Brain & Nervous System Parkinson's Disease Treatment Eligibility for End-Stage Parkinson's Disease Hospice Care By Colleen Doherty, MD Colleen Doherty, MD Colleen Doherty, MD, is a board-certified internist living with multiple sclerosis. Learn about our editorial process Published on October 24, 2021 Medically reviewed Verywell Health articles are reviewed by board-certified physicians and healthcare professionals. These medical reviewers confirm the content is thorough and accurate, reflecting the latest evidence-based research. Content is reviewed before publication and upon substantial updates. Learn more. by Isaac O. Opole, MD, PhD Medically reviewed by Isaac O. Opole, MD, PhD LinkedIn Isaac O. Opole, MD, PhD, is a board-certified internist specializing in geriatric medicine. For over 15 years, he's practiced at the Kansas University Medical Center, where he is also a professor. Learn about our Medical Expert Board Print Parkinson's disease (PD) is caused by the loss of functional dopamine-producing nerve cells deep within the brain. The loss of dopamine in the brain causes symptoms like stiffness, slow movements, balance problems, and depression. As a progressive disease, PD's symptoms slowly worsen over time. While the disease affects people in unique ways, there are typical patterns of progression, defined by five stages. In stage 1 and stage 2 of Parkinson's, patients may experience mild shaking and stiffness. As the disease advances into stages 3 and 4, loss of balance and slowness of movement (bradykinesia) begin to impair daily functioning. Verywell / Jessica Olah Stage 5 is the final, most debilitating stage of PD. In this stage, patients are wheelchair- or bedbound and require 24-hour nursing care. Eventually, patients become candidates for hospice care, a service that focuses on easing symptoms and improving patient comfort at the end of life. This article reviews what is needed for a hospice care referral. You'll also learn about the symptoms of end-stage Parkinson's disease. What Are the Stages of Parkinson's Disease? Symptoms of End-Stage Parkinson's Patients are said to have end-stage Parkinson's disease at stages 4 and 5 of the disease. At these stages, symptoms are so severe that medication stops working well, and patients require full-time caregiver assistance. Tips on Caring for a Loved One With Parkinson's Disease Motor (movement-related) symptoms that accompany end-stage PD include: Advanced bradykinesia: Movements are extremely slow, and patients have frequent freezing episodes (when they are suddenly unable to move). Significant speech changes: Patients may have a very soft voice and experience speech freezing (when they cannot get their words out). Increased fall risk: Patients are at an increased risk of falling from a combination of poor balance, severe stiffness, and orthostatic hypotension (low blood pressure when changing positions). Severe dysphagia: Difficulty swallowing can lead to weight loss, malnutrition, dehydration, and a lung infection called aspiration pneumonia. Very Limited Mobility In stage 4 of Parkinson's, patients may be able to stand on their own, but they cannot move without assistance or a wheelchair. In stage 5, patients cannot stand or move on their own and require a wheelchair all the time or are bedridden. Non-motor symptoms, which are symptoms not related to movement, may also be present in end-stage PD. Among them are: Parkinson's dementia: A significant, permanent decline in attention, memory, and problem-solving may be present. Psychosis: Hallucinations (seeing or hearing things that aren't there) or delusions (firmly believing something that is clearly not true) may occur. Severe constipation: Slowed gut motility from PD, immobility, and dehydration all contribute to constipation. Urinary problems: Patients often have to urinate frequently and may experience incontinence (uncontrollable loss of urine). Sleep disorders: Insomnia or other sleep disorders may develop or worsen. Hospice Eligibility The goal of hospice care is to optimize comfort and ease physical, emotional, and mental suffering during the dying process. Members of a hospice care team include a doctor, nurse, social worker, and home health aide. A spiritual counselor and rehabilitation therapists like a speech therapist or physical therapist may also be part of the team. In the United States, hospice care is available to patients who are expected to live six months or less. With Medicare insurance coverage, two doctors are needed to certify a six-month-or-less prognosis. There are no formal PD eligibility guidelines for determining when a hospice referral should be made. Instead, doctors and hospice agencies usually consider factors relevant to PD like a patient's history of falls, hospitalizations, withdrawal from activities, inability to perform self-care, and/or lack of benefit from medication. They may also use general guidelines intended to cover an array of neurological disorders. For