Hospice Diagnoses

General Guidelines of Hospice Diagnoses

1. Disease progression – documented by worsening clinical status, symptoms, signs and laboratory results:

A. Clinical Status: Recurrent or intractable infections such as pneumonia, sepsis or upper urinary tract. Progressive inanition documented by:

Weight loss not due to reversible causes such as depression or use of diuretics.
Decreasing anthropomorphic measurements (mid-arm circumference, abdominal girth), not due to reversible causes such as depression or use of diuretics.
Decreasing serum albumen or cholesterol
Dysphagia leading to recurrent aspiration and/or inadequate oral intake documented by decreasing food portion consumption.

B. Symptoms:

Dyspnea with increasing respiratory rate
Cough, intractable
Nausea/vomiting poorly responsive to treatment
Diarrhea, intractable
Pain requiring increasing doses of major analgesics more than briefly

C. Signs:

Decline in systolic blood pressure to below 90 or progressive postural hypotension
Ascites
Venous, arterial or lymphatic obstruction due to local progression or metastatic disease
Edema
Pleural/pericardial effusion
Weakness
Change in level of consciousness

D. Lab Results (if available—not required to establish hospice eligibility):

Increasing pCO2 or decreasing pO2 or decreasing SaO2
Increasing calcium, creatinine or liver function studies
Increasing tumor markers (e.g. CEA, PSA)
Progressively decreasing or increasing serum sodium or increasing serum potassium

2. Decline in Karnofsky Performance Status (KPS) from < 70% due to progression of disease:

100 = normal; no complaints; no evidence of disease; able to work
90 = able to carry on normal activity; minor symptoms; able to work
80 = normal activity with effort; some symptoms; able to work
70 = cares for self; unable to carry on normal activity; independent; not able to work
60 = disabled; dependent; requires occasional assistance; cares for most needs
50 = moderately disabled; dependent; requires considerable assistance and frequent care
40 = severely disabled; dependent; requires special care and assistance
30 = severely disabled; hospitalized; death not imminent
20 = very sick; active supportive treatment needed
10 = moribund; fatal processes rapidly progressing

3. Dependence on assistance for two or more activities of daily living (ADLs):

Feeding
Ambulation
Continence
Transfer
Bathing
Dressing

4. Progressive stage 3-4 pressure ulcers despite optimal care

5. Co morbidities:

Although not the primary hospice diagnosis, the presence of the following diseases, the severity of which is likely to contribute to a life expectancy of six months or less, should be considered in determining hospice eligibility.

Chronic obstructive pulmonary disease
Congestive heart failure
Ischemic heart disease
Diabetes mellitus
Neurologic disease (CVA, ALS, MS, Parkinson’s)
Renal failure
Liver Disease
Neoplasia
Acquired Immune Deficiency Syndrome
Dementia

6. Recent impaired nutritional status

Evidenced by (check all appropriate):

unintentional, progressive weight loss of 10% over past six months
serum albumin less than 2.5gm/dl (may be helpful prognostic indicator but should not be used by itself)

General Guidelines

General Guidelines of Hospice Diagnoses

1. Disease progression – documented by worsening clinical status, symptoms, signs and laboratory results:

A. Clinical Status: Recurrent or intractable infections such as pneumonia, sepsis or upper urinary tract. Progressive inanition documented by:

Weight loss not due to reversible causes such as depression or use of diuretics.
Decreasing anthropomorphic measurements (mid-arm circumference, abdominal girth), not due to reversible causes such as depression or use of diuretics.
Decreasing serum albumen or cholesterol
Dysphagia leading to recurrent aspiration and/or inadequate oral intake documented by decreasing food portion consumption.

B. Symptoms:

Dyspnea with increasing respiratory rate
Cough, intractable
Nausea/vomiting poorly responsive to treatment
Diarrhea, intractable
Pain requiring increasing doses of major analgesics more than briefly

C. Signs:

Decline in systolic blood pressure to below 90 or progressive postural hypotension
Ascites
Venous, arterial or lymphatic obstruction due to local progression or metastatic disease
Edema
Pleural/pericardial effusion
Weakness
Change in level of consciousness

D. Lab Results (if available—not required to establish hospice eligibility):

Increasing pCO2 or decreasing pO2 or decreasing SaO2
Increasing calcium, creatinine or liver function studies
Increasing tumor markers (e.g. CEA, PSA)
Progressively decreasing or increasing serum sodium or increasing serum potassium

