Hospice and Palliative Medicine: Benefit Rules, Prognosis, and Symptom Control
The Hospice and Palliative Medicine domain of the CAQ exam tests whether you can apply Medicare hospice rules, prognosticate reliably, and manage symptoms in seriously ill patients - not merely recite drug names. Many items fuse eligibility criteria with pharmacology, communication, and ethics.
Hospice eligibility and the benefit
- Two physicians certify a prognosis of six months or less if the disease follows its usual course; recertification occurs each benefit period, and a face-to-face encounter by a hospice physician or nurse practitioner is required before the third benefit period and every subsequent one.
- Eligibility rests on clinical data, not a single laboratory value: FAST stage 7c in dementia, NYHA class IV heart failure, or Karnofsky ≤50% with declining function.
- Election waives Medicare payment for curative treatment of the terminal diagnosis only; unrelated problems (a hip fracture, a new cancer) are still covered.
- Levels of care: routine home care, continuous home care (≥8 hours in a 24-hour day during crisis), general inpatient care, and respite (maximum 5 consecutive days).
Symptom management
- Oral morphine 30 mg ≈ IV morphine 10 mg ≈ oral hydromorphone 6 mg; reduce 25–50% for incomplete cross-tolerance, then titrate.
- Opioids are first-line for dyspnea in hospice; oxygen helps only documented hypoxemia.
- Glycopyrrolate or scopolamine for terminal secretions; haloperidol for hyperactive delirium.
Worked example
A patient takes oral morphine 30 mg every 12 hours plus 15 mg every 4 hours as needed, averaging three rescue doses daily: 60 + 45 = 105 mg oral per day. Dividing by 3 gives 35 mg IV morphine daily; subtracting about 30% for cross-tolerance yields roughly 25 mg/day, i.e., a 1 mg/hour infusion plus a PRN bolus.
Traps that cost marks
- Calling palliative care synonymous with hospice - palliative care begins at diagnosis.
- Forgetting the waiver covers only the terminal diagnosis.
- Ordering oxygen for dyspnea without hypoxemia, or escalating scheduled opioid for incident pain instead of giving a pre-emptive bolus.
- Fearing respiratory arrest when opioids are titrated to dyspnea.