NCP Domain 7 · Care of the Patient Nearing the End of Life
EOL Care Evidence
The last days and hours of life are a distinct clinical phase with its own rules, quality measures, and care requirements, which differ by country. This page explains the US Medicare rules in detail, plus an England/UK module (NHS- and NICE-anchored) covering how the last days of life are approached there.
Viewing as: Patient & Family · Change
Scope: regulatory payment rules (SIA, aggregate cap), quality measures (HVLDL, HCI), the HOPE instrument, and access patterns near death, plus an additive England/UK module below. This page does not provide clinical protocols or treatment recommendations.
United States: what the evidence shows
The Service Intensity Add-on (SIA; 42 CFR §418.302) provides additional Medicare payment for registered nurse and medical social worker visits in the last 7 days of life for patients on the Routine Home Care level of care — creating a regulatory and financial incentive for skilled bedside presence at the moment of dying.
The Hospice Visits in the Last Days of Life (HVLDL) quality measure tracks whether a patient received at least one skilled nursing or social work visit in the final 3 days of life. It is publicly reported on Care Compare and is a direct indicator of care presence at the moment of death.
Federal regulation (42 CFR §418.64(d)) requires Medicare-certified hospices to provide bereavement counseling for family members and others in the plan of care for at least one year following the patient's death — extending the hospice's obligation beyond the moment of dying into the bereavement period.
The HOPE (Hospice Outcomes and Patient Evaluation) instrument became the CMS-mandated quality-reporting tool for hospice beginning October 2025. HOPE includes a spiritual and existential concerns item (F3000) but does NOT include the PHQ-2, PHQ-9, GAD-7, or HADS — meaning psychological severity is not captured in the standardized EOL quality measurement framework.
The FY2026 hospice aggregate payment cap is $35,361 per beneficiary (CMS-1835-F). MedPAC's March 2026 report confirmed this figure alongside documentation of ESRD patients as a growing share of hospice with historically lower access (31.4% lower in 2024) and concurrent care barriers that limit hospice uptake for this population.
The VBID Model's Hospice Benefit Component (HBC) ended December 31, 2024. The full VBID model was terminated at the end of 2025. No CMS demonstration model currently provides concurrent hospice and curative coverage at scale for fee-for-service beneficiaries.
The HOPE assessment, which replaced the Hospice Item Set on October 1, 2025, includes item F3000, 'Spiritual/Existential Concerns,' asking whether the patient and/or caregiver was asked about such concerns (coded 0=No/skip, 1=Yes and discussion occurred, 2=Yes but refused) with a date field.
Public reporting of HOPE-based measures will occur no earlier than November 2027 (FY 2028), with two process measures added no sooner than FY 2028, using four quarters of CY 2026 data.
In the FY 2027 final rule (CMS-1851-F), CMS finalized a Medicare.gov Care Compare icon identifying hospices that fail to submit any quality data or submit less than the required 90% under the Hospice Quality Reporting Program, effective no earlier than FY 2028.
For FY 2026 (final rule CMS-1835-F), CMS set a 2.6% hospice payment update (about $750M) and an aggregate cap of $35,361.44.
PROPOSED: For FY 2027, CMS proposed (CMS-1851-P) a 2.4% payment update (about $785M) and an aggregate cap of $36,210.11.
Country module · England / UK
England & UK: what the evidence shows
Values in Care's first non-US country module, additive alongside the US content above, not a replacement. UK end-of-life care is anchored in NHS commissioning and NICE Clinical Guideline NG31, rather than Medicare/CMS regulation: a genuinely different regulatory and funding structure, not just a relabeling of the same rules.
NICE Clinical Guideline NG31 (England) addresses recognising dying, communication and shared decision-making, maintaining hydration, and pharmacological symptom control including anticipatory prescribing. It was developed after the Liverpool Care Pathway — the prior standard approach — was withdrawn when an independent government report found its uncritical implementation could lead to poor care. Implementation barriers include the need for further clinician training and 24/7 availability of specialist support.
The Leadership Alliance for the Care of Dying People's five priorities — which replaced the Liverpool Care Pathway after criticism that it promoted a tick-box approach — are: recognising that someone is dying, communicating sensitively with them and their family, involving them in decisions, supporting them and their family, and creating an individualised care plan that includes adequate nutrition and hydration.
A survey of 210 respiratory physicians across England, Wales, and Northern Ireland found patients with advanced nonmalignant respiratory disease (COPD, asbestosis, diffuse parenchymal lung disease) had markedly less access to hospice in-patient and day care than patients with malignant lung disease. Only 21.5% of respondents had formal end-of-life policies for chronic respiratory disease, and 87.9% had no formal process for initiating end-of-life discussions with these patients.
A UK mixed-methods study of 147 bereavement services and 24 staff/volunteer interviews found 67.3% of services reported groups with unmet needs before the pandemic — most frequently people from minoritised ethnic communities (49%), sexual minority groups (26.5%), and deprived areas (24.5%). A quarter of services (25.2%) did not collect ethnicity data at all, limiting visibility into who isn't being reached.
A survey of 127 UK childhood bereavement services (108 responses) found 85% are located in the voluntary/charitable sector, and 44% of host organizations are hospices — illustrating a structural difference from the US: UK hospice and bereavement provision is predominantly voluntary-sector and charity-funded, distinct from the US's primarily Medicare-funded hospice benefit (see the Service Intensity Add-on and HVLDL claims above).
Tradition-authority guidance for the UK context, not yet researched
The tradition guidance elsewhere (see Tradition Guides) is drawn from US-based and international authoritative sources and applies wherever it's read. It is not UK-specific guidance. A UK-specific tradition-authority layer (e.g. Church of England, UK Islamic councils) has not been researched for this module and would need its own dedicated cycle.
Related: Grief & Bereavement Evidence
The hospice bereavement obligation begins at the moment of death and extends for at least one year, the direct downstream of the EOL care phase.
View bereavement evidence →