When is it time to contact hospice for an evaluation?

Patient is 87 years old, female

Moderate to severe cognitive dysfunction:
forgets own name, marital status, age, birthdate, most names but not necessarily faces, day/date/year, location other than general (knows she's at my house,) recent events, etc.

History of 1 mild stroke, 2000, residual mild cognitive loss, no physicl impairment

Fractured right femur Feb., 2007, repaired with screws so no general anesthesia. Total confusion while in hosp, regained some stability after dc, but not prior level.

Severe emphysema Dx approx. 1997, currently on 4L O2 24/7, O2 sat 99%

Asked DR (PCP) if ALZ, said yes without formal testing. Never to neuro or psych.

Aricept ineffective.

Significant weight loss, loss of strength, mobile with assistance and walker but very unsteady, shuffles, hunched over, rarely lifts head upright, PT dc after 8 wks due to lack of comprehension and forward progress. Housebound. Complains of frequent pain in affected leg.

Current meds include 81 mg aspirin, .25 mg xanax, 50 mg. zoloft, duoneb (albuterol sulfate/ipratropium bromide) inhalant for nebulizer, tylenol arthritis strength.

Wants to know why she isn't dead yet, feels she's lived long enough. She is DNR.

Although I am not an expert, I understand that Medicare will only pay for Hospice if the doctor(s) have said the patient has 6 months or less to live if the illness runs its normal course. Go to www.medicare.gov and type in Hospice - you will find an pdf file which explains Medicare covered hospice information.

karenlee,

Unfortunately, we're unable to provide medical advice regarding specific patient-related issues, and therefore, recommend that you consult with the patient's physician regarding future treatment options. However, I've attached a brochure which states the Association's official position regarding end-of-life care and palliative care, in particular, that may be of some benefit as you consider the issue of hospice care and its appropriate timing. Please feel free to call us on our helpline if you'd like to discuss further.

This message has been edited. Last edited by: Jin K.,

Please contact a hospice anyway, regulations for dementia are different than for cancer. My mom has been on hospice for 2 years and one of the reasons she got on was because of her significant weight loss. Too many dementia patients have this great support system out there for them but don't know they are eligble for it. All they can say is no and you can keep getting reevaluated. ASK

Dear KL:
I've only just seen this post you made in July.

She appears to fit hospice criteria now.

BUT . . . I AM VERY CONCERNED ABOUT ATTACHING A DIAGNOSIS OF ALZHEIMER'S TO HER BECAUSE:

She has severe emphysema, she is on 4 litres of O2 and still extremely symptomatic.

SHE MAY WELL BE HYPOXIC, (very low level of O2 in the body), AND HER "DEMENTIA" SYMPTOMS MAY BE SECONDARY TO THAT. That is a very frequent state of affairs in such a condition.

If this were my mother, because of the severity of her respiratory condition, I would NOT have the primary attempting to manage her condition. I would definitely have a Pulmonary Specialist handling this.

Management of a patient with the severity of her condition is a very delicate balancing act. To do this optimally, requires the expertise of an Internist who is Board Certified in Pulmonary Medicine.

Also, if there were reason to have her dementia managed, especially in light of her pulmonary status, I would also definitely have my mother assessed by Neurology in order to obtain an accurate diagnosis.

However, I don't know this poor woman, what going to the MD is like for her, and perhaps she is past the point where one would wish Neuro input. BUT, I WOULD DEFINITELY HAVE THE PULMONARY MD HANDLE HER RESPIRATORY CONDITION.

I hope all is going well. Did you obtain hospice services?

Dear Johanna,

I had forgotten I posted this. Thank you so much for your response.

Mom entered hospice care on Aug. 8 with a Dx of debility (Adult Failure to Thrive.) Her AD has never been formally diagnosed, and since breaking her hip in February she is housebound. Hospice gave her co-morbidities of AD, COPD, and osteoporosis......all parts of the greater whole.

When mom was still able to make the decision, she appointed me her patient advocate and after careful thought and discussion, she requested a DNR order that has been in place for at least 5 years now.

I understand the acute nature of her pulmonary condition, but her dementia severely compromises her ability to participate in any pulmonary rehab or even the use of inhalers. She does have nebulizer treatments 4 times a day.

Since her admission to hospice mom has suffered a major decline in both cognitive and physical abilities, and I believe she is beginning the slow process of withdrawing and shutting down before death.

I thank you for your concern, especially with your nursing background. If mom were in better overall health I might feel more aggressive treatment was called for. As it is, I only wish to keep her comfortable and safe, and secure in the knowledge that she is deeply loved. Those are her wishes and I am relieved I have no moral conflict carrying them out.