Roadblocks

Beyond Typical General Inpatient (GIP) Level of Care Criteria: What Does 'Stability' Mean?

Welcome to AAHPM Quarterly's inaugural Roadblocks column. Each quarter, this column will use a clinical case to focus on a specific scenario faced by hospice and palliative care teams. Two or more interdisciplinary team members will comment on the specific regulatory, operational, ethical, or clinical “stuck points” highlighted in the case, opening doors for follow-up discussion and debate on AAHPM Connect. No author will take sides; instead, authors will be asked to lean into the gray areas to move our collective knowledge base forward.

The Case

You work for a community-based hospice agency and are asked to comment on the appropriate site for end-of-life care for a 70-year-old woman admitted to a local acute care hospital.

She has a medical history of ovarian cancer. Despite an initial excellent response to chemotherapy and abdominal debulking surgery, she has developed a malignant small bowel obstruction that was complicated by a small perforation of her intestine. After a course of critical care, including antibiotics, placement of a decompressive gastrostomy tube, pressor support, and percutaneous drainage of an intra-abdominal abscess, she has stabilized.

The patient, in consultation with her family, has elected to elect the hospice benefit. At this time, she is able to drink small amounts of fluid, makes a moderate amount of urine, and has waxing and waning mental status. The inpatient team estimates a prognosis of days to a few weeks. Though she was initially uncomfortable, complaining of nausea and abdominal pain, the palliative care team at the hospital adjusted her oral morphine concentrate and haloperidol dosing and she is now comfortable, with minimal dose changes for several days.

The inpatient team mentions that due to her religious beliefs, her family is strictly opposed to a death at home, and the hospital utilization review committee is pressuring the inpatient team to “discharge the patient and have them admitted to inpatient hospice (General Inpatient [GIP] Level of Care, at the hospital itself).” The primary attending confides in you that she feels conflicted, as she wants to honor the patient’s wishes, satisfy the hospital stakeholders who are pressuring her, and ensure the patient’s disposition is in line with hospice regulations.

How do you navigate this situation? How would you mediate this tension, where the patient’s family and primary attending are “stuck” in the middle?

Read how two interdisciplinary team members would handle this situation. Then, we want to hear from you!

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Perspective: George Handzo, BCC APBCC CSSBB
Director of Health Services, Research, and Quality, HealthCare Chaplaincy Network

Because I am a chaplain, my priority would be to obtain clarity from the family about their apparent unwillingness to let the patient die at home on religious grounds. In 40 years of healthcare chaplaincy, I have never heard of a religion which would have this objection, nor did a search identify one.

However, it is not uncommon for patients and families to misunderstand the beliefs of their faith group. If this turns out to be the case, the normal procedure would be to identify a faith leader from their community whose opinion they would trust and have that leader talk to them.

Even if the family belief turns out to be sincerely held, it may be specific to certain circumstances that can be overcome. Is the room the patient would die in an issue? Who will need to be with them? How long will the body stay in the house after death? Would discharging the patient to the house of a relative who would welcome her solve the problem?

One possibility in circumstances like this is that religion is used as a justification for what is really a psychological barrier. This possibility does not seem likely in this case since the family has consented to hospice, but it needs to be considered in case this issue is psychological instead of religious.

If it turns out that the religious objection is firmly and sincerely held—even if it is not part of the belief of a particular faith community—it must be respected. I would represent to the team and administration that the patient cannot go home without seriously violating the family’s beliefs, which would constitute unethical care. I would support the team in efforts to find another solution, even if that solution stretches normal procedure.

Perspective: Joel Policzer, MD MS FACP FAAHPM
Senior Medical Director for Academic Affairs, VITAS Healthcare

While it might appear that the stakeholders are stuck between the proverbial rock and hard place, my assessment is that there is only a “hard place”: the hospital that wants the patient out.

Many might hold the conventional wisdom that the hospice GIP level of care is only for patients who have acute, ongoing symptoms that need management, and it is clearly described that this patient currently has her symptoms managed with appropriate medications, that there have not been dosing changes, and that she is able to take small sips of fluid.

However, this patient is far from a stable “custodial” situation. She likely has abdominal carcinomatosis, has already had one bowel obstruction, and is at high risk for another obstruction, which is painful despite the gastrostomy tube. It has been shown that in women with ovarian cancer, a bowel obstruction is a preterminal event, and median survival after the obstruction is 93 days.¹

In addition, the patient’s alertness waxes and wanes, and this will complicate her oral intake, leading to dehydration and further clinical decline. So, while this patient may be “stable”at this time, her risk of rapid deterioration is high. The Centers for Medicare & Medicaid Services (CMS) has acknowledged that GIP care may be appropriate when a patient needs medication adjustment, observation, or other stabilizing treatment after hospital discharge,² and this patient clearly falls into that category: she needs observation for the high likelihood of rapid onset of symptoms and deterioration.

If she were to stabilize, not need adjustments in medication or other interventions, then she could transition to a skilled facility. If the logistics of this transition are expected to take time, then the billing status of the patient could change; the hospice would bill for Routine Home Care instead of GIP, which would take the patient off CMS’s radar.

References

1. Mooney SJ, Winner M, Hershman DL, et al. Bowel obstruction in elderly ovarian cancer patients: a population-based study. Gynecol Oncol. 2013;129(1):107-112. doi:10.1016/j.ygyno.2012.12.028
2. National Hospice and Palliative Care Organization. A compliance guide to hospice inpatient care. June 2018, revised Feb 2022. https://www.nhpco.org/wp-content/uploads/NHPCO_GIP_Compliance_Guide.pdf

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