Terminal Prognosis

Hospice Eligibility Quick Reference Guide
If someone has partial qualifications they can be assessed for Palliative Care

Alzheimer’s/Dementia (1 and 2 be present: 3 shows additional support)
1.Must show ALL of the following:

• Unable to ambulate (walk) without assistance
• Unable to dress without assistance
• Unable to bathe without assistance
• Urinary and fecal incontinence, intermittent or constant

1. Must be stage 7A or beyond on FAST scale (scale is progressive cannot skip stages):
   • 7A – Ability to speak is limited to 1 to 5 words a day
   • 7B – All intelligible (understandable by listener) vocabulary is lost
   • 7C – Ambulatory ability is lost (non-ambulatory)
   • 7D – Cannot sit up without assistance (e.g., patient will fall over if there are no lateral rests (arms) on the chair)
   • 7E – Loss of ability to smile
   • 7F – Loss of ability to hold up head independently
2. The following secondary conditions to the functional impairment: aspiration pneumonia, pyelonephritis or other upper urinary tract infection, septicemia, decubitus ulcers, multiple, stage 3-4, fever, recurrent after antibiotics, inability to maintain sufficient fluid and calorie intake with 10% or >loss of total body weight during the previous 6 months or serum albumin <2.5 gm/dL

Heart Disease (1 and 2)

1. Significant symptoms of recurrent congestive heart failure at rest, classified as NYHA Class IV and/or ejection fraction <20%
2. Optimal treatment with diuretics and vasodilators or angina pectoris at rest is resistant to standard nitrate therapy, and is not a candidate or declines invasive procedures
3. Secondary conditions such as delirium, pneumonia, stasis ulcers and pressure ulcers

Renal Disease (1 and 2 must be present: any from 3 supportive)

1. The patient is not seeking dialysis or renal transplant (or)
2. Is discontinuing dialysis.
3. Nausea/vomiting, pruritis, restlessness, oliguria, edema, abnormal labs such as hyperkalemia, creatinine clearance <10cc/min (15 for diabetics), serum creatinine >6gm/dL (8 for diabetics), documented weight loss of 10% or > of total body weight or decrease in MUAC, serum albumin <2.5 gm/dL

Stroke and Coma (Chronic phase patients) (1 and 2)

1. Poor functional status, Karnofsky score < / =40
2. Poor nutritional status evidence by weight loss over previous 3 months, serum albumin <2.5 gm/dL
3. Secondary conditions could include dysphagia, pneumonia, and pressure ulcers

Liver Disease (1 and 2 must be present: 3 adds support)
1. The patient should show both:

• Prothrombin time prolonged more than 5 seconds over control, or International Normalized Ratio (INR)> 1.5
• Serum albumin <2.5 gm/dL
  

2. End stage liver disease is present and the patient shows at least one of the following:

• Ascites, refractory to treatment or patient non-compliant
• Spontaneous bacterial peritonitis
• Hepatorenal syndrome (elevated creatinine and BUN with oliguria (<400ml/day) and urine sodium
• Hepatic encephalopathy, refractory to treatment, or patient non-compliant
• Recurrent Variceal bleeding, despite intensive therapy
  

3. Documentation of the following factors will support eligibility for hospice care:

• Progressive malnutrition; Muscle wasting with reduced strength and endurance; Continued active alcoholism (> 80 gm ethanol/day); Hepatocellular carcinoma; HBsAg (Hepatitis B) positivity; Hepatitis C refractory to interferon treatment

Patients awaiting liver transplant who otherwise fit the above criteria may be certified to the Medicare hospice benefit, but if a donor organ is procured, the patient must be discharged from hospice.

Pulmonary Disease (1 and 2 should be present: 3 or 4 show additional support)

1. Disabling dyspnea at rest resulting in decreased functional capacity, little or no response to bronchodilators (may be documented by FEV1 post bronchodilators < 30%)
2. Progression documented by increasing ER visits, Physician and/or respiratory failure, use of antibiotics
3. Hypoxemia at rest of room air O2 sat <88%, pO2 </=55mm Hg
4. Hypercapnia with PCO2 > / =50%

Cancer (1 and 2 must be present: 3 shows additional support)

1. Disease with metastases at presentation or
2. Progression from an earlier stage of disease to metastatic disease with either

• A continued decline in spite of therapy or
• Patient declines further disease directed therapy
  

   3.  Supporting signs/symptoms (pain requiring increasing doses of major analgesics, documented weight loss or decrease          in MUAC)