Hospice care is a specialized form of medical support focused on comfort and quality of life for individuals facing a terminal illness. This palliative approach shifts the goal of care away from attempting to cure the underlying disease. Because of this fundamental difference in philosophy, the question of whether a person on hospice can go to the hospital for treatment is common and often misunderstood. While a patient always retains the right to seek any medical care they choose, doing so without coordination can have significant consequences. Understanding the distinction between hospice’s model of palliative care and the hospital’s model of acute, curative care is crucial for families navigating this stage of life.
Hospice Care and the Default Rule
A person on hospice care is always free to go to a hospital emergency room or be admitted for any reason. However, seeking acute hospital care generally runs contrary to the hospice election agreement the patient signed upon enrollment. Hospice care is structured to provide all necessary medical, nursing, and support services in the patient’s place of residence, whether that is a private home, a nursing facility, or an assisted living center. The patient has already acknowledged that they are pursuing comfort-focused care for their terminal illness, rather than curative treatment.
The hospital environment is centered on diagnosis, aggressive intervention, and cure, which conflicts with the hospice philosophy. If a patient is admitted for treatment of the terminal illness or a related condition, they are essentially seeking curative care. This action violates the terms of the hospice benefit, which covers palliative care only, and carries immediate implications for enrollment.
Financial and Enrollment Implications
The most significant consequence of an uncoordinated hospital visit is financial, especially for patients utilizing the Medicare Hospice Benefit. By electing the benefit, the patient waives their right to Medicare payment for any services related to the terminal illness or its associated conditions, except for those provided or arranged by the hospice agency. This means that if the patient is admitted to the hospital for a condition related to their terminal diagnosis, Medicare will not pay the hospital bill. The patient is then financially responsible for all hospital costs, including physician fees, medications, and room charges.
The hospice agency is also required to terminate the patient’s enrollment because they sought curative treatment, though the patient can re-elect the benefit later by starting a new benefit period. It is possible for the patient to receive hospital treatment for a condition entirely unrelated to the terminal illness, such as a broken leg. In this case, the hospital stay would be covered by Medicare Part A or private insurance, but the hospital’s billing department must be aware of the distinction to avoid coverage issues.
When Hospitalization is Coordinated by Hospice
A hospice patient may be admitted to a hospital or an inpatient facility with full coverage under their hospice benefit in specific circumstances. This occurs when the patient experiences symptoms that become intractable and cannot be managed safely or effectively in their current residence. Examples include uncontrolled pain, severe respiratory distress, or catastrophic bleeding that requires immediate, intensive intervention. The hospice team coordinates this planned transfer to the General Inpatient (GIP) level of care.
GIP is a short-term, acute level of palliative care provided in a facility, such as a hospital unit or a dedicated hospice inpatient facility. The goal of GIP is to stabilize crisis symptoms before the patient returns to routine home care, not to cure the underlying illness. During this coordinated stay, the hospice physician remains the primary decision-maker. The hospice agency is financially responsible for the care, ensuring the patient remains within the terms of their benefit.
Crisis Management Alternatives within Hospice
Before considering an emergency room visit, families should contact their hospice team immediately, as they are available 24 hours a day. Hospice services are designed to manage crises and prevent unnecessary hospitalizations by bringing a higher level of care to the patient’s residence. One alternative is Continuous Care (CC), a temporary, intensive nursing service provided in the patient’s home. This service is crucial for managing acute symptoms that require constant monitoring.
CC involves shifts of skilled nursing care, often lasting eight to twenty-four hours a day, to actively manage a temporary crisis until symptoms stabilize, such as acute pain or severe agitation. Another option is Inpatient Respite Care, a planned, short-term stay in an approved facility. Respite care is intended to provide the primary caregiver a maximum of five consecutive days of rest, with the patient’s care fully managed by the hospice team.