When do people begin hospice care?

Ideally all patients would begin hospice care as soon as they are eligible, when they have a prognosis of 6 months left to live. Studies have shown that the earlier a patient is admitted to hospice during the course of their terminal illness the better the quality of life experienced by both patient and family members. 

However it is sometimes difficult for medical providers to know when that 6 month threshold has been reached. Unfortunately many patients do not receive hospice care until the last few days or weeks of their lives, which limits the benefits they can receive from this specialized program of care. 

Patients who begin receiving palliative care earlier in the course of an illness, while still undergoing treatment, may be referred for hospice care in a more timely manner and will already be benefiting from the whole-person care provided by the palliative care team, so this is the best possible scenario during the difficult situation of facing a terminal illness.

At varying times. I think people begin too late, frankly. It depends on the goals of therapy. If people are trying to aggressively beat a disease, usually from my experience, the doctors and the patients don't even discuss hospice. But there are different goals of therapy and sometimes the goal is palliation. We try to broach that subject with palliative care. Evidence supports that when you begin palliative care earlier, you really do get better outcomes. Palliative care focuses on symptoms and quality of life. 

Sometimes illnesses come hand in hand with certain symptoms that can't be remedied, so they have to be dealt with. It could be pain, nausea, a variety of things. Hospice usually comes into play towards the end of life, when patients are trying to either control an advanced disease or receiving palliative care only. Some diseases are so indolent that people can live with them for years and years, even if incurable. That wouldn't be a good time to refer to hospice. But when the disease starts to take a turn for the worse or becomes unresponsive to therapy, or the symptoms are becoming less manageable and the patient needs more support, we often encourage them to consider hospice. 

 A referral to Hospice should not mean “this is it, death is imminent.” Hospice coverage is actually for up to 6 months. The care means you can get a different level of support, which focuses more on quality of life. I have had patients respond to treatment after being referred to Hospice though. One patient was discharged from Hospice after having a remarkable response to a new oral agent.