instance, the Medicare hospice guidelines for neurological illnesses state that patients must meet one of the following two criteria to be eligible for hospice: Critically impaired breathing, including shortness of breath at rest, vital capacity less than 30%, oxygen need at rest, and refusal of a ventilator (a breathing machine) Rapid disease progression with either a critical nutrition impairment in the prior year or life-threatening complications in the prior year It's important to note that the first criterion—critically impaired breathing—is unlikely to be applicable in Parkinson's disease. Primary respiratory problems are not typical in advanced PD. That said, breathing problems may occur in patients with PD who develop severe aspiration pneumonia as a result of an impaired swallowing ability. The second criterion—evidence of rapid disease progression in the prior year—tends to be more useful for patients with end-stage PD. To clarify, rapid disease progression means that patients are bedridden, have unintelligible speech, require a pureed diet, and/or need major assistance with activities of daily living (ADLs). All of these symptoms or circumstances are common in end-stage PD. According to the second criterion, along with rapid disease progression, patients must have a critical nutrition impairment or a life-threatening complication in the prior year. A critical nutrition impairment is common in end-stage PD and means that patients are: Unable to maintain sufficient fluid/calorie intake Continue to lose weight Experience dehydration Refuse artificial feeding methods Life-threatening complications that may occur in end-stage PD include: Recurrent aspiration pneumonia Stage 3 or 4 pressure ulcers Keep in Mind Most patients with PD die from the same diseases—heart disease, stroke, and cancer—that others do. As such, hospice care may be considered even before a patient with PD reaches the end stages of their disease (as long as their life expectancy prognosis is six months or less). Palliative Care as an Option If your loved one is not eligible for hospice, the good news is that they can still receive palliative care. This type of care focuses on alleviating symptoms, discomfort, and stress associated with any illness, including PD. The main difference between palliative care and hospice is that palliative care can be given along with standard treatments, including therapies intended to prolong life. Summary Symptoms of end-stage Parkinson's disease include very limited mobility, extremely slow movements, falls, and cognitive and psychotic problems. Hospice care may be considered when patients have a life expectancy of six months or less. If not eligible for hospice, patients can obtain similar symptom-easing benefits from palliative care services. A Word From Verywell Deciding when it is time to enter hospice care can be a difficult decision for a person and their loved ones. However, being admitted to hospice level of care can ensure a person and their caregivers have access to a variety of services they need at this stage. While the criteria say a person should be predicted to be in their last six months of life to begin hospice care, rest assured there is no time limit placed on hospice services. Frequently Asked Questions Frequently Asked Questions How long does the final stage of Parkinson's last? There is no definite timeline when it comes to the final stage of Parkinson's disease. Hospice care is available when a patient has a life expectancy of six months or less. What are the first steps toward getting hospice care? First, discuss hospice care with the person with PD and include their family members/caregivers. Next, set up a meeting with the patient's primary care doctor or neurologist to review goals of care and hospice eligibility and services. Does insurance cover hospice care? Most insurance plans, including Medicare, Medicaid, and private health insurance, cover hospice care services. Was this page helpful? Thanks for your feedback! Sign up for our Health Tip of the Day newsletter, and receive daily tips that will help you live your healthiest life. Sign Up You're in! Thank you, {{form.email}}, for signing up. There was an error. Please try again. What are your concerns? Other Inaccurate Hard to Understand Submit 7 Sources Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy. Parkinson's Foundation. Stages of Parkinson's. Luquin M-R, Kulisevsky J, Martinez-Martin P, Mir P, Tolosa ES. Consensus on the definition of advanced Parkinson's disease: A neurologists-based Delphi study (CEPA Study). Parkinsons Dis. 2017; 2017: 4047392. doi:10.1155/2017/4047392 Schapira AHV, Chaudhuri KR, Jenner P. Non-motor features of Parkinson disease. Nat Rev Neurosci. 2017;18(8):509. doi:10.1038/nrn.2017.62 Akbar U, McQueen RB, Bemski J et al. Prognostic predictors relevant to end-of-life palliative care in Parkinson's disease and related disorders: a systematic review. 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