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Old Age: Not a Hospice Diagnosis

By October 30, 2008

It happens to me all the time. I do an assessment for hospice care on an elderly patients with multiple medical conditions that are contributing to their demise but not one standing out as the potential cause of death. These are the patients who deteriorate gradually over time. With advanced age comes hardening of the arteries, increased risk for blood clots and in turn heart attacks or stroke, brittle bones and frail skin, and increased susceptibility to infections as the immune system fails. These patients always have one of these problems and often have all.

When I see these patients that are essentially dying of old age, I have to look through the lense of the Centers for Medicare and Medicaid (CMS). You see, CMS doesn't recognize old age as a hospice diagnosis, and even worse, the CDC doesn't recognize old age as even a valid cause for death. Both agencies have decided that death must be more specific. For example, instead of "Old Age" or "Advanced Age" on a death certificate, it might read something like "Acute myocardial infarction related to underlying atherosclerotic coronary heart disease" even though the deceased was already bed bound, frail, and suffering from pneumonia.

To satisfy CMS, I have to look beyond the big picture and search for something more specific. I pull out my CMS guidelines for hospice admission and review the requirements for every illness the patient has. If I'm lucky, I might find that the patient squeaks by on a particular guideline. If I'm not so lucky then I have to qualify the patient under an obscure diagnosis called "Decline in Health Status", "Debility", or "Failure to Thrive". These are really just fancy words for "Dying of Old Age". But it's not enough for CMS to see documentation that a patient is ill and frail with multiple conditions. I have to document recent weight loss, mid-arm circumference, the patient's body mass index (BMI), their palliative performance score (PPS), the presence of infections and bed sores, and the list goes on.

I wonder what it would mean if I could admit patients to hospice with a diagnosis of "Advanced Age"? What if we began to recognize advanced age a universal and unpreventable cause of death? What would it mean to our health care system to have the financial, social, and personal aspects of long-term care front and center? What if addressed the problems of aging in the same way as we addressed the problems of heart disease and cancer?

The Leading Causes of Death (Minus "Old Age")

Killer Number One: Heart Disease

I Have Severe Heart Disease. Am I Ready for Hospice?

The Aging Heart by Mark Stibich, Ph.D, About.com's guide to Longevity

Killer Number Two: Cancer

What is Palliative Chemotherapy?

Killer Number Three: Stroke

Comments
December 8, 2009 at 1:40 am
(1) M Godshall says:

You have stated my dilemma perfectly. I am caring for my mother who is simply dying of old age with mobility limited to 80 steps a day, chronic pain and a daily medical cocktail to treat diabetes/neoropathy, heart failure, panic attacks and depression, constipation, hemorroids, arthritis, thyroid issues, asthma, and a predisposition to urinary infections. She is miserable, but has good daily indictors and a good appetite. I believe she would benefit from Hospice care – better pain meds, counseling, and help deciding the balance between curative and comfort care.

December 15, 2010 at 1:10 am
(2) Barbara says:

My mother passed away in October of this year. She had no terminal illness. She was 86 years old. The diagnosis that was given to us that made her a hospice candidate about 2 months prior to her death was “failure to thrive” My frustration in this process is the seemingly newness of people with advanced age that have no chronic terminal illness as a diagnosis yet they slip from their family care givers on a daily basis. My mother’s journey, which I choose to call it, began about a year and half ago. She was living independently in her own home and fell and was hospitalized. She fractured vertebra in her back, contracted a urinary infection, but was released to recover in my care. She moved into my house to recoup with the idea of resuming her life independently. That did not happen. Instead, she slowly lost interest in doing her physical therapy, in eating, and just wanted to sleep all the time. She lost interest in socializing with her extended family which she loved and instead only wanted to be with me (her daughter) and her grandchildren. Despite our efforts and prodding her to exercise, to eat, to engage, she slept. She was also declining cognitively, and I could see the internal struggle she was experiencing. She would acknowledge that her mind was “mush.” I was incredibly frustrated. Her doctor made house visits, and every visit he assured us her vitals were strong. He would prescribe appetite stimulates and even anti depressants. Nothing worked. She continued to slip away. Frustrated with the medical route, I decided to call in Hospice. Their assessment confirmed what I thought. My mother was dying. Hospice was amazing in many ways. The first amazing thing was for us who were caregivers. We no longer pushed her to do the normal life sustaining things like eating, getting out of bed, showering, etc. Hospice taught me that people who are dying need different things that those who are living. They need to be comfortable; they need time and space to process their journey from this world to the next. What I hope changes is that failure to thrive becomes a recognized diagnosis so that care givers have the tools they need to respond to the dying person as soon as possible. I was fortunate to have traveled this journey with my mother with my daughter’s help. A secondary change would be to arm the institutions (nursing homes) with tools to help those in the same situation without family care givers. It is a fact that people live longer and our system needs to change to respond to new needs.

