Hospice care is never a single person’s decision. It involves the patient, the patient’s own doctor, and a hospice physician, all playing distinct roles. The patient (or their legal representative) ultimately chooses whether to elect hospice, but two physicians must first certify that the person has a life expectancy of six months or less if their illness follows its expected course. Understanding who does what in this process can make a difficult moment feel less overwhelming.
The Patient Has the Final Say
No one can be placed in hospice against their will. Entering hospice is a voluntary election: the patient signs a statement acknowledging that they understand hospice focuses on comfort rather than cure, and that they are choosing this path. If the patient is physically or mentally unable to make decisions, a legal representative (sometimes called a surrogate, healthcare proxy, or power of attorney, depending on the state) can sign the election on their behalf. That representative follows the same process the patient would, including choosing or confirming an attending physician.
This also means the patient can change their mind. Anyone receiving hospice can revoke the benefit at any time by submitting a written statement with an effective date. Doing so returns them to standard Medicare coverage, and they can re-elect hospice later if they choose.
Two Physicians Must Certify the Prognosis
Before hospice coverage begins, Medicare requires certification from two categories of physician. The first is the hospice’s own medical director (or a physician on the hospice’s care team). The second is the patient’s personal attending physician, if they have one. Both must agree that the patient’s illness is terminal with a life expectancy of six months or less, assuming the disease progresses as expected.
This dual certification must happen within the first two calendar days after hospice care starts. It can initially be verbal, but a written and signed certification is required to follow. For the first two benefit periods (each lasting 90 days), recertification comes from the hospice physician alone. After those initial periods, the patient enters unlimited 60-day benefit periods, and before each one, a hospice doctor or nurse practitioner must conduct a face-to-face visit and document clinical findings that still support a six-month prognosis.
How Doctors Determine a Six-Month Prognosis
Predicting life expectancy is not an exact science, and physicians rely on a combination of clinical guidelines, functional decline, and disease-specific criteria. Medicare’s framework outlines general signs of decline that apply across diagnoses: progressive weight loss, increasing dependence for daily activities, recurrent infections, and worsening lab values. When a patient shows a pattern of overall deterioration despite appropriate treatment, that trajectory supports a hospice-eligible prognosis.
Heart Failure
For heart failure, the benchmark is Class IV on the New York Heart Association scale. This means the person cannot carry on any physical activity without discomfort, and symptoms like breathlessness or chest pain may be present even at rest. An ejection fraction (a measure of how well the heart pumps) of 20% or below can support the prognosis, though it is not required if that test hasn’t already been done. Repeated hospitalizations and poor response to medication strengthen the case.
Dementia
Dementia eligibility uses a tool called the FAST scale, which tracks functional loss in stages. A person generally needs to score at stage 7c or higher, meaning they have lost the ability to walk, dress, bathe, and communicate meaningfully, and they are largely dependent for all daily needs. On top of that, secondary complications tied to the advancing dementia should also be present: things like recurring infections, pneumonia, pressure ulcers, difficulty swallowing, or a weight loss of 10% or more over six months. These complications signal that the disease has reached a point where the body is breaking down.
Cancer and Other Illnesses
For cancer, eligibility often hinges on whether the disease has progressed despite treatment, the patient has declined further treatment, or the cancer has metastasized with continued decline. Other conditions like liver disease, lung disease, kidney failure, and stroke each have their own sets of clinical markers, but the underlying logic is the same: the illness is advancing, the body is weakening, and curative options are no longer realistic.
Who Usually Brings It Up First
In practice, the conversation about hospice can start from several directions. A primary care doctor or specialist may raise the topic when treatments stop working. A hospital discharge planner might suggest it after a series of admissions. A hospice agency can evaluate a patient at the request of family members or a physician. And sometimes it is the patient or family who initiates the discussion after recognizing that quality of life has become more important than pursuing aggressive treatment.
There is no single “right” person to start the conversation. What matters is that the patient’s physician agrees the clinical picture supports a terminal prognosis, and that the patient or their representative voluntarily elects the benefit. A hospice agency cannot simply admit someone on its own. Beginning in 2026, CMS has formally clarified that the physician member of the hospice’s care team may recommend admission, but the certification and election requirements remain the same.
What Happens After Election
Once hospice is elected, the focus of care shifts from trying to cure the illness to managing pain, symptoms, and emotional well-being. Medicare covers medications related to the terminal diagnosis, medical equipment like hospital beds and oxygen, nursing visits, aide services, social work, chaplain support, and bereavement counseling for the family. The patient gives up Medicare coverage for curative treatments of the terminal illness specifically, but can still receive standard Medicare benefits for unrelated conditions.
The initial benefit period lasts 90 days, followed by a second 90-day period, and then unlimited 60-day periods after that. There is no cap on how long someone can remain in hospice, as long as a physician continues to certify that the prognosis remains six months or less. Despite this flexibility, most people enter hospice late. The median length of stay for patients who died in hospice in 2023 was just 18 days, according to MedPAC data. The average was considerably higher at 96 days, pulled up by a smaller number of patients with longer stays. That 18-day median suggests many families wait until the very end, potentially missing weeks or months of support that hospice could have provided.
When a Patient Cannot Decide
If a person with a terminal illness lacks the mental capacity to understand and elect hospice, their designated representative steps in. Federal regulations allow this representative to sign the election statement, choose or confirm the attending physician, and later revoke hospice if circumstances change. Who qualifies as a representative varies by state law but typically follows a hierarchy: a healthcare power of attorney comes first, followed by a court-appointed guardian, then a spouse or close family member as defined by state statute.
This is particularly relevant for people with advanced dementia, who by definition cannot make their own medical decisions by the time they reach hospice eligibility. Having advance directives and a healthcare proxy in place well before this stage removes uncertainty and keeps the decision in the hands of someone the patient chose while they still could.