Portal de Periódicos da CAPES

Hospice Care and the Emergency Department: Rules, Regulations, and Referrals

2010; Elsevier BV; Volume: 57; Issue: 3 Linguagem: Inglês

10.1016/j.annemergmed.2010.06.569

1097-6760

Sangeeta Lamba, Tammie E. Quest,

Family and Patient Care in Intensive Care Units

Emergency clinicians often care for patients with terminal illness who are receiving hospice care and many more patients who may be in need of such care. Hospice care has been shown to successfully address the multidimensional aspects of the end-of-life concerns of terminally ill patients: dying with dignity, dying without pain, reducing the burden on family and caregivers, and achieving a home death, when desired. Traditional emergency medicine training may fail to address hospice as a system of care. When they are unfamiliar with the hospice model, emergency clinicians, patients, and caregivers may find it difficult to properly use and interact with these care services. Potential poor outcomes include the propagation of misleading or inaccurate information about the hospice system and the failure to guide appropriate patient referrals. This article reviews the hospice care service model and benefits offered, who may qualify for hospice care, common emergency presentations in patients under hospice care, and a stepwise approach to initiating a hospice care referral in the emergency department. Emergency clinicians often care for patients with terminal illness who are receiving hospice care and many more patients who may be in need of such care. Hospice care has been shown to successfully address the multidimensional aspects of the end-of-life concerns of terminally ill patients: dying with dignity, dying without pain, reducing the burden on family and caregivers, and achieving a home death, when desired. Traditional emergency medicine training may fail to address hospice as a system of care. When they are unfamiliar with the hospice model, emergency clinicians, patients, and caregivers may find it difficult to properly use and interact with these care services. Potential poor outcomes include the propagation of misleading or inaccurate information about the hospice system and the failure to guide appropriate patient referrals. This article reviews the hospice care service model and benefits offered, who may qualify for hospice care, common emergency presentations in patients under hospice care, and a stepwise approach to initiating a hospice care referral in the emergency department. The word hospice comes from the Latin word hospitium, meaning a guesthouse of rest for weary travelers. Dr. Cicely Saunders began the modern hospice movement during the 1960s, when she established St. Christopher's Hospice near London.1Bennahum D.A. Hospice and palliative care: concepts and practice.in: Forman W. Kitzes J. Anderson R.P. The Historical Development of Hospice and Palliative Care. 2nd ed. Jones and Bartlett, Sudbury, MA2003Google Scholar There she provided comprehensive palliative care for dying patients. Currently, hospice care serves as a model for quality, compassionate care for those facing a life-limiting illness or injury and involves a team-oriented approach to medical care, pain management, and emotional/spiritual support tailored to the patient and family needs.1Bennahum D.A. Hospice and palliative care: concepts and practice.in: Forman W. Kitzes J. Anderson R.P. The Historical Development of Hospice and Palliative Care. 2nd ed. Jones and Bartlett, Sudbury, MA2003Google Scholar Hospice is not a place, but a care system. Care is provided in a place the patient calls home, including private residences, nursing homes, and residential facilities. The majority (70.3%) of patients receive hospice care at home.2National Hospice and Palliative Care OrganizationNHPCO facts and figures: hospice care in America.http://www.nhpco.org/files/public/Statistics_Research/NHPCO_facts-and-figures_Nov2007.pdfGoogle Scholar Hospice care can also be provided in an inpatient hospice facility or an acute care hospital setting, and the percentage of hospice patients receiving such care has increased.2National Hospice and Palliative Care OrganizationNHPCO facts and figures: hospice care in America.http://www.nhpco.org/files/public/Statistics_Research/NHPCO_facts-and-figures_Nov2007.pdfGoogle Scholar In 1982, Congress included a provision to create a Medicare hospice benefit, which has since become the standard for the provision of hospice care services. Patients are eligible for hospice services if they have a prognosis of 6 months or less if their disease runs its usual course because some patients may outlive this prognosis.2National Hospice and Palliative Care OrganizationNHPCO facts and figures: hospice care in America.http://www.nhpco.org/files/public/Statistics_Research/NHPCO_facts-and-figures_Nov2007.pdfGoogle Scholar, 3Cope J.W. Olds J.W. Physicians and the Medicare hospice benefit.Caring. 