From ICU to IPU: Bridging the Gap in End-of-Life Care

Key Message: Innovative hospice care pathways allow patients receiving intensive medical treatments to access inpatient hospice outside the hospital. These models address structural barriers to hospice, expand equitable access, and offer replicable strategies for delivering compassionate, patient-centered care at the end of life.

Abstract: Background
Access to hospice care remains a pressing issue, with nearly one million eligible patients dying each year without its support (1). While disparities in access based on race, geography, and socioeconomic status are well documented (2,3), less attention is given to structural barriers from intensive medical treatments. Many patients approach the end of life following hospitalizations involving interventions such as vasopressors or mechanical ventilation. These interventions typically must be withdrawn before transitioning to hospice, which can delay or prevent access. Although hospital-based hospice may help (4), it lacks the comfort of a dedicated inpatient hospice unit. Alternative care pathways are needed to expand access for this population.

Objective
To describe the development and implementation of care pathways at two independently operating inpatient hospice units that partner with hospitals to address barriers posed by intensive treatments, offering a replicable model to expand equitable access to hospice care.

Innovative Practices and Pathways
We outline care pathways supporting hospice unit access for patients receiving intensive treatments in the hospital.
• Compassionate Extubation: ICU teams partner with hospice to transfer patients on mechanical ventilation for planned extubation with anticipatory symptom management and family-centered support.
• High-Flow Nasal Cannula: Patients on heated, humidified high-flow oxygen are accepted for weaning, with proactive dyspnea management and clear goal setting.
• Inotrope and Vasopressor Weaning: Patients on continuous infusions are admitted for intentional weaning, prioritizing comfort over hemodynamic monitoring.
• LVAD Deactivation: Interdisciplinary teams coordinate logistics, medication management, and support before and after device deactivation.

Conclusion
By adapting hospice care to accommodate complex medical needs, inpatient hospice units enable access outside the hospital. These practices expand options for those who might otherwise die in the hospital and offer valuable lessons for hospice and palliative care teams seeking to deliver equitable, patient-centered care at the end of life.

References: 1. Cagle JG, Lee J, Ornstein KA, Guralnik JM. Hospice Utilization in the United States: A Prospective Cohort Study Comparing Cancer and Noncancer Deaths. J Am Geriatr Soc. 2020;68(4):783-793. doi:10.1111/jgs.16294
2. Aker N, Griffiths S, Kupeli N, et al. Experiences and access of palliative and end of life care for older people from minority ethnic groups: a scoping review. BMC Palliat Care. 2024;23(1):228. Published 2024 Sep 17. doi:10.1186/s12904-024-01555-8
3. Anwar A, Amin MK, Anwar S, Shahzad M. Bridge the Gap: Addressing Rural End-of-Life Care Disparities and Access to Hospice Services. J Pain Symptom Manage. 2024;68(4):e280-e286. do:10.1016/j.jpainsymman.2024.07.001
4. Frederick W, Smith R, McSpadden S, et al. How do you ethically integrate a GIP hospice service into the hospital? The Hospitalist. Published January 2, 2024.