Going to the Hospital After You've Elected Hospice

Can you go to the hospital while you're on hospice?

Yes — a person on hospice can go to a hospital, and going does not by itself end the hospice benefit. Under Medicare's rules, revoking hospice requires a signed written statement from the patient or their representative, and a verbal statement is not accepted 1Ref 1Centers for Medicare & Medicaid Services (2024).Medicare Benefit Policy Manual, Chapter 9 - Coverage of Hospice Services Under Hospital Insurance.That revoking the hospice benefit requires a signed written statement and a verbal revocation is not accepted; that there is no waiting period to re-elect hospice; that hospice election runs through certification of terminal illness; and that the hospice's plan of care governs the services provided for palliation and management of the terminal illness.. What electing hospice does change is the aim of treatment: care meant to cure the terminal illness stops 2Ref 2Centers for Medicare & Medicaid Services (2024).Hospice Care Coverage.What Medicare's hospice benefit covers and does not cover: care for the terminal illness and related conditions, that treatment aimed at curing the terminal illness stops when hospice is elected, and that Medicare continues to cover care for health problems that are not part of the terminal illness.. Everything else that is confusing about hospital visits on hospice follows from that single distinction.

The fear underneath the question is usually not about rules. It is that a family who has finally, painfully agreed to comfort will be punished for a moment of panic at 2am — that the ambulance will undo the decision. It will not. The benefit is not that fragile, and neither is the decision.

Three doors, three different consequences

There are three ways a person on hospice ends up in a hospital bed, and they are not the same event. One is arranged by the hospice and keeps the benefit intact. One is for a problem that has nothing to do with the dying illness, and Medicare keeps covering it. Only the third — treatment meant to cure the terminal illness — takes the person out of the benefit, and only by signature.

Most of the panic in an emergency department comes from families who think they are in row three when they are in row one or two.

The word doing all the work is related

Hospice covers care for the terminal illness and the conditions related to it, and Medicare goes on covering health problems that are not part of that illness 2Ref 2Centers for Medicare & Medicaid Services (2024).Hospice Care Coverage.What Medicare's hospice benefit covers and does not cover: care for the terminal illness and related conditions, that treatment aimed at curing the terminal illness stops when hospice is elected, and that Medicare continues to cover care for health problems that are not part of the terminal illness.. Relatedness is not a technicality. It decides who arranges the care, who is billed for it, and whether the hospice team even learns the person went in. The hospice — through its physician and its plan of care — determines which services are for the palliation and management of the terminal illness 1Ref 1Centers for Medicare & Medicaid Services (2024).Medicare Benefit Policy Manual, Chapter 9 - Coverage of Hospice Services Under Hospital Insurance.That revoking the hospice benefit requires a signed written statement and a verbal revocation is not accepted; that there is no waiting period to re-elect hospice; that hospice election runs through certification of terminal illness; and that the hospice's plan of care governs the services provided for palliation and management of the terminal illness..

Some of it is obvious. A woman dying of heart failure who slips on ice and breaks a wrist has broken an unrelated wrist. A man dying of lung cancer who cannot catch his breath is having a symptom of the illness he is dying of, and that is hospice's to solve, at any hour.

The middle is where families get hurt. Dehydration, a urinary infection, a bowel obstruction, a pressure sore — these can be related or not, depending on the illness and on the judgment of the hospice physician, and the judgment is written down somewhere the family has not read.

One practical thing follows from all of this: an emergency department cannot coordinate with a hospice it does not know exists. The hospice's name and number, said at the registration desk, changes what happens next.

What an emergency room visit does, and does not, do

It does not revoke hospice. Revocation is a document, not an event — Medicare requires a signed written statement, and a verbal one is not accepted 1Ref 1Centers for Medicare & Medicaid Services (2024).Medicare Benefit Policy Manual, Chapter 9 - Coverage of Hospice Services Under Hospital Insurance.That revoking the hospice benefit requires a signed written statement and a verbal revocation is not accepted; that there is no waiting period to re-elect hospice; that hospice election runs through certification of terminal illness; and that the hospice's plan of care governs the services provided for palliation and management of the terminal illness.. A night in an emergency department, an admission after a fall, fluids for dehydration: none of these ends the benefit on their own. What ends it is a signature. The thing worth reading slowly, then, is whatever is on the clipboard.

The moment to watch for arrives in a particular sentence, and hospital staff say it kindly: we'd need you to come off hospice for us to do this. That sentence means the proposed treatment is aimed at the terminal illness, which is the one thing the benefit does not cover 2Ref 2Centers for Medicare & Medicaid Services (2024).Hospice Care Coverage.What Medicare's hospice benefit covers and does not cover: care for the terminal illness and related conditions, that treatment aimed at curing the terminal illness stops when hospice is elected, and that Medicare continues to cover care for health problems that are not part of the terminal illness.. It is a real choice, and it is sometimes the right one. It is almost never a choice that has to be made in a corridor within the next four minutes.

Before anything is signed, the hospice can be called from the emergency department. That is what the twenty-four-hour line is for. A hospice nurse can often say, in one sentence, whether the thing being proposed is something the hospice can do at home tonight.