2. Decline in Karnofsky Performance Status (KPS) from < 70% due to progression of disease:

100 = normal; no complaints; no evidence of disease; able to work
90 = able to carry on normal activity; minor symptoms; able to work
80 = normal activity with effort; some symptoms; able to work
70 = cares for self; unable to carry on normal activity; independent; not able to work
60 = disabled; dependent; requires occasional assistance; cares for most needs
50 = moderately disabled; dependent; requires considerable assistance and frequent care
40 = severely disabled; dependent; requires special care and assistance
30 = severely disabled; hospitalized; death not imminent
20 = very sick; active supportive treatment needed
10 = moribund; fatal processes rapidly progressing

3. Dependence on assistance for two or more activities of daily living (ADLs):

Feeding
Ambulation
Continence
Transfer
Bathing
Dressing

4. Progressive stage 3-4 pressure ulcers despite optimal care

5. Co morbidities:

Chronic obstructive pulmonary disease
Congestive heart failure
Ischemic heart disease
Diabetes mellitus
Neurologic disease (CVA, ALS, MS, Parkinson’s)
Renal failure
Liver Disease
Neoplasia
Acquired Immune Deficiency Syndrome
Dementia

6. Recent impaired nutritional status

Evidenced by (check all appropriate):

unintentional, progressive weight loss of 10% over past six months
serum albumin less than 2.5gm/dl (may be helpful prognostic indicator but should not be used by itself)

Adult Failure to Thrive

The patient must meet ALL of the following (1, 2 and 3):

1. < 40% decline in Karnofsky Performance Status:

40 = severely disabled; dependent; requires special care and assistance
30 = severely disabled; hospitalized; death not imminent
20 = very sick; active supportive treatment needed
10 = moribund; fatal processes rapidly progressing

2. Unexplained weight loss resulting in:

Body Mass Index below 22 kg/m²
Body Mass Index = 703 x (patient’s weight in pounds) ÷ (height in inches)²

3. The patient is refusing enteral or parenteral nutritional support or has not responded to such nutritional support, despite adequate caloric intake.

Accepted ICD-9-CM Codes for Failure to Thrive:

783.7 Failure to Thrive
799.3 Debility Unspecified
799.9 Other unknown and unspecified causes of morbidity and mortality

In the absence of one or more of these findings, rapid decline or co-morbidities may also support eligibility for hospice care.

Patients are eligible for hospice care if in the physician’s clinical judgment they have a life expectancy of six months or less. These determinants are to be used as guidelines and do not take the place of a physician’s clinical judgment. Coverage for hospice care may still be appropriate for patients not meeting these determinations due to co-morbidity or rapid decline.

Advanced End Stage Senescence or Debility

The patient has:

Karnofsky Performance Status < 50%:

40 = severely disabled; dependent; requires special care and assistance
30 = severely disabled; hospitalized; death not imminent
20 = very sick; active supportive treatment needed
10 = moribund; fatal processes rapidly progressing

AND

At least one of the following conditions within the past 12 months:

Aspiration Pneumonia
Pyelonephritis or other upper urinary tract infection
Speticemia
Decubitus ulcers, multiple, stage 3-4
Fever, recurrent after antibiotics
Inability to maintain sufficient fluid and caloric intake with > 10% weight loss during the previous six months

OR

A serum albumin of < 2.5 gm/dl
Significant dysphagia with associated aspiration measured objectively (e.g., swallowing test or a history of choking/gagging with feeding)

In the absence of one or more of these findings, rapid decline or co-morbidities may also support eligibility for hospice care.

Amyotrophic Lateral Sclerosis

Patients should fulfill 1, 2 or 3:

1. Critically impaired breathing capacity (within the 12 months preceding hospice admission)

Vital capacity (VC) < 30% of normal (if available)
Dyspnea at rest
Patient declines mechanical ventilation, with external ventilation used for comfort measures only

2. Rapid ALS progression (within the 12 months preceding hospice admission)

from independent ambulation, to wheelchair, to bed bound status
from normal to barely intelligible or unintelligible speech
from normal to pureed diet
from independence in most or all activities of daily living (ADLs) to needing major assistance in all ADL’s by caretaker

Critical