2006; 25: 12-15PubMed Google Scholar, 4Centers for Medicare & Medicaid Services, Medicare Coverage DatabaseLCD (local coverage determination) for hospice: determining terminal status (L25678).http://www.cms.gov/mcd/viewlcd.asp?lcd_id=25678&lcd_version=27&show=all#topGoogle Scholar, 5Harmon D. No time limit on Medicare hospice benefit.Am J Hospice Palliat Med. 2005; 22: 93Crossref PubMed Google Scholar, 6Emanuel E.J. Ash A. Yu W. et al.Managed care, hospice use, site of death, and medical expenditures in the last year of life.Arch Intern Med. 2002; 162: 1722-1728Crossref PubMed Scopus (145) Google Scholar, 7Center for Medicare EducationThe Medicare hospice benefit.Issue brief. 2001; 2 (Accessed September 30, 2010.): 1-6http://www.MedicareEd.orgGoogle Scholar, 8Hoyer T. A history of the Medicare hospice benefit.Hospice J. 1998; 13: 61-69PubMed Google Scholar, 9Miller P.J. Mike P.B. The Medicare hospice benefit: ten years of federal policy for the terminally ill.Death Stud. 1995; 19: 531-542Crossref PubMed Scopus (15) Google Scholar In general, for a patient to receive hospice care, (1) 2 physicians, an attending physician and the hospice medical director, certify that, to the best of their judgment, the patient is terminally ill and more likely than not to die within 6 months if the disease runs its normal course; and (2) the patient/family consents to the hospice philosophy of a comfort care approach with respect to their terminal illness. There is no penalty if a patient survives longer. Patients may become ineligible for hospice services with improvement in their health status, a so-called hospice graduate, but may re-enroll if their clinical condition declines. Hospice care emphasizes quality of life and "living until you die."10SUPPORT Principal InvestigatorsA controlled trial to improve care for seriously ill hospitalized patients The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT).JAMA. 1995; 274: 1591-1598Crossref PubMed Google Scholar Patients may have any diagnosis to qualify, with noncancer primary diagnoses now comprising greater than 58% of all admissions to hospice.2National Hospice and Palliative Care OrganizationNHPCO facts and figures: hospice care in America.http://www.nhpco.org/files/public/Statistics_Research/NHPCO_facts-and-figures_Nov2007.pdfGoogle Scholar To assist physicians in determining prognosis and initiating a hospice referral, broad guidelines for many cancer- and non–cancer-related conditions exist (Table 1).4Centers for Medicare & Medicaid Services, Medicare Coverage DatabaseLCD (local coverage determination) for hospice: determining terminal status (L25678).http://www.cms.gov/mcd/viewlcd.asp?lcd_id=25678&lcd_version=27&show=all#topGoogle Scholar These are not hard-and-fast rules, and coexisting conditions or a rapid functional decline can outweigh strict adherence to these guidelines.Table 1General hospice eligibility guidelines.⁎Adapted from the Centers for Medicare & Medicaid Services, Medicare Coverage Database. LCD (local coverage determination) for hospice: determining terminal status (L25678).4 Available at: http://www.cms.gov/mcd/viewlcd.asp?lcd_id=25678&lcd_version=27&show=all#top.General guidelinesProgression of life-limiting disease as documented by: Decline in clinical status: recurrent infections, intractable pain or vomiting/diarrhea, dysphagia Multiple hospital admissions or emergency department visits Decline in functional status: dependence on assistance with activities of daily living Impaired nutritional status: weight loss 10% during past 6 mo, serum albumin level 40 mL/year) or increased emergency department visits/hospitalizationsCor pulmonale or right-sided heart failure (not caused by valve disease or left-sided heart failure)Hypoxemia at rest (PaO2 <55 mm Hg or sat 50 mm Hg) (records within last 3 mo)Resting tachycardia Dementia1. Patients with all the following characteristics: Stage 7 or beyond according to the Functional Assessment Staging Scale Unable to ambulate, dress, bathe without assistance Urinary and fecal incontinence, intermittent or constant No consistently meaningful verbal communication: limited to 6 or fewer intelligible words2. Presence of comorbid conditions associated with decreased survival, such as aspiration, pyelonephritis, septicemia, pressure ulcers (stage 3-4), fever despite antibiotics3. Nutritional impairment If patient has G-tube, nutritional impairment with weight loss >10% during 6 mo, serum albumin <2.5 g/L In the absence of G-tube, decreased oral intake LiverNot a transplant candidateImpaired synthetic function: albumin level 1.5Ascites despite maximum diureticsSpontaneous bacterial peritonitisHepatorenal syndromeHepatic encephalopathy despite managementRecurrent variceal bleeding