If you do stop hospice, can you go back?

Yes. There is no waiting period to re-elect hospice after a revocation 1Ref 1Centers for Medicare & Medicaid Services (2024).Medicare Benefit Policy Manual, Chapter 9 - Coverage of Hospice Services Under Hospital Insurance.That revoking the hospice benefit requires a signed written statement and a verbal revocation is not accepted; that there is no waiting period to re-elect hospice; that hospice election runs through certification of terminal illness; and that the hospice's plan of care governs the services provided for palliation and management of the terminal illness., and the National Institute on Aging's consumer guidance states plainly that people can leave hospice and return to it 4Ref 4National Institute on Aging (NIH) (2024).Frequently Asked Questions About Hospice Care.That a person can leave hospice care and return to it later.. Re-electing hospice after revocation runs through certification again, the same as the first election did 1Ref 1Centers for Medicare & Medicaid Services (2024).Medicare Benefit Policy Manual, Chapter 9 - Coverage of Hospice Services Under Hospital Insurance.That revoking the hospice benefit requires a signed written statement and a verbal revocation is not accepted; that there is no waiting period to re-elect hospice; that hospice election runs through certification of terminal illness; and that the hospice's plan of care governs the services provided for palliation and management of the terminal illness. — which is why a family asking how quickly can hospice start hears roughly the same answer the second time as the first.

Going on hospice more than once is ordinary. People revoke to try one more round of treatment, or because a hospital promised something, or because a daughter flew in from out of state and could not bear it. Then they come back.

What a revocation costs is momentum. The equipment leaves the house with the benefit. The nurse line stops being yours. The team that had learned the person's particular way of hiding pain has to be rebuilt from a chart. None of that is an argument against revoking. It is an argument against revoking at 2am because a form was handed to someone frightened and alone.

The call that usually beats the drive

The hospice's nurse line is staffed twenty-four hours a day, and it exists for exactly the hour when a family is standing over a bed deciding whether to load someone into a car. A hospice can escalate care where the person already is: continuous home care during a brief crisis at home, or general inpatient care when a symptom cannot be controlled in the current setting 3Ref 3Centers for Medicare & Medicaid Services (2024).Medicare-Certified 4 Levels of Hospice Care.The definitions of Medicare's four hospice levels of care, including continuous home care for a brief crisis at home and general inpatient care for symptom control that cannot be achieved in the person's current setting.. Neither requires an emergency room.

Most hospices also leave a comfort kit in the house — a small box of rescue medications for terminal symptoms, which families in one study described as easy to use and effective 5Ref 5Peer-reviewed study (see article) (2014).Comfort Care Kit: Use of Nonoral and Nonparenteral Rescue Medications at Home for Terminally Ill Patients with Swallowing Difficulty.The existence of a home hospice comfort kit of rescue medications for terminal symptoms, which families in the study reported as easy to use and effective. Not used here for any medication choice, dose, or interval.. Every item in it carries a label saying what it treats and how it is to be given. The label, and the nurse on the line, are the only two authorities on that box. An article is not one of them.

Hospices ask families to call, rather than drive, when:

• pain is not controlled after the medication on the label has been given as directed
• breathing is frightening at rest, or has changed suddenly
• agitation or confusion is making the person unsafe
• vomiting will not stop, or there has been a seizure
• bleeding soaks through dressings
• the caregiver has reached the end of what they can do tonight

None of that asks a family to make a diagnosis. It asks them to make a phone call.

When the hospital is right anyway, and when the pattern is the point

Some things belong in an emergency department. A fall with an obviously deformed limb. Bleeding that will not slow. An injury with nothing to do with the terminal illness — the kind of care Medicare continues to cover 2Ref 2Centers for Medicare & Medicaid Services (2024).Hospice Care Coverage.What Medicare's hospice benefit covers and does not cover: care for the terminal illness and related conditions, that treatment aimed at curing the terminal illness stops when hospice is elected, and that Medicare continues to cover care for health problems that are not part of the terminal illness.. Hospice does not mean declining all care. It means care aimed at comfort, which sometimes means a splint. The question at 2am is only which place can fix this thing tonight.

Whether that place is an inpatient hospice house, a hospital, or the bedroom depends on the symptom, and the hospice is the fastest way to find out.

But a pattern of hospital runs is information about the hospice, not only about the illness. If symptoms keep collapsing at home, symptom management is what is failing. In a national cohort of Medicare beneficiaries discharged alive from hospice, burdensome transitions — hospitalization, readmission, and death in a hospital — were more common after care from for-profit hospices and after short stays 6Ref 6Peer-reviewed cohort study (see article) (2024).Hospice Readmission, Hospitalization, and Hospital Death Among Patients Discharged Alive from Hospice.That among Medicare beneficiaries discharged alive from hospice, burdensome transitions — hospitalization, readmission, and hospital death — were more likely after for-profit hospice care and after short stays..

That finding is a reason to ask two questions before enrolling, when there is still time to ask them. The first is about hospice organization types: who owns this agency, and what does ownership change here. The second is blunter, and worth asking out loud: what would cause you to discharge us?