance is involved (as is often the case), the hospice facility has to follow the guidelines of the insurance company such as Medicare guidelines. Physicians and clinicians make a judgment call based on the information available to them. That decision rests on them and sometimes need to be revised as more information is obtained. If you have a question about whether your loved one is ready for hospice care, it is best to call his physician or a local hospice facility for guidance.
References
- Reisberg, B., "Functional Assessment Staging (FAST)," Psychopharmacology Bulletin, 1988, 24, pp 653 - 659.
