End-of-Life Care for Persons With Alzheimer's Disease

Because of the rapidly increasing number of older adults with chronic disabling conditions and because of advancements in lifesaving technologies, end-of-life care has become a significant component of the health care system. Although end-oflife care is a relatively common option for patients with terminal cancer, it has become available only recently for patients with Alzheimer’s disease. In September 2001 Medicare issued a memorandum that stated that claims for hospice services should not be automatically denied just because a patient has a diagnosis of dementia (personal communication, Alzheimer’s Association, 2004). The National Hospice and Palliative Care Organization reported that approximately 8 percent of patients in hospices in 2002 had Alzheimer’s disease (1). Current federal Medicare regulations require that a patient have a prognosis of less than six months of life in order to be eligible for hospice benefits. This requirement is widely viewed as being inadequate, especially in regard to Alzheimer’s disease. Although the guidelines for determining prognoses of selected noncancer diseases are based on severity-of-illness criteria, it can be challenging and controversial to apply these guidelines to the end stage of Alzheimer’s disease (2). The practice guideline of the American Psychiatric Association briefly discusses hospice care in end-stage Alzheimer’s disease, but it lacks practical information (3). This column explores end-of-life situations unique to patients with end-stage Alzheimer’s disease and their caregivers that demonstrate why practice guidelines and Medicare criteria should be revised. Clinical issues