Palliative Care vs Hospice: Differences, Costs and How to Choose

Palliative care is extra support for the symptoms and stress of a serious illness. It can start at any stage, including at diagnosis, and it can run alongside treatment meant to cure or control the illness. Hospice is comfort care for people whose doctor certifies a life expectancy of six months or less and who have chosen comfort instead of treatment aimed at the illness itself. Hospice is a form of palliative care, but palliative care is not limited to the end of life.

What is palliative care?

Palliative care is specialized medical care focused on relief from the symptoms and stress of a serious illness. It is available at any age and any stage, and it is based on what you need rather than how long you are expected to live. You keep your regular doctors and can keep having treatment to cure or control the illness.

A palliative team often includes doctors, nurses, social workers and chaplains, sometimes with pharmacists, dietitians and therapists. They treat problems such as pain, breathlessness, fatigue, nausea, poor sleep, anxiety and depression. They also help you and your family understand your options and match your care to your goals.

Research supports the idea that more support early on can help. In a 2010 randomized trial of people with newly diagnosed metastatic lung cancer, those who received palliative care alongside standard cancer treatment had better quality of life and less depression. They also lived a median of 11.6 months, compared with 8.9 months for those on standard care alone. It was one trial in one type of cancer, so it does not prove the same result for every illness, but it is a common reason oncologists suggest palliative care early.

What is hospice care?

Hospice is a program of comfort care for the last phase of a terminal illness. The focus shifts from trying to cure the disease to controlling symptoms and supporting you and your family. Care is usually given at home, but it can also be given in a nursing home, a hospital or a dedicated inpatient unit.

A hospice team typically includes a nurse, a doctor, a social worker and spiritual and counseling support, and the hospice arranges the medicines and equipment related to your illness. Medicare also requires hospices to offer bereavement counseling to family for up to a year after the death.

Medicare pays hospices a daily rate in one of four levels of care:

• Routine home care: the usual level, for care at home.
• Continuous home care: round-the-clock nursing during a short crisis at home.
• General inpatient care: a stay in an inpatient facility for pain or symptoms that can't be managed at home.
• Inpatient respite care: a stay of up to five days in an approved facility to give caregivers a break.

Palliative care vs hospice at a glance

Who qualifies for Medicare hospice?

To get the Medicare hospice benefit you need Medicare Part A, and two things must be true. Your hospice doctor and your regular doctor, if you have one, certify that you are terminally ill with a life expectancy of six months or less. And you sign a statement choosing hospice instead of other Medicare-covered treatment for the terminal illness.

Six months is an estimate, not a cutoff. Coverage comes in two 90-day periods followed by an unlimited number of 60-day periods. After the first six months, the hospice medical director or hospice doctor must recertify, with a face-to-face meeting. Many people live longer than expected and stay in hospice for as long as they continue to qualify.

Hospice is not limited to cancer. It can also cover other illnesses a doctor certifies as terminal, such as advanced heart, lung or kidney disease.

What do palliative care and hospice cost?

Costs depend on your coverage. These are the Original Medicare figures; plans vary.

Medicare does not pay for room and board, so the biggest bill for many families is the facility itself if the patient lives in a nursing home or assisted living. Medicaid and most private insurers also cover hospice, but rules vary by state and plan. The National Cancer Institute notes that Medicare and most Medicaid and private insurance plans pay for hospice services. If you have a Medicare Advantage plan, call the plan before choosing a hospice and ask which hospices it works with.

Can you leave hospice?

Yes. Hospice is a choice you can reverse. To stop, you or your representative signs a statement revoking the election, with an effective date that can't be earlier than the day you sign. You give up the rest of hospice coverage for that election period and get back the Medicare coverage you set aside. You can choose hospice again later if you still qualify.

You can also switch to a different hospice; ask your hospice or Medicare how the timing works. You do not have to leave your regular doctor. If you name your own doctor or nurse practitioner as your attending provider, they stay involved alongside the hospice team.

How to choose a hospice

Hospices differ in staffing, response times and what they offer. Medicare.gov's Care Compare tool lets you look up hospices near you. When you talk to a hospice, consider asking:

1. Is the hospice Medicare-approved and, if you have a Medicare Advantage or private plan, in network?
2. How quickly can a nurse come out at night or on a weekend, and who do we call?
3. Which medicines and equipment do you cover, and which ones will we pay for?
4. Do you have an inpatient unit, and where would respite stays take place?
5. What bereavement and spiritual support is available to the family?

When to ask for each

Consider palliative care if you have a serious illness and symptoms, side effects or decisions are weighing on you, even if you are still seeking treatment. Consider hospice when treatment is no longer helping or has become too burdensome, and the main goal is comfort and time at home. Doctors, hospital social workers and case managers can refer you to either one.

Whichever you choose, put your wishes in writing. An advance directive or living will and a DNR order, where appropriate, tell the care team what you want if you can't speak for yourself.

What to do next

• Ask your doctor whether you would benefit from palliative care now, and whether a hospice evaluation makes sense.
• Read our guides on hospice care and terminal diagnosis next steps.
• Use the end-of-life checklist to line up documents and decisions, and see hospice and funeral planning when you are ready to talk about arrangements.
• Expect some grief before a death as well as after it, and read about anticipatory grief.