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Prior parts of this book addressed that the Medicare Hospice Benefit is prognosis-based, which means that the patient must have a limited life expectancy, and the hospice is responsible for caring for and covering all cost for the terminal or primary diagnosis and all diagnoses that contribute to the terminal prognosis. The benefit covers services, drugs, supplies, and medical equipment related to the terminal diagnosis and diagnoses that contribute to the terminal prognosis. The hospice physician determines which diagnosis is the primary one and which comorbidities contribute to the terminal prognosis by reviewing all available clinical information from the referral source and outcomes from the interdisciplinary comprehensive assessment. Determining relatedness of diseases to the terminal diagnosis is a complex process, so it is extremely important for the hospice physician to have as much information about the patient as possible. Determining relatedness is not a one-time event; it is a continuous process that begins at admission and continues throughout the hospice service period. A patient may have a disease process at the time of admission that does not contribute to the terminal prognosis, but as the disease progresses and the patient’s status declines over time, that same disease process may contribute to the terminal prognosis and become the responsibility of the hospice interdisciplinary group (IDG) to manage.

The hospice IDG works together toward common goals determined by the patient, family, and IDG collaboratively. This means individualizing the care to manage the terminal diagnosis and diagnoses that contribute to the terminal prognosis. However, there are common symptoms at the end of life that a patient may experience no matter the specific diagnosis(es)—Table 4.1 outlines these common symptoms. A common goal is the preservation of quality of life and dignity for the patient. Adequately managing common symptoms at the end of life contributes to maintaining the quality of life the patient and family desires (National Cancer Institute, 2016).

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TABLE 4.1 Common Symptoms at the End of Life





  • Progress of disease

  • Pain medication side effects

  • Coughing

  • Decreased food and fluid intake

  • Balance rest and activity for energy conservation

  • Medications that increase brain activity, alertness, and energy


  • Pain

  • Shortness of breath

  • Psychosocial, emotional, or spiritual turmoil

  • Medication to relieve anxiety

  • Counseling to relieve psychosocial, emotional, or spiritual turmoil

  • Relaxation, breathing, and guided imagery exercises

Shortness of breath

  • Disease progression

  • Excess fluid in the abdomen

  • Loss of muscle strength

  • Hypoxia/hypoxemia

  • Pneumonia

  • Infection

  • Opioids to relieve shortness of breath in patients

  • Bronchodilators to relieve swelling and inflammation, which may relieve these spasms

  • Increase in oxygen if shortness of breath is caused by hypoxemia

  • Cool fan placed toward the patient’s face

  • Having the patient sit up or prop to a 45-degree angle in bed

  • Teaching a patient to do breathing and relaxation exercises, if able

  • Consideration of antibiotics if shortness of breath is caused by an infection



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