As a clinician, you understand better than most that there comes a point in a patient’s illness when the treatment plan and the patient’s wishes are no longer moving in the same direction. That gap, when it appears, is the signal that a goals-of-care conversation is overdue. And in many cases, it is also when a hospice referral becomes the most appropriate and compassionate next step.

This guide is written specifically for physicians, nurse practitioners, physician assistants, and care managers practicing in Fulton County. It covers the clinical and practical considerations for hospice referrals, in a way that preserves trust with your patient and their family.

What “Aligning Goals of Care” Actually Means in Practice

Goals of care is a term used often, but it describes something very specific: the process of ensuring that a patient’s medical treatment plan reflects what that patient most values and most fears as their illness progresses. For patients with advanced, life-limiting illness, those goals frequently shift over time.

A patient who once wanted every available intervention may, after recurrent hospitalizations or a declining functional trajectory, begin expressing a desire to be home, to be comfortable, and to spend time with family rather than in treatment settings. When that shift occurs and the clinical picture aligns with a prognosis of six months or less, hospice becomes not just an option but often the most aligned choice available.

Learn more about what hospice care is and who it is designed to serve.

Explore: Hospice Care

Medicare Hospice Eligibility: A Clinical Refresher

A patient qualifies for the Medicare Hospice Benefit when two physicians certify that the patient has a terminal illness with a life expectancy of six months or less if the disease follows its expected course, and the patient elects to receive hospice care rather than curative or life-prolonging treatment for that terminal diagnosis.

It is important to note what this does not mean. The patient does not have to stop all treatment. Conditions unrelated to the terminal diagnosis can still be treated. And critically, the decision is reversible. A patient can revoke the hospice election at any time and return to curative care.

Conditions that commonly meet hospice eligibility criteria include:

• Advanced cancer with declining performance status and weight loss despite treatment
• End-stage heart failure with NYHA Class IV symptoms, frequent hospitalizations, and declining response to diuretics
• COPD with resting dyspnea, FEV1 below 30% predicted, and recurrent exacerbations requiring hospitalization
• Dementia at FAST Scale Stage 7 with inability to ambulate, minimal verbal communication, and complications such as aspiration pneumonia or urinary tract infections
• End-stage renal, hepatic, or neurological disease with functional decline and comfort-focused goals

See how Golden Rule Hospice’s physical support and management services address these conditions.

If you have questions about a specific patient’s eligibility, you can call our team at (470) 395-6567 and speak with a clinical staff member directly.

Recognizing When Goals Have Shifted

One of the most important clinical skills in end-of-life care is recognizing the moment when a patient’s stated goals and the trajectory of their illness are no longer compatible. This does not always announce itself clearly.

Some patterns to look for in your own patients:

Repeated hospitalizations within a short window. When a patient is hospitalized two or more times within 90 days for the same underlying condition, that pattern often reflects disease progression that treatment is no longer reversing.

Declining functional status across visits. A patient who has gone from independent to requiring assistance to now being bed-bound within six to twelve months is demonstrating functional decline that warrants a direct goals conversation.

The patient or family expressing fatigue with treatment. Phrases like “I just want to be home” or “I don’t want to go back to the hospital” are direct signals. These expressions deserve to be taken seriously and followed with a structured goals-of-care conversation rather than redirected back to a treatment plan.

Weight loss of 10% or more in six months in the absence of a reversible cause.

Caregiver distress. When the people supporting the patient are visibly overwhelmed, that is often a sign that the patient’s care needs have outpaced what the current care plan can support.

If you have already read about the benefits of referring earlier rather than later, our blog post on how early hospice referrals can significantly help patients and families provides a helpful framework for thinking through timing.

Common Referral Barriers and How to Address Them

Even when the clinical picture is clear, referrals are sometimes delayed. Below are the concerns we hear most often from referring clinicians, and how to think through them.

“My patient isn’t ready to stop fighting.” Hospice is not about stopping. It is about redirecting the fight toward comfort, dignity, and quality of life. Many patients who initially resist the word “hospice” accept it readily once it is reframed around what they will gain, including consistent clinical support at home, better pain and symptom management, and more time focused on what matters to them rather than on appointments and procedures.

“I’m not sure the prognosis is certain enough.” Hospice eligibility does not require certainty. It requires a clinical judgment that, based on the disease’s expected course, the patient’s life expectancy is six months or less. Prognostic uncertainty is expected and accounted for in how the Medicare Hospice Benefit is structured. If the patient stabilizes or improves, they can be discharged from hospice.

“I don’t want to lose the relationship with my patient.” Patients who enroll in hospice retain their relationship with their primary care physician. The hospice medical director coordinates with, not replaces, the referring provider. You remain an important part of the care picture.

“The family won’t accept it.” Family readiness often follows patient readiness. If the patient has expressed comfort-focused goals, the goals-of-care conversation should center those wishes. The hospice social work and chaplaincy team can also provide meaningful support to families working through grief, anticipatory loss, and resistance to the transition.

Learn more about our Family and Caregiver Support services.

Prognostic Indicators by Diagnosis: A Quick Reference

Identifying decline in non-cancer diagnoses can be harder than identifying decline in cancer. Below are commonly used clinical indicators:

Dementia (FAST Scale): Stage 7a or beyond. The patient cannot walk without assistance, has fewer than six intelligible words, and requires full assistance with all ADLs.

Heart Failure: Ejection fraction below 20%, persistent NYHA Class IV symptoms, frequent hospitalizations despite optimized medical therapy, consideration or discontinuation of ICD therapy.

COPD: FEV1 below 30% predicted, dyspnea at rest, three or more hospitalizations or ER visits in the past year, hypoxia requiring supplemental oxygen.

Liver Disease: Child-Pugh Class C, ascites refractory to treatment, hepatic encephalopathy, spontaneous bacterial peritonitis, hepatorenal syndrome.

Renal Disease: GFR below 15, decision to forgo dialysis initiation, or withdrawal from dialysis with comfort-focused goals.

Documentation of these indicators, combined with a prognosis narrative supported by clinical evidence, forms the foundation of a strong hospice certification.

How to Make a Referral in Fulton County

Making a referral to Golden Rule Hospice is straightforward. You can reach our clinical team at (470) 395-6567, where staff is available 24 hours a day, seven days a week. You can also submit referral documentation directly. We serve patients throughout Fulton County and across 18 counties in the Atlanta region.

Our intake team will gather clinical information, confirm insurance coverage, and coordinate with you on timing. Medicare and Medicaid cover hospice 100%, and most private insurance plans provide coverage as well. You can review payment details on our Who Pays for Hospice page.

When your patient is experiencing difficult symptoms in the final days of life, our clinical team is equipped to respond. 

Ready to Refer a Patient?

If you are caring for a patient in Fulton County whose goals and clinical trajectory suggest hospice may be the right next step, our team is here to support that conversation. You can call us at (470) 395-6567 or visit our contact page to reach us directly. We are glad to consult with you before a formal referral is made.