Navigating the Hospice IPU Landscape for Symptom Management

Introduction: Understanding the IPU and GIP Level of Care

The Inpatient Hospice Unit (IPU) plays a pivotal role in the continuum of hospice care, providing around-the-clock clinical oversight for patients whose symptoms cannot be managed in the home setting. Unlike home hospice care, the IPU is designed specifically for short-term, intensive symptom management and end-of-life support in a medically supervised environment. These units are located within hospitals, free-standing hospice facilities, or long-term care settings.

One of the primary reasons a patient is admitted to the IPU is for General Inpatient (GIP) level of care. GIP care is a Medicare-defined benefit used when symptoms require more intensive management than can be provided at home or in a residential hospice setting. GIP admission must be medically justified, reviewed daily, and documented with specific evidence of symptom crises. ^{(1) (2) (3)}

Symptoms Requiring IPU Admission

Patients entering the IPU are often experiencing complex, multifaceted symptoms that surpass the ability of home caregivers or outpatient teams to manage. The following are common symptoms necessitating transfer to an IPU: ⁽⁴⁾

Uncontrolled Pain
Pain unresponsive to outpatient medication regimens and often requires frequent medication adjustments and close clinical monitoring.

Severe Dyspnea (Shortness of Breath)
Respiratory distress, particularly at rest, may need oxygen titration, opioids, or even palliative sedation.

Delirium or Agitation
Terminal restlessness, hallucinations, or acute agitation may require antipsychotic medications and a controlled setting to ensure safety.

Intractable Nausea and Vomiting
This can result from disease progression or treatment side effects and often requires close monitoring, medication changes, and support.

Terminal Complications
Conditions such as active bleeding, seizures, and advanced wounds that require intensive intervention.

Symptom Management: Medications and Decision-Making Framework

Pain and symptom management in the IPU require special consideration and must be swift, effective, and tailored to the individual patient’s situation. Criteria used for choosing appropriate medications are outlined in the table below.

Decision-Making Criteria for Medication Selection ^(5) (6)

Medication Access in IPUs: Models and Systems ⁽⁷⁾

The medication access source and medication availability in IPU settings help determine the selection of medication(s) during an IPU admission. While an IPU may have multiple points of access, medications need to be readily available to manage a crisis and will usually become the first line of treatment.

• Automated Dispensing Systems (ADS) (e.g., Pyxis, Omnicell): Provide real-time access, reduce delays in administration, and enhance tracking and compliance.
• Medication Cabinet/E-Kit: Emergency medication for immediate treatment storage provides immediate access for essential drugs during acute events.
• Local Pharmacies: May serve as backup when internal systems are not stocked with specialized medications, especially at night or for less common needs.
• Mail Order: May serve as an option for specialty medications and/or medication not stocked in the IPU. Mail order is not suitable for emergencies.

Top Medications Used in IPUs: ⁽⁹⁾

Case Study

Background

Patient Mr. James B is a 68-year-old male with a diagnosis of Stage IV pancreatic cancer with hepatic metastases. He is being admitted directly to a hospice in-patient unit under GIP level of care due to uncontrolled abdominal and back pain that is unresponsive to the outpatient opioid regimen (oxycodone extended-release 40mg twice daily and oxycodone immediate-release 5mg every 4 hours as needed). Mr. James B has a life expectancy of less than 7 days, a DNR status, and a severe pain rating of 9/10.

Clinical Goals

1. Achieve effective pain control within 24 hours
2. Transition to comfort-focused palliative care
3. Maintain patient dignity and respect during dying process

Decision-Making Criteria for Medication Selection

Medication Selection for Patient JB ⁽⁸⁾

• Parenteral hydromorphone
  • Rationale: High potency, rapid onset, effective in opioid-tolerant patients; allows titration via PCA or nurse administered IV push
  • Access: Stocked in ADS Machine
  • Cost: Comparable to IV morphine however due to its potency, less volume is required, and in this case, it is more effective
  • Plan/Dosing: Initiate at 0.5mg IV every 30 minutes as needed; titrate to basal PCA or continuous infusion
• Parenteral or sublingual lorazepam*
  • Rationale: Addressing terminal agitation and anxiety; complements pain control strategy
  • Access: Stocked in ADS machine
  • Plan/Dosing: 0.5-1mg IV/SL every 4-6 hours as needed
  • *Alternative is midazolam IV or SL in times of shortage/availability issues.
• Avoid these medications:
  • Fentanyl transdermal patch: Slow onset, poor titration, and not suitable for rapid pain control
  • Oral medications: Patient minimally responsive, poor oral absorption, difficult to administer
  • Methadone: Complex medication, not suitable for short prognoses

Outcome

The patient has significant relief within 6 hours of hospice admission with pain reduced to 3/10. Patient was transitioned to comfort-focused supportive care and died peacefully on day 4 of admission.

This case highlights structured, evidence-based symptom management in the IPU using accessible and cost-conscious, and effective medications. Appropriate use of IV hydromorphone and adjunct medications aligned with hospice goals ensure the patient maintains dignity and respect at the end of life.

Summary

The IPU remains a cornerstone for managing complex hospice cases when home care is unable to sufficiently fulfill needs. Hospice teams must understand when and how to escalate to GIP care, navigate medication access models, and coordinate rapid symptom relief while aligning with patient and family goals. By mastering this landscape, teams ensure dignity, comfort, and peace for those in their final days.

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Further Reading from Enclara Pharmacia

• The Top Five Challenges of Hospice Inpatient Medication Management and How a Pharmacy Solutions Provider Can Help – Enclara Pharmacia
• Behind the Curtain: The People Behind Enclara’s IPU Automated Dispensing Program – Enclara Pharmacia
• Factors Influencing Hospice Pharmacy Spend – Enclara Pharmacia

References

1. General Inpatient Care. CGS A Celerian Group Company. [Online] December 08, 2021. Link.
2. Medicare Benefit Policy Manual. [Online] June 25, 2024. Link.
3. Hospice General Inpatient (GIP) Level of Care Frequently Asked Questions. [Online] July 2021. Link.
4. A Compliance Guide to Hospice General Inpatient Care. National Alliance for Care At Home. [Online] Feburary 2022. Link.
5. Enclara Pharmacia. Factors Influencing Hospice Pharmacy Spend. Enclara Pharmacia. [Online] 2021. Link.
6. Maddison, Andre, Fisher, Judith and Johnston, Grace. Preventative Medication Use Among Persons With Limited Life Expectancy. National Library of Medicine. [Online] January 19, 2011.
7. Pozniak, Alyssa, et al. National Alliance for Home Care. Analysis of Trends in General Inpatient Care (GIP) Utilizaiton. [Online]
8. Enclara Pharmacia. The Top Five Challenges of Hospice Inpatient Medication Management and How a Pharmacy Solutions Provider Can Help. Enclara Pharmacia. [Online] July 26, 2021.
9. Clinical Pharmacology [database online]. Tampa, FL: Elsevier/Gold Standard, Inc.; 2024. [Online]