RenalCreatinine clearance <10 mL/min ( 8 (>6 if diabetic)Signs or symptoms associated with uremia: hyperkalemia, pericarditisOliguriaIntractable fluid overloadNot receiving dialysis or refusing dialysis HIVCD4 of <25 despite antiretroviral therapy, decreased functional status plus one of the following:CNS lymphomaPersistent wastingMycobacterium avium complex bacteremiaProgressive multifocal leukoencephalopathyVisceral kaposis or systemic lymphoma resistant to chemotherapyCryptosporidium or toxoplasmosis resistant to therapyCHF, Congestive heart failure; NYHA, New York Heart Association; FEV, forced expiratory volume; G-tube, gastrostomy tube; CNS, central nervous system. Adapted from the Centers for Medicare & Medicaid Services, Medicare Coverage Database. LCD (local coverage determination) for hospice: determining terminal status (L25678).4Centers for Medicare & Medicaid Services, Medicare Coverage DatabaseLCD (local coverage determination) for hospice: determining terminal status (L25678).http://www.cms.gov/mcd/viewlcd.asp?lcd_id=25678&lcd_version=27&show=all#topGoogle Scholar Available at: http://www.cms.gov/mcd/viewlcd.asp?lcd_id=25678&lcd_version=27&show=all#top. Open table in a new tab CHF, Congestive heart failure; NYHA, New York Heart Association; FEV, forced expiratory volume; G-tube, gastrostomy tube; CNS, central nervous system. The hospice agency is paid a per-diem rate for all care provided to the patient related to the hospice diagnosis and in turn is the patient's care manager. Hospice care is provided by a multidisciplinary team: physician, nurse, social worker, chaplain, home health aide, volunteers, and therapists. Members of the hospice team make regular visits to assess the patient and provide additional care and support services. They are on call 24 hours a day, 7 days a week to meet patient and caregiver needs. The hospice team develops a care plan to meet each patient's needs and conducts regular interdisciplinary meetings to discuss ongoing issues.2National Hospice and Palliative Care OrganizationNHPCO facts and figures: hospice care in America.http://www.nhpco.org/files/public/Statistics_Research/NHPCO_facts-and-figures_Nov2007.pdfGoogle Scholar Hospice care includes management of the patient's pain and other distressing symptoms; assisting the patient with the emotional, psychosocial, and spiritual aspects of dying; provision of symptom and comfort-related pharmacotherapies, medical supplies, and durable medical equipment, including home oxygen; coaching of caregivers on how to care for the patient; speech and physical therapy; short-term inpatient care when active dying occurs or when symptoms become difficult to manage at home or when the caregiver needs respite time; and bereavement care, as well as counseling to the surviving family and caregivers for 1 year after the patient's death.2National Hospice and Palliative Care OrganizationNHPCO facts and figures: hospice care in America.http://www.nhpco.org/files/public/Statistics_Research/NHPCO_facts-and-figures_Nov2007.pdfGoogle Scholar, 3Cope J.W. Olds J.W. Physicians and the Medicare hospice benefit.Caring. 2006; 25: 12-15PubMed Google Scholar, 4Centers for Medicare & Medicaid Services, Medicare Coverage DatabaseLCD (local coverage determination) for hospice: determining terminal status (L25678).http://www.cms.gov/mcd/viewlcd.asp?lcd_id=25678&lcd_version=27&show=all#topGoogle Scholar, 5Harmon D. No time limit on Medicare hospice benefit.Am J Hospice Palliat Med. 2005; 22: 93Crossref PubMed Google Scholar, 6Emanuel E.J. Ash A. Yu W. et al.Managed care, hospice use, site of death, and medical expenditures in the last year of life.Arch Intern Med. 2002; 162: 1722-1728Crossref PubMed Scopus (145) Google Scholar, 7Center for Medicare EducationThe Medicare hospice benefit.Issue brief. 2001; 2 (Accessed September 30, 2010.): 1-6http://www.MedicareEd.orgGoogle Scholar, 8Hoyer T. A history of the Medicare hospice benefit.Hospice J. 1998; 13: 61-69PubMed Google Scholar, 9Miller P.J. Mike P.B. The Medicare hospice benefit: ten years of federal policy for the terminally ill.Death Stud. 1995; 19: 531-542Crossref PubMed Scopus (15) Google Scholar Hospice care is typically fully covered under Medicare, Medicaid, and private insurers. Additionally, uninsured persons may access it through local hospice agencies willing to provide unreimbursed care.11Lorenz K.A. Rosenfeld K.E. Asch S.M. et al.Charity for the dying: who receives unreimbursed hospice care?.J Palliat Med. 2003; 6: 585-591Crossref PubMed Scopus (12) Google Scholar Current Medicare daily reimbursement rates are approximately $143.10 for home care, $643.64 for inpatient hospice, $155.61 for respite care, and $834.43 for continuous home care.12Department of Health and Human ServicesCorrection to Annual Change in Hospice Payment Rates. Department of Health and