Hospice of the Comforter

In the geriatric population, “adult failure to thrive” (AFTT) is used as a diagnosis for those individuals who show significant signs of decline and weight loss which cannot be attributed to a single condition. Usually, it is caused by multiple chronic conditions and functional losses. Often, the causes of the deteriorating condition are irreversible or sometimes even unidentifiable.

Four syndromes are prevalent and predictive of adverse outcomes in elderly with failure to thrive: impaired physical function, malnutrition, depression, and cognitive impairment.¹ It is recommended that when possible, treatment interventions address any identifiable diseases. However, since AFTT patients are frail and elderly, the potential benefits and burdens of treatment should first be considered.

If it is determined that the goals of care are safety and comfort focused, it may be best to consider hospice. Medicare² has provided the following criteria for determining when a hospice referral would be appropriate for someone with AFTT:

1. The nutritional impairment associated with the adult failure to thrive syndrome should be severe enough to impact on a beneficiary's weight. It is expected that the Body Mass Index (BMI) of beneficiaries electing the Medicare Hospice Benefit for the adult failure to thrive syndrome will be below 22 kg/m² and that the patient is either declining feeding tube or IV nutritional support or has not responded to such nutritional support, despite an adequate caloric intake.

BMI (kg/m²)=703 x (weight in pounds) divided by (height in inches)²

2. The disability associated with the adult failure to thrive syndrome should be such that the individual is significantly disabled. (Significant disability is demonstrated by those who spend most of their time in bed and require assistance with most activities, including self-care such as bathing and toileting.)

AFTT is used as the hospice admission diagnosis if the individual has no other individual diagnosis causing the terminal decline. For instance, someone with stage 4 rapidly advancing cancer who has weight loss and disability would have the cancer as the primary hospice diagnosis. However, an elderly patient who has diabetes, chronic renal failure and peripheral vascular disease with poor appetite, progressive weight loss and debility could be appropriate for hospice care with the adult failure to thrive diagnosis. The AFTT diagnosis in this case is related to the multiple chronic conditions.

The hospice team can offer many supportive interventions that will help both the patient and the caregivers cope with the AFTT terminal progression, whether the patient resides at a home or in a facility. Initially, the team will help to assess the patient’s and caregivers’ needs and develop a care plan based upon their goals. For AFTT patients, care needs often center on personal care assistance, medication management for multiple chronic conditions, comfort measures, social and spiritual support, and placement of medical equipment related to reduced mobility. In the course of care, as needs change, the hospice team can adapt their frequency of visits and interventions to the patient’s declining status.

Sometimes, a patient with AFTT may actually improve under hospice care, showing signs of weight gain and an increased level of activity. If this should happen over a period of time, the physician and hospice team may determine that the patient is no longer showing signs of terminal decline and develop a plan for discharge from hospice services. The team will teach the patient and caregivers how to continue to optimize care and promote health improvement.

^{1. RUSSELL G. ROBERTSON M.D., and MARCOS MONTAGNINI M.D., Geriatric Failure to Thrive Am Fam Physician. 2004 Jul 15;70(2):343-350. http://www.aafp.org/afp/2004/0715/p343.html}

^{2. Palmetto GBA (Medicare Administrative Contractor) http://www.cms.gov/medicare-coverage-database/indexes/lcd-list.aspx?Cntrctr=227&name=Palmetto+GBA+(11004%2c+RHHI)&ContrNum=11004&CntrctrType=RHHI&ContrTypeId=3&s=48&bc=BBAAAAAAAAAA&#ResultsAnchor}