December 15, 2010 at 10:19 am
(3) dying says:

I agree Barbara. Well said!

December 25, 2010 at 1:14 am
(4) Liz says:

My mother-in-law is 101 and in a nursing home. I could see her going down hill quickly. She had not taken badly needed meds for 6 days and had not eaten or drank food. I insisted to her Dr. that he call in Hospice. She became agitated, combative and was living in the 1930′s. We tried talking to her like we knew all about that time, so she would not get upside. She wanted to get up and go to the bathroom, but they had a diaper on her and she can not stand on her own legs. She was small in the first place, but has lost down to about 70 lbs. So, Hospice has come in and they are giving her meds to make her more comfortable. The hospice nurse explained that she is in a transition, that her spirit has told her body she has lived long enough, not to eat, drink or take meds. She is not living in this world. I only want her to be comfortable in this time of her life. Some do not agree with this. Her throat has already started closing up. Today we found a aide had taken her to the restroom and left her slumped over on the commode, laying on the wheelchair with her other hand on the rail. She could have passed out or fallen and busted her head on the tile floor. Tomorrow, I will address this with the nurse. She was suppose to have a catherer in her and the diapers renmoved. I am tired from running back and forth to the NH, because they are not tending to her properly. I have had to pay private sitters to stay with her day and night. It is like the NH does not have time for her. Hospice is the only care to get when a patient goes this far. They explained some things to her which miraculously she understood. Like Jesus would be coming for her, wait on him to take her hand. Now I have to deal with silly aides that do not know what to do or follow orders. What a shame for our older people.

February 4, 2011 at 1:38 am
(5) Nicole says:

I am going through something similar to the stories on here. I am writting from a motel room because my grandma is (dying) she has no terminal illness or any of the main reasons for death, one doctor said her heart beats like a 20 year old. My grandma was fine, she had some memory issues but normal just getting old. she lived alone, i live three hours from her so i would call her on the phone everyweek. she would sound great, but our conversations were more like friends that was the only differentence. She went to Ny for christmas and new years with to visit my aunts family and when she came back she wouldnt leave bed, stoped eating. i saw her two weeks ago she looked like she was tired and had the flu she spoke normaly to me. day by day she has stoped speaking normaly, breathing shallow. Hospice says she is dying, and it will be soon. why i am writting is, what advice would you give looking back?

March 20, 2011 at 11:40 am
(6) Cheryl, RN says:

My advice to you is not to look back. It sounds as if your grandmother went on her trip and possibly took care of some final business in her own way. She may have known she was dying when she went and now she is just waiting to be called home. Enjoy the time you have with her and do not be afraid to talk about death or to say your goodbyes. Tell her you love her and let her know how much she has meant to you and that you will always have those memories.
I am a Director of Patient Care with a hospice in the state of Arizona and have been in the hospice field for many years. My advice to you is to remember that your grandmother lived her life the way she wanted and do not second guess that you should have come sooner or invited her to live with you. It is as important for the elderly to keep their independance for as long as they desire just as it is for you and I.

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