People enrolling in hospice expect that they will be supported through the dying process, ideally within the comfort of their own homes. This means that patients and caregivers assume they will receive physical, emotional, logistical, and bereavement support from a coordinated multidisciplinary team of healthcare professionals through their final days and beyond. Yet, as demonstrated in Luth et al., 1 a substantial portion of hospice enrollees with dementia—as many as one in four—will have their hospice experience disrupted by a “live discharge,” which refers to patient-or hospice-initiated disenrollment from hospice while still alive. 2, 3

Why is it that people are disenrolled from hospice alive? The problem of live discharge is an artifact of the development of the Medicare Hospice Benefit in the early 1980s, which included several cost-saving measures, notably that enrollees have a prognosis of 6 months or less if the disease runs its expected course. 4 At the time, hospice recipients were primarily comprised of cancer or acquired immunodeficiency syndrome (AIDS) patients. 5 While prognosis is relatively easy to determine in people with advanced cancer or AIDS, it is notoriously difficult to estimate in people living with dementia (PLWD). 6 As a result, PLWD are up to four times more likely to experience hospice-initiated discharge because their “condition stabilizes or improves”(extended prognosis), and they no longer meet the 6-month prognosis requirement. 2, 3