The Third R: Hospice Recertification*

graduation-300x205I heard about a guy that ordered a T-shirt in anticipation of his hospice nurse’s final home visit. Even in the digital age, it took a bit of planning to get the shirt created and delivered.

Though I’m making up parts of the story I don’t recall, I’m probably not far wrong . . .

So, when the nurse entered the room where his rented hospital bed was located, the patient pulled back the sheets to reveal his new fashion statement. On the shirt, in bold letters, it read:

I graduated from hospice.

Based on evaluations from the nurse—including face time with a hospice doctor—the patient knew his condition had stabilized. Several doctors had once told him, as honestly as they could, that his illness would likely cause his death in six months or less. But by a miracle (if you believe in them), or fate/luck (words some prefer), or those doctors literally being dead wrong about the course of the illness, he had improved. This fortunate fellow had beaten the odds and would be dismissed from hospice care because he no longer qualified for the benefits.

He’d graduated!

Would the illness he had still be the culprit that will put him six feet under? Maybe. Probably. But, according to the doctors with their educational and experiential acumen, this gentleman was no longer near death’s proverbial gloomy door.

If his health nosedived and the old (or a new) illness caused him to be “appropriate” again, could our lucky lad easily re-enter hospice care? Yes. But he’d have to be “recertified,” with the illness again being determined as life-threatening based on hospice guidelines.

Occasionally I wonder about my made-up man and his T-shirt when the hospice team reviews the current patients that may be recertified*. These “recerts” probably won’t “graduate.” They won’t soon have a last visit from a nurse, but will have a next and a next visit as they continue to deal with their illness.

Some patients, you see, will be in hospice well past the “six months or less” criteria.

Here are the bare bone facts. Once you enter hospice, a patient has 90 days of care covered by Medicare. Before the first 90 days concludes, the medical team will review the patient’s case. If “approved” for continued care, they patient will enter a second 90-day period. Near the end of those months (yes, add it up and it’s six months total), there will be another review. According to medical experts, is the illness still likely to cause death within six months?

If yes, the patient continues under care. But a change occurs with the timetable. Instead of 90 days, the patient (based on the exciting Medicare guidelines) must be recertified every 60 days.

In the hospice team meeting, we always review a few (and sometimes quite a few) patients in their second or third or more “cert period.” I think of these as the “dismal reports” . . . for we discuss weight loss for people whose bodies have already lost so much, or how little they eat compared to several months before, or how once they walked with assistance, but are now bedbound. Bluntly speaking, how and how badly has the patient worsened?

Sigh. Some illnesses are glacially slow, with cruelty doled out in miniscule portions.

I recall one patient (though these facts, like the guy with the T-shirt, is blurred for confidentiality) about to enter his (or her) 16th recertification. 16! First recert: 90 days. Second: 90 days. Third: 60 days. I’ll do the rest of the math for you: this one patient, entering a 16th recertification period, had been in hospice care for 34 months. Nearly three years!

How can that be? Because the patient was determined to have “six months or less to live” in each mandated evaluation.

Some die in hospice within 24 hours. About one third of patients die in less than a week after entering hospice care. In 2013, according to the National Hospice and Palliative Care Organization,

. . . the median (50th percentile) length of service in 2013 was 18.5 days, a decrease from 18.7 days in 2012. This means that half of hospice patients received care for fewer than 18 days and half received care for more than 18 days.

18 days.

Patients do “graduate” from hospice, and some linger for years. However, both are rare.

But what isn’t rare is the support and care hospice will try to provide in the moment that matters most: here and now, with the people you love. Whether there are one or multiple recertifications, I hope every patient and caregiver views each day as a gift.

(Hospice vigorously protects a patient’s privacy. I’ll take care with how I share my experiences. Any names used are fictitious. Events are combined and/or summarized.)

*No, the 3 Rs aren’t the olde reading, ‘riting, and ‘rithmatic (ha!), but the hospice-based 3 Rs of Revocation, Respite, and Recertification. I’ve already written some about Revocation and Respite.


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  1. I met one of my graduates from hospice(when I worked for hospice) in the ICU a few weeks ago. She had been discharged for extended prognosis. She came back to the hospital because she had fallen and broken her hip. She coded while in the OR trying to fix it and died a few days later. She was great, her family was crazy…

  2. I had a family member go in and out of hospice several times over an almost 2 year period. I remember how upset she was that her illness was not following the doctor’s orders. She had given away most of her possesions in the first weeks of her first hospice entry making her continuing time on this earth more of an inconvenience than she’d planned on. As annoyed as she was, we were grateful and after her passing we gathered to retrieve all of the items we’d loaned her while she waited for her time and it gave us a chance to remember her. When I use the items I loaned her now, I remember her and how her long wait brought us together to support her in ways she did not intend but served us all.

    • Thanks! Dying and death seem to have their own persnickety schedules. And we humans, frustrated or generous or both, often can only scramble to play catch up . . . whether with our feelings or our gifts. I am so glad you helped her with “things” while supporting her with love!

  3. In order to qualify for hospice, a patient has to be certified as having a prognosis of less than six months to live, but sometimes patients live longer. Medicare patients who receive the hospice benefit must waive other Medicare benefits that could prolong life.

    (And by the by, Wiley . . . I sent you a thank-you email for your response, but it bounced back. Hmmmm?)

    • Thanks for reading and responding, Wiley. Yes, as I understand it, the hospice Medicare benefit means other benefits may no longer be available. In a sense, hospice trumps other benefits. However, most of the medical “guesses” that a person has six months or less to live take into consideration other factors . . . including treatments that could be covered but are no longer deemed able to cure and also the patient/family’s wishes as they consider options for quality of life care.

      (And by the by, Wiley . . . I sent you a thank-you email for your response, but it bounced back. Hmmmm?)

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