Elder Care Interprofessional Provider Sheets

Differentiating Palliative Care and Hospice Care

Qi T Yu, DO, and Paul E Stander, MD, M.B.A, F.A.C.P, Banner University Medical Center, University of Arizona, Phoenix

August 2016

TIPS ABOUT WHEN TO CONSULT PALLIATIVE CARE VS HOSPICE CARE

  • Palliative care should be considered for any person of any age, at any stage of a serious illness, and regardless of life expectancy, ideally at the time of diagnosis.
  • Hospice services should be offered to patients with a life-limiting illness who are expected to survive for no more than six months.
  • Not sure how long a patient will survive? Ask yourself "would I be surprised if this patient dies in the next six months?" If the answer to that question is "no," then a hospice referral is indicated.

It is not uncommon for patients and clinicians alike to equate hospice care and palliative care, believing they are the same thing. While both modes of care are designed to maximize a patient's quality of life and functional status by focusing on symptom relief and patient comfort, the two modes of care are different.

What's the Difference?

Hospice care is a type of bundled care, which is prognosis-dependent, provided to patients with a life expectancy of six months or less and who are no longer receiving any active or curative treatment of their underlying life-limiting illness. Palliative care, on the other hand, is prognosis-independent. While provided to patients with serious illnesses, the care is provided in conjunction with active therapies that may have curative or disease-modifying intent. See Table 1.

Why Does It Matter?

Lack of understanding of the difference between the two forms of care (i.e., a belief that palliative care is only given as part of hospice care during terminal phases of an illness) leads to delay in instituting palliative treatments to patients who might benefit from them. Often, clinicians wait to enlist palliative care services until the late stages of an illness when patients are eligible for hospice care. 

Indeed, a survey of physicians providing care to patients with lung cancer found that most physicians refer only a small percentage of patients for palliative care consultation, often because of concern that the term "palliative care" is equated with hospice care, and will alarm patients and families. Thus, most physicians preferred to refer patients for palliative care consultation only when death was imminent.

Similar findings were noted in another study of lung cancer patients seen in hospital and outpatient settings. Only 13% of the patients were receiving support from a palliative care service in the year after their diagnosis.

What Are The Benefits of Palliative Care?

There is increasing evidence supporting early institution of palliative care, particularly for patients with advanced illness (both cancer and non-cancer illnesses) even if not in the terminal phases of their disease. In an important study of patients with Stage IV lung cancer, patients who received palliative care in addition to conventional cancer treatments had increased survival compared to those who only received conventional cancer treatments.

In addition to potential survival advantages, other studies demonstrate improved outcomes such as lower rates of depression, improved quality of life, improved patient/ family experience, and less use of resuscitation efforts at the final stage of life. There are even data to support the benefit of palliative care consultation in intensive care units (ICUs) leading to shorter ICU stays, transfer of appropriate patients to lower-intensity care sites, and emotional support for ICU staff dealing with challenging and/or morally distressing situations. Several studies have shown that instituting palliative care prior to the terminal stage of an illness results in lower costs of care.

As the evidence of clinical benefits and cost savings from palliative care continues to mount, an increasing number of hospitals and health systems are implementing palliative care consultation services. Some of these services include interprofessional palliative care teams that assist and co-manage patients throughout treatment of their terminal illness.

Although palliative care services are increasingly available in hospitals, they are less common in outpatient and home settings. A major reason for this is the limited reimbursement and insurance coverage for such services. As the U.S. healthcare system continues to evolve from a "volume-based" to a "value-based" system, those financial barriers should diminish, particularly as palliative care services continue to show both cost and value benefits.

Palliative Care vs Hospice Care: How to Decide

All patients experiencing poor symptom control or uncontrolled pain due to cancer, chronic disease or other complex issues are candidates for palliative care consultation. Hospice care, on the other hand, should be considered for patients with an estimated survival of 6 months or less. 

The 6-month time interval as a requirement for hospice services is an arbitrary criterion established by Medicare. Because establishing a firm life expectancy is difficult, it can be challenging for clinicians to determine exactly when to refer a patient for hospice care. In fact, clinicians frequently overestimate life expectancy, which often results in delays in referring patients to hospice. A better approach is to ask the "surprise" question - "would I be surprised if this patient dies in the next six months?" If the answer to that question is "no," then a hospice referral is indicated. But, if the answer is "yes" and the patient nonetheless has a life-limiting illness, palliative care consultation should be considered because of its potential to improve symptom control and quality of life.

Table 1.  Contrasting Palliative Care and Hospice Care
Characteristic
Palliative Care
Hospice Care
Timing of Care
 
Begins with diagnosis of a debilitating or life-limiting illness and poor symptom or pain control.
During terminal phase of illness
 
Eligibility Criteria
No eligibility criteria
Prognosis for life-expectancy of 6 months or less
Site of Care
Home, outpatient clinics , hospital, extended care facility
Home, inpatient hospice unit, extended care facility
Treatment
 
Provide symptom support and comfort care, concurrently with all other care, including curative care and disease-modifying treatments.
Focus on comfort without seeking curative or disease-modifying treatment
Payment
 
Medicare, Medicaid, and private insurance cover palliative care.
Patients are responsible for insurance copayments (20% under Medicare).
Adults:
  • Medicare benefit provides full coverage (through Medicare Part A and Part D) for hospice services related to terminal diagnosis.
  • Medicaid also provides full coverage for hospice services.
Children under age 21:
  • Medicaid and Children's Health Insurance Program (CHIP) provide coverage for hospice care, and also covers concurrent curative and hospice care.

References and Resources

  • Campbell ML, Weissman DE, and Nelson JE. Palliative care consult in the ICU. Palliative Care Network of Wisconsin Fast Facts. August 2015. Accessed June 10, 2016
  • Grant M, and Dy SM. The Hospice andPalliative Care Approach to Serious Illness. Edited by C. Porter Storey, Jr. 4th ed. UNIPAC 1. Glenview, IL: American Academy of Hospice and Palliative Medicine, 2012.
  • Parikh RB, Kirch RA, Smith TJ, Temel JS. Early specialty palliative care--translating data in oncology into practice. N Engl J Med. 2013 Dec 12;369(24):2347-51. 
  • Reville B, Miller MN, Toner RW, Reifsnyder J. End-of-life care for hospitalized patients with lung cancer: utilization of a palliative care service. J Palliat Med. 2010 Oct;13(10):1261-6.
  • Smith CB, Nelson JE, Berman A, et al. Lung cancer physician's referral practices for palliative care consultation. Ann Oncol. 2012;23(2):382-7.
  • Temel JS, Greer JA, Muzikansky A, etal. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010 Aug 19;363(8):733-42.