Human Services, Washington, DC2009Google Scholar Patients may continue to follow up with their primary care provider as well. The hospice is responsible for all care related to the hospice-qualifying condition for which the patient is certified. Because hospice is the care manager, the agency will typically ask patients and their surrogates to call them first before seeking emergency care outside of hospice to determine whether the condition is related to hospice certification diagnosis and whether the hospice can manage the crisis without an emergency department (ED) visit. While receiving hospice care, patients may present to the ED for conditions related to or not related to their hospice diagnosis, and reimbursement responsibility may vary. For example, when a patient receiving hospice care for cancer presents to the ED with a laceration from a minor injury that is unrelated to the cancer, the regular insurer is billed and pays for related charges. In contrast, if the same patient presents to the ED for a pathologic femur fracture, the condition is related to the cancer (primary certifying diagnosis), and the hospice would be held fiscally responsible for hospital services. If a patient does not call hospice before seeking ED care, the patient may be held fiscally responsible for all related ED charges. For a patient to be referred for hospice care, the clinician would need to recognize the signs of an end-of-life trajectory with limited prognoses. Function and clinical decline with serious, chronic, irreversible illness at the end of life generally follow one of 4 trajectories: (1) a relatively short period of obvious steady decline at the end, after a diagnosis of advanced malignancy; (2) long-term disability, with periodic exacerbations/remissions and an unpredictable timing of death, characteristic of those dying with chronic organ-system failure; (3) a slowly dwindling course with self-care deficits, usually from frailty or dementia; (4) sudden death. It is estimated that 90% of patients will experience one of the first 3 trajectories.13Lunney J.R. Lynn J. Hogan C. Profiles of older Medicare decedents.J Am Geriatr Soc. 2002; 50: 1108-1112Crossref PubMed Scopus (279) Google Scholar, 14Lynn J. Perspectives on care at the close of life Serving patients who may die soon and their families: the role of hospice and other services.JAMA. 2001; 285: 925-932Crossref PubMed Scopus (262) Google Scholar Admittedly, recognition of these trajectories in the emergency setting can present a significant challenge.15Chan G.K. End-of-life and palliative care in the emergency department: a call for research, education, policy and improved practice in this frontier area.J Emerg Nurs. 2006; 32: 101-103Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar Despite widespread availability, hospice care is globally underutilized.16Gazelle G. Understanding hospice—an underutilized option for life's final chapter.N Engl J Med. 2007; 357: 321-324Crossref PubMed Scopus (58) Google Scholar In 2007, of the total 2.4 million deaths in the United States, 38% of patients received hospice care.2National Hospice and Palliative Care OrganizationNHPCO facts and figures: hospice care in America.http://www.nhpco.org/files/public/Statistics_Research/NHPCO_facts-and-figures_Nov2007.pdfGoogle Scholar When patients do receive hospice care, the median length of service is about 20 days, with approximately one third (31%) of patients served by hospice receiving care for only 7 days or fewer.2National Hospice and Palliative Care OrganizationNHPCO facts and figures: hospice care in America.http://www.nhpco.org/files/public/Statistics_Research/NHPCO_facts-and-figures_Nov2007.pdfGoogle Scholar Reasons for late hospice referrals are multifactorial and include reluctance of physicians to prognosticate and communicate the resultant prognosis, unwillingness of patients or surrogates to accept the terminality of their illness, considering hospice only for those who are imminently dying, and racial/ethnic factors.16Gazelle G. Understanding hospice—an underutilized option for life's final chapter.N Engl J Med. 2007; 357: 321-324Crossref PubMed Scopus (58) Google Scholar, 17Teno J.M. Shu J.E. Casarett D. et al.Timing of referral to hospice and quality of care: length of stay and bereaved family members' perceptions of the timing of hospice referral.J Pain Symptom Manage. 2007; 34: 120-125Abstract Full Text Full Text PDF PubMed Scopus (154) Google Scholar, 18Quill T.E. Is length of stay on hospice a critical quality of care indicator?.J Palliat Med. 2007; 10: 290-292Crossref PubMed Scopus (9) Google Scholar, 19Han B. Remsburg R.E. Iwashyna T.J. Differences in hospice use between black and white patients during the period 1992 through 2000.Med Care. 2006; 44: 731-737Crossref PubMed Scopus (35) Google Scholar, 20Labyak M. Ten myths and facts about hospice care.Home Healthc Nurse. 