Hospice Eligibility: Key Criteria and When to Consider Hospice Care

What It Means to Be Eligible for Hospice Care

Hospice eligibility is based on medical needs and goals of care; not on age or a single diagnosis.

Someone may be eligible for hospice when:

• They have a serious, life-limiting illness.
• A doctor believes that, if the illness follows its usual course, life expectancy may be about six months or less.
• The focus of care has shifted away from curing an illness and toward comfort and quality of life.

Hospice teams and providers reassess eligibility regularly. If a person’s condition stabilizes or improves, hospice care can be paused or discontinued. If the illness progresses, hospice care can also be recertified and continued.

General Criteria for Hospice Care

While specific guidelines vary by diagnosis, most hospice programs use a combination of prognosis, functional status, and symptom burden to determine eligibility. Common signs include:

• Limited life expectancy. The person has an illness that isn’t expected to be cured, and their provider assesses their life expectancy to be about six months or less.
• Declining functional status. They have less energy and are spending more time in bed or a chair. They also need more help with daily tasks like bathing, dressing, or walking.
• Increasing symptoms. Pain, shortness of breath, nausea, confusion, or other symptoms are becoming harder to control despite ongoing treatment.
• Frequent hospital or ER visits. There are repeated trips for infections, breathing problems, falls, or complications related to the illness.
• Goals of care focused on comfort. The person and their family are more interested in comfort, time at home, and avoiding burdensome treatments than in additional tests or hospital stays.

No single factor automatically “qualifies” someone. Providers look at the whole picture, including medical history, recent changes, and what the person wants for their care.

How Providers Decide If Hospice Is Appropriate

Hospice eligibility is usually determined through a conversation and a clinical assessment involving:

• The person’s primary care provider or specialist
• A hospice medical director or hospice nurse
• The patient and family, who share what they’re seeing at home and what matters most

The provider may review:

• Medical records and test results
• Recent hospital and ER visits
• Changes in weight, appetite, and strength
• Whether daily routines now require regular assistance
• Current medications and treatments

If the person appears to meet criteria and wants hospice, the provider can write a hospice referral, and the hospice team will schedule an initial visit (often in the home or facility).

Eligibility is reviewed regularly, typically at the start of care and then at set intervals. Hospice continues as long as the person still meets criteria and the focus remains on comfort.

Illnesses Commonly Served by Hospice

Hospice care is available to people with many different diagnoses, including but not limited to:

• Dementia and Alzheimer’s disease
• Cancer
• Heart disease (such as heart failure)
• Lung disease such as COPD (chronic obstructive pulmonary disease) or pulmonary fibrosis
• Kidney or liver failure
• Neurological conditions such as Parkinson’s disease, ALS, or complications from stroke

Within each of these, there are more detailed clinical guidelines that providers use, such as how advanced the disease is, how often complications occur, and how much the illness is affecting everyday life.

Condition-Specific Examples

While only a provider can determine eligibility, it can help to see how this looks in different illnesses. Here are some general patterns:

Alzheimer’s Disease and Other Dementias

Hospice may be appropriate when a person with Alzheimer’s disease or another type of dementia:

• Can no longer walk without help, speak clearly, or manage daily care
• Has trouble eating or swallowing, or has lost a significant amount of weight
• Has frequent infections or other complications
• Needs full assistance with bathing, dressing, toileting, and getting in and out of bed

Cancer

For cancer, hospice is often considered when:

• The cancer is spreading despite treatment
• Treatments are no longer expected to help
• Symptoms such as pain, fatigue, or shortness of breath are increasing
• The person prefers to focus on time at home and comfort rather than more aggressive care

COPD and Other Advanced Lung Diseases

People with COPD or other advanced lung disease may be eligible when they:

• Are short of breath with minimal activity or even at rest
• Have had multiple hospitalizations or ER visits for breathing problems
• Need increasing oxygen or medications to manage symptoms
• Find that simple activities like walking across the room or talking for long periods leave them exhausted

Heart Disease, Including Heart Failure

For advanced heart disease, including heart failure, hospice may be appropriate when:

• There have been frequent hospitalizations for heart-related issues
• The person has symptoms like shortness of breath, swelling, or chest discomfort despite treatment
• Fatigue and weakness significantly limit daily activities
• The focus is shifting from trying new procedures to staying comfortable at home

Parkinson’s Disease and Other Neurologic Conditions

Hospice can also support people with Parkinson’s disease and other neurologic conditions when they:

• Have significant difficulty walking, talking, or performing daily activities
• Experience frequent falls or injuries
• Have trouble swallowing, leading to weight loss or recurring pneumonia
• Need extensive help from caregivers to manage daily life and stay safe

Hospice Insurance Coverage at a High-Level

Financial concerns often keep families from asking about hospice, but in many cases, cost is not a major barrier.

In many cases:

• Medicare hospice benefits usually cover the core services for eligible patients: nursing, diagnosis-related medications, equipment/supplies, and counseling/spiritual support.
• Medicaid and most private insurers also include hospice coverage.
• Many hospice programs can help families understand their benefits and explore financial assistance if needed.

Coverage details vary, which is why it’s important to talk with the hospice team’s financial counselor or admissions staff to get a clear picture for your situation.