INSULIN IS ONE OF THOSE CONTROVERSIAL HOSPICE MEDICATIONS WHEN IT COMES TO DECIDING COVERAGE.

However, let’s think through this more systematically and objectively…

Who covers the cost of insulin?

1.   Is the diabetes related to the primary diagnosis?

a.     It can most likely be considered related in patients with CHF, end-stage renal, coronary artery disease, or cerebrovascular disease.

                 i.     In this case, if there is clear evidence that tight glycemic control is necessary to the primary diagnosis, the hospice should cover the insulin.

b.     It may or may not be the case if the primary diagnosis is peripheral artery disease when the peripheral artery disease is directly impacting the prognosis. This also would apply to patients with peripheral artery disease which results in a gangrenous limb.

            i.     If it is decided by the hospice medical director that it is not related, taking the above information into account, document why it is not necessary and the hospice does not have to cover the cost of any anti-diabetic medications.

THINGS TO CONSIDER ABOUT THIS CONTROVERSIAL TOPIC:

• Does tight glycemic control (which possibly entails testing sugars, feeding when patient is not hungry in order to avoid a hypo-glycemic event, and sticking when insulin is ‘needed’) directly affect the patient’s primary diagnosis or overall prognosis?

• If no, the patient can continue these medications if they see fit as they will likely be covered by supplemental insurance but are not considered to be a part of the hospice benefit coverage.

• Some patients often feel like controlling his or her sugars is the only thing they have control of at this point – therefore, in these situations, continuing the insulin is very much appropriate.

• Are they continuing a diet that warrants frequent blood sugar checks and tight glycemic control?

• Does the patient want to continue insulin? Just like everything else in hospice, the patient has the right to refuse – in which case you document that education was given to the patient and support their right to live out the end of their life as they see fit and appropriate!

“As always, we are there to support and help the patient!”

As always, we are there to support and help the patient! However, we have a duty to follow the CMS guidelines under the hospice benefit, which unfortunately, requires some financial responsibility.

Jaymie Wilson, APRN-CNP, ACHPN

For more clinical-based information on diabetes and insulin at end-of-life, please visit Palliative Care Network of Wisconsin – Fast Facts and Concepts, #258 (listed in the resources below). 

References:

Cote, T. & Correoso-Thomas, L. (2012). The hospice medical director manual (2nd ed). Chicago, IL: American Academy of Hospice and Palliative Medicine.

Jeffreys, E. & Rosielle, D. (2012, July). Diabetes management at the end-of-life. Palliative Network of Wisconsin, Fast Facts and Concepts #258.