Hospice Care

Introduction

Hospice care is a specialized form of palliative care provided to terminally ill patients with a prognosis of ≤6 months. It focuses on comfort, dignity, symptom control, and emotional support, rather than curative treatment. Unlike general palliative care, hospice care is exclusively for end-of-life patients.

Definition of Hospice Care

According to the World Health Organization (WHO):“Hospice care is a form of palliative care provided to patients who are in the final stages of a terminal illness, focusing on symptom relief, psychological support, and quality of life rather than curative treatments.”

Key Features of Hospice Care

• Provided when curative treatments are stopped.

• Focuses on quality of life rather than prolonging survival.

• Multidisciplinary approach: Physicians, nurses, psychologists, social workers, spiritual care providers.

• Delivered at home, hospice centers, or hospitals.

Hospice Care vs. Palliative Care

Feature	Hospice Care	Palliative Care
Definition	End-of-life care	Supportive care at any disease stage
Eligibility	Life expectancy ≤6 months	Any stage of serious illness
Goal	Comfort and dignity	Improve quality of life
Treatment	Symptom relief only	Can be combined with curative treatments
Location	Home, hospice facility	Hospital, home, nursing home

Eligibility Criteria for Hospice Care

Patients with an estimated survival of ≤6 months due to terminal illness. Common conditions include:

1. Cancer (most common indication)

• Metastatic or end-stage cancers

• Unresponsive to chemotherapy/radiotherapy

2. End-Stage Neurological Diseases

• Advanced dementia

• Amyotrophic lateral sclerosis (ALS)

• End-stage stroke with minimal consciousness

3. End-Stage Cardiorespiratory Diseases

• Advanced heart failure (NYHA class IV)

• End-stage chronic obstructive pulmonary disease (COPD)

• Pulmonary fibrosis

4. Renal & Hepatic Failure

• End-stage renal disease (not on dialysis)

• Cirrhosis with hepatic failure

5. Geriatric Frailty Syndrome

• Bedridden elderly with multiple organ failure

• Severe malnutrition, pressure ulcers, recurrent infections

Principles of Hospice Care

1. Patient-Centered Care – Focuses on the patient’s preferences and comfort.

2. Symptom Control – Pain, dyspnea, nausea, delirium, and anxiety are aggressively managed.

3. Psychosocial & Spiritual Support – Counseling for patients and families.

4. Bereavement Support – Helps families cope after the patient’s death.

5. Ethical Decision-Making – Advance directives, do-not-resuscitate (DNR) orders, and withdrawal of life-sustaining treatment.

Hospice Symptom Management

1. Pain Management (WHO Analgesic Ladder)

• Mild Pain: Paracetamol, NSAIDs

• Moderate Pain: Weak opioids (Tramadol, Codeine)

• Severe Pain: Strong opioids (Morphine, Fentanyl)

Adjuvant Analgesics

• Neuropathic Pain: Gabapentin, Pregabalin

• Bone Pain: Bisphosphonates, Radiotherapy

• Visceral Pain: Hyoscine butylbromide

2. Dyspnea Management

• Morphine: First-line for breathlessness relief.

• Oxygen therapy: If hypoxia is present.

• Benzodiazepines (Midazolam, Lorazepam): If anxiety-induced.

3. Nausea & Vomiting

• Metoclopramide (prokinetic)

• Haloperidol (opioid-induced nausea)

• Ondansetron (chemotherapy-induced nausea)

4. Delirium & Terminal Agitation

• Haloperidol: First-line for palliative sedation.

• Midazolam: For severe restlessness.

5. Constipation (Opioid-Induced)

• Laxatives: Senna, Lactulose.

• Methylnaltrexone: If resistant to laxatives.

6. Death Rattle (Respiratory Secretions)

• Glycopyrrolate, Scopolamine: To reduce secretions.

Ethical and Legal Considerations in Hospice Care

1. Advance Directives

• Living wills: Specifies patient’s wishes for end-of-life care.

• Durable Power of Attorney: Legal representative to make decisions.

2. Do-Not-Resuscitate (DNR) Orders

• Prevents unwanted cardiopulmonary resuscitation (CPR).

3. Palliative Sedation vs. Euthanasia

• Palliative Sedation: Legal, sedates patient for comfort without hastening death.

• Euthanasia: Illegal in most countries, actively ends life.

4. Withdrawal of Life Support

• Discontinuation of ventilators, feeding tubes, and dialysis when futile.

Hospice Care in Special Populations

1. Pediatric Hospice Care

• Play therapy, music therapy for psychological support.

• Parental guidance and family counseling.

• Fentanyl patches, Methadone for long-term pain control.

2. Geriatric Hospice Care

• Polypharmacy risk: Reduce unnecessary medications.

• Cognitive decline: Address decision-making capacity.

MCQs for Postgraduate Exam

1. Which of the following is NOT a criterion for hospice care eligibility?

a) Life expectancy <6 months

b) Reversible illness

c) Need for symptom relief

d) No further curative treatment planned

Answer: b) Reversible illness

2. Which medication is first-line for dyspnea in hospice patients?

a) Salbutamol

b) Morphine

c) Codeine

d) Lorazepam

Answer: b) Morphine

3. Which drug is preferred for opioid-induced constipation in hospice care?

a) Loperamide

b) Ondansetron

c) Methylnaltrexone

d) Metoclopramide

Answer: c) Methylnaltrexone

4. Which statement about palliative sedation is TRUE?

a) It hastens death intentionally

b) It is the same as euthanasia

c) It is used for intractable symptoms at the end of life

d) It is illegal in most countries

Answer: c) It is used for intractable symptoms at the end of life