2002; 20: 148Crossref PubMed Scopus (1) Google Scholar, 21Moinpour C.M. Polissar L. Conrad D.A. Factors associated with length of stay in hospice.Med Care. 1990; 28: 363-368Crossref PubMed Scopus (7) Google Scholar Patients and families may feel that hospice care "hastens" death and is equal to "giving up." Although the main focus of hospice care is on quality of life and not curative treatments, some evidence suggests that patients do not have shorter lives as a result of hospice enrollment alone. The improved psychosocial support under hospice may sometimes even prolong mean survival.22Connor S.R. Pyenson B. Fitch K. et al.Comparing hospice and non hospice patient survival among patients who die within a three-year window.J Pain Symptom Manage. 2007; 33: 238-246Abstract Full Text Full Text PDF PubMed Scopus (344) Google Scholar An ED visit does not equate to stopping hospice care, and hospices typically do not automatically terminate patients from hospice if they seek emergency care. Sometimes hospice providers in the home or inpatient setting may themselves initiate the call to emergency services for a transfer if hospitalization is indicated and the hospice is unable to manage that aspect of care. Although it may seem reasonable to expect that a patient or surrogate who accepts the hospice philosophy of comfort care would naturally choose a do-not-resuscitate (DNR) status, this is not always true, especially in the initial phase of hospice care, when patients and families may have a difficult time accepting the terminality of the disease. A DNR status is not a requirement for hospice service. Therefore, patients under hospice care who do not have a DNR order in place may present to the ED, regardless of the hospice care manager, insurance carrier paying for hospice care, or region of practice. When death is imminent, efforts are usually made to renegotiate code status before the initiation of transfer; however, this may not be achieved and resuscitation may then occur. Advance directives are a key component of patient-centered, end-of-life care. Ideally, advanced care planning is a longitudinal process of structured discussion and documentation that is woven into the regular process of hospice care and gets reviewed and updated regularly. These advance planning documents usually fall into 2 categories: those that relate to instructions for medical care and those that involve the designation of a proxy decisionmaker for the patient. Instructional directives are the do-not-intubate, DNR, and do-not-transfer orders, simple medical directives that cover a single topic. In terminally ill patients, advance directive accessibility and validity may often be a source of misunderstanding or anxiety for ED providers and is therefore discussed further in the "Caring for the Hospice Patient in the ED" section. A lack of a DNR order or initiation of a transfer to the ED does not necessarily terminate hospice services, but a patient may decide to opt out of hospice care for a number of reasons, which include the following: (1) patient or surrogates may disagree with a comfort care approach and have difficulty accepting the natural decline of terminal illness; (2) they may request care directed at prolonging life that cannot be provided by hospice; (3) they may desire a second opinion; and (4) they may be dissatisfied with the hospice care model or service. From the perspective of hospice services, a patient may also be discharged from hospice care if "beneficiary behavior is disruptive, abusive, or uncooperative to the extent that delivery of hospice care is seriously impaired."7Center for Medicare EducationThe Medicare hospice benefit.Issue brief. 2001; 2 (Accessed September 30, 2010.): 1-6http://www.MedicareEd.orgGoogle Scholar Emergency physicians experience ambivalence and discomfort in treating patients with hospice and palliative care needs, as outlined in a recent study on ED provider perspectives.23Smith A.K. Fisher J. Schonberg M.A. et al.Am I doing the right thing? provider perspectives on improving palliative care in the emergency department.Ann Emerg Med. 2009; 54: 86-93Abstract Full Text Full Text PDF PubMed Scopus (195) Google Scholar This study highlighted structural barriers to the provision of optimal palliative care in the ED, such as a chaotic environment, competing demands, and long wait times, as well as communication challenges. ED providers expressed distress and conflict over cases in which patients' wishes or written advance directives were in conflict with the wishes of family. Resident trainees expressed concern that training in pain management is inadequate and expressed regret that dying patients they had cared for received suboptimal pain management. The study also outlined an earlier introduction to