A Trial of Concurrent Care: Shedding Light on the Gray Zone.

Abstract

Patients are hospice eligible when they have an estimated prognosis of 6 months and the readiness to forgo attempts at disease-modifying treatments related to their terminal illness. The decision to enroll in hospice is relatively clear when the prognosis is based on an incurable illness for which there are no further life-prolonging therapies. However, when the prognosis is based on a serious chronic illness for which possible interventions remain but must be forgone to access hospice support, the decision process is more complex. Such patients may benefit from a trial of concurrent care, receiving both disease-modifying and comfort-focused hospice care, while determining whether or not to pursue further treatment. This article illuminates the need for concurrent care for hospice patients with serious illness. We present a case to exemplify this gap and offer a framework for managing patients in transition between disease-modifying therapies and hospice care. The case describes an 86-year-old woman with dry gangrene of her foot who was admitted to hospice for end-of-life care and, after a trial period on hospice, chose to pursue further treatment. Integrating concurrent care into the Medicare Hospice Benefit allows patients to receive care that aligns with their values, even as they experience and collect new information about their condition. We propose the TRIAL framework to assess evolving goals of care for hospice patients with serious chronic illness.