What are the Medicare Hospice Guidelines for Congestive Heart Failure?

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Answered by: Christy, An Expert in the Hospice Basics Category
One of the most difficult diseases to predict in its end stages is congestive heart failure. It is hard for a doctor to know exactly when a patient will benefit from hospice care. Naturally, the patient wants his or her care to be covered by Medicare, so Medicare Hospice Guidelines were established to give physicians a tool for making a timely referral.

Although these guidelines are not set in stone, they are the best way to determine if disease progression is in its end stages. Therefore, as a general rule, a physician has to be able to answer this question in order to meet Medicare Hospice Guidelines for any non-cancer diagnosis: Based on established guidelines, will the patient live six months or less?

Each disease has different symptoms, so separate guidelines were created for each. Here are some of the necessary criteria for establishing a congestive heart failure patient as terminal.

Clinical Symptoms

The history and physical for a patient with end stage congestive heart failure should show an ejection fraction of 20% or less. This means that the heart is no longer able to pump blood back into the blood stream efficiently. The patient typically makes multiple trips to the emergency room for heart related reasons such as shortness of breath, chest pain, weakness, or possibly recurring infections. Various medical interventions, such as diuretics for swelling or vasodilaters, no longer work. The patient usually shows a weight loss of 10% or more in the last six months. There will also be symptoms of dementia due to lack of blood flow to the brain.

Clues for the Caregiver

A caregiver will not necessarily be expert in the clinical symptoms of congestive heart failure, but he or she will definitely notice the decline in activities of daily living. When these things begin to happen, the caregiver should talk to the patient’s doctor about hospice care.

A person who is in the end stages of heart disease will no longer be able to eat, dress or move without assistance. He or she will be confused more often. The patient’s clothes will not fit anymore. There will be more falls, and the patient will be more susceptible to infections such as pneumonia and urinary tract infections. There is often swelling in the extremities. It is most noticeable in the feet.

The caregiver’s input is extremely helpful as the doctor tries to determine if the patient meets Medicare Hospice Guidelines for congestive heart failure. The guidelines ask for most of these symptoms to be present. Medicare is aware that it is difficult to make an exact prognosis, so the physician will have to continue to certify that the disease is in its end stages if the patient lives more than six months. This isn’t unusual, and it shouldn't be a reason to avoid hospice care. In fact, the sooner care begins, the more it can improve the patient’s quality of life. As the focus shifts to quality of life instead of curing the disease, both the patient and the caregiver will benefit.

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