hospice as a possible solution to educate family members, reduce family fear, and prevent some of the ED visits.23Smith A.K. Fisher J. Schonberg M.A. et al.Am I doing the right thing? provider perspectives on improving palliative care in the emergency department.Ann Emerg Med. 2009; 54: 86-93Abstract Full Text Full Text PDF PubMed Scopus (195) Google Scholar Despite the fact that patients who receive hospice services are made aware of the 24-hour on-call hospice provider, some will still activate emergency services because this is perhaps an ingrained "learned behavior" and an automatic response to the trigger of perceived distress. Patients and caregivers often face difficulty because end-of-life approaches and a visit to the ED may signal a physical, spiritual, or psychosocial crisis. The crisis may therefore be related to poor symptom control or a conflict in goals of care between the patient (who may desire life-improving measures) and caregivers (who insist on life-prolonging measures). The crisis may occur when the patient needs a medication unavailable in the home or faces loss of a support device (such as tracheostomy or gastrostomy). Also, like all care systems that can sometimes become overwhelmed, a hospice nurse on call may not be able to respond in time. Because a patient is not required to elect a DNR status, the patient/surrogates may even be instructed by the hospice to call emergency services as the patient deteriorates, if they are a "full code." These calls to 911 may not always represent a desire for aggressive care but rather an expression of fear, panic, and an inability to cope with distressing signs and symptoms or impending loss of life.24Reeves K. Hospice care in the emergency department.J Emerg Nurs. 2008; 34: 350-351Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 25Reeves K. Hospice care in the emergency department: important things to remember.J Emerg Nurs. 2000; 26 (quiz 528): 477-478Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar This panic is also exacerbated by late referrals to hospice care, as previously described. When such a patient presents to the ED, general management principles apply and establishing early contact with the hospice and primary care provider is essential (Figure 1).24Reeves K. Hospice care in the emergency department.J Emerg Nurs. 2008; 34: 350-351Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 25Reeves K. Hospice care in the emergency department: important things to remember.J Emerg Nurs. 2000; 26 (quiz 528): 477-478Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Attention to advance directives and goals of care are paramount while pain and nonpain symptoms are simultaneously managed.26Stump B.F. Klugman C.M. Thornton B. Last hours of life: encouraging end-of-life conversations.J Clin Ethics. 2008; 19: 150-159PubMed Google Scholar, 27Bailey F.A. Ferguson L. Williams B.R. et al.Palliative care intervention for choice and use of opioids in the last hours of life.J Gerontol A Biol Sci Med Sci. 2008; 63: 974-978Crossref PubMed Scopus (8) Google Scholar, 28Ferris F.D. von Gunten C.F. Emanuel L.L. Competency in end-of-life care: last hours of life.J Palliat Med. 2003; 6: 605-613Crossref PubMed Scopus (44) Google Scholar The following is a suggested approach to managing some of the common ED presentations in a patient receiving hospice care. In general, advance directive completion rates are variable, but in a multistate analysis of nursing home residents, rates of written DNR orders as a component of advance directive completion have been shown to be higher for patients under hospice care (86%) compared with nonhospice patients (67%).29Miller S.C. Mor V. Wu N. et al.Does receipt of hospice care in nursing homes improve the management of pain at the end of life?.J Am Geriatr Soc. 2002; 50: 507-515Crossref PubMed Scopus (220) Google Scholar Similarly, in a large cohort of decedents the advance directive completion rate was reportedly highest for those receiving home hospice care (82%).30Teno J.M. Clarridge B.R. Casey V. et al.Family perspectives on end-of-life care at the last place of care.JAMA. 2004; 291: 88-93Crossref PubMed Scopus (1216) Google Scholar Often, in the context of life-threatening situations in a hospice-care patient, decisions about resuscitation and the use of life-sustaining interventions will frequently arise in the ED.23Smith A.K. Fisher J. Schonberg M.A. et al.Am I doing the right thing? provider perspectives on improving palliative care in the emergency department.Ann Emerg Med. 2009; 54: 86-93Abstract Full Text Full Text PDF PubMed Scopus (195) Google Scholar Sometimes, changes in health status, interfamily conflicts, and issues with institutional protocols pose challenges to the implementation of pre-existing advance planning documents and make discussions of relevant decisions