Hospice Care for Sepsis/Septic Shock

Sepsis is different from other serious or chronic diseases that often lead to a hospice diagnosis because of the speed at which it develops. If not treated and addressed quickly, a sepsis-related infection can spread quickly throughout the body and worsen, often within a matter of hours or a few days. As soon as sepsis is diagnosed, it should be brought to the immediate attention of hospice admissions personnel, because that’s when VITAS can help. 

What is Sepsis or Septic Shock?

Sepsis is a life-threatening condition that arises when the body’s immune system responds inadequately to an infection, a response that damages the body’s own tissues and major organs. Most sepsis-related infections are caused by bacteria, but they can also stem from fungi, viruses or parasites. The bloodstream, lungs, brain, urinary tract, skin and abdominal organs are the most common locations for a primary sepsis infection.

What are the Three Stages of Sepsis?

Sepsis is classified into three stages, and if a referral to hospice is necessary, it should be made quickly.

1. Sepsis

Sepsis is the initial infection, which sets off an inflammatory immune response that affects the entire body. Most people recover from mild sepsis if antibiotics, fluids and supportive treatments are started early, preferably within hours of diagnosis.

2. Severe Sepsis

Severe sepsis impacts and impairs blood flow to vital organs, including the brain, heart and kidneys. It can also cause blood clots to form in internal organs, arms, fingers, legs and toes, leading to varying degrees of organ failure and gangrene (tissue death). Among hospitalized patients, sepsis is the leading cause of death (34%).¹ Symptoms of severe sepsis include:

• Difficulty breathing
• Shock
• Kidney damage (marked by lower urine output), liver damage and other metabolic changes
• Delirium/changes in mental status
• Excessive bleeding
• Increased levels of lactate in the blood

3. Septic Shock

Septic shock evolves when severe sepsis produces a dramatic drop in blood pressure.

Are you a healthcare provider? Learn about the clinical characteristics of end-stage sepsis and download a PDF of our hospice eligibility guidelines.

What is the Difference Between Sepsis and Septic Shock?

Sepsis is caused by an infectious agent that invades the body, such as a bacterium, virus, or fungus.

Septic shock is a severe form of sepsis that develops when a patient’s blood pressure drops dangerously low as it tries to fight the infection. Typically, blood pressure is difficult to bring back to normal with standard blood pressure medications and additional fluids.

How Do You Get Sepsis or Septic Shock?

Patients develop sepsis when their body is unable to fight off an infection, usually because of underlying health conditions or chronic diseases that weaken the immune system. In about 73% of sepsis cases, patients already have sepsis when they enter the hospital, and another 26% develop it during their hospital stay.¹

Before sepsis develops, vulnerable patients are already likely to be compromised because of other diseases or illnesses, especially cancer, dementia, stroke, and chronic lung, heart, liver, or kidney disease.¹ Factors such as poor nutrition, declining functional or cognitive status, or uncontrolled symptoms can make it difficult for the body to fight off the infection that leads to sepsis.

Septic shock is not something that patients can contract, since it’s caused by sepsis. It develops when sepsis turns more severe and causes a dramatic drop in blood pressure that is difficult to manage with standard treatments.

To diagnose sepsis and identify the source of infection, doctors rely on a variety of factors and tests, including temperature, heart rate, respiratory rate, blood/platelet counts, biomarker analysis, and other cultures/tests.

Who is Most at Risk for Sepsis or Septic Shock?

Some patients are more susceptible to sepsis than others, including those who:

• Are very young or very old
• Are suffering from a chronic illness or a drug-resistant bacterial infection
• Have weakened immune systems from HIV, cancer treatments, transplant drugs, diabetes or major trauma
• Have underlying illnesses (40% of hospitalized patients) that would make them eligible for hospice care, including advanced cancer, heart failure, advanced lung disease (shortness of breath at rest or with minimal exertion, with or without oxygen), and dementia accompanied by any difficulty with activities of daily living (eating, bathing, dressing, toileting, personal hygiene, etc.)
• Rely on invasive devices, including intravenous catheters, breathing tubes or ventricular assist devices for the heart

When is a Sepsis Patient Eligible for Hospice Care? 

Sepsis patients are eligible for hospice care when a physician makes a clinical determination that life expectancy is six months or less if the condition or disease runs its expected course.

Many sepsis infections, however, occur in patients who are already seriously ill, hospitalized, in the intensive care unit (ICU) or recovering from a hospital procedure. However, elderly or debilitated patients may be successfully managed and discharged to outpatient care, only to begin a persistent and progressive decline from the latent effects of this insidious disease. Ideally, patients who develop sepsis and have survived the initial hospitalization from sepsis, but are now experiencing decline, should be evaluated for participation in goals-of-care conversations. These conversations serve to identify their preferences for end-of-life care. If eligible, hospice care is the most care these individuals can receive at home.

Hospice admissions personnel should be contacted immediately when severe progressive sepsis is diagnosed, because time is of the essence when a potentially rapid, progressive infection occurs late in the disease progress or in patients whose health is already unstable or compromised. If sepsis does not result in the patient’s death, hospice care may be the best option to manage long-term symptoms, address pain and support the patient and family.

How Can Hospice Help Patients with Sepsis?

Recent research shows that approximately 40% of patients who entered the hospital with sepsis and died were eligible for hospice care before admission. It is a common misconception that patients being treated for sepsis must remain in a hospital, though much of the time they are eligible to receive compassionate hospice care offering:

• Pain management and symptom control: Hospice specializes in ensuring patients are comfortable by reducing pain and enabling them to enjoy life, while remaining in control of day-to-day decisions as much as possible. When symptoms become severe, continuous care can be introduced, with shifts of staff providing 24-hour care until symptoms are under control.
• Emotional and spiritual assistance: Hospice can give patients the resources needed to maintain their emotional and spiritual well-being.
• Services provided wherever a patient calls home: VITAS offers care for patients wherever they live—in their homes, long-term care facilities, or assisted living communities. If symptoms become too difficult to manage at home, inpatient services can provide around-the-clock care until the patient is able to return home.

How to Approach Conversations About Hospice

Opening the discussion about hospice care can be met with apprehension when those involved are not equipped with the relevant resources. Those hoping to have a goals-of-care conversation should consider an approach that includes:

• Clarifying the patient’s health status and disease progression
• Being educated in all the available options
• Identifying future goals of both the patient and their family
• Preparing to talk and staying open to listening
• Being proactive within the conversation

Here are some additional tips for families and patients who face the challenges of serious illness, hospitalization, or the numerous procedures that put them at risk of sepsis:

• Read and share "Considering Hospice: A Discussion Guide for Families."
• Make your wishes known now: Talk about them, write them down, share them. If you are a patient at risk for sepsis, make sure to document your wishes and preferences for end-of-life care now, before a crisis arises. Decide what interventions you want and do not want if you face a life-limiting diagnosis or a potentially deadly infection like sepsis. When you have completed advance directives, such as a living will or durable power of attorney for healthcare decisions, your family, healthcare proxy and healthcare team can make decisions about end-of-life care without disagreement or guilt.

¹ Rhee C., et al. “Prevalence, Underlying Causes and Preventability of Sepsis-Associated Mortality in US Acute Care Hospitals.” JAMA Network Open. 2019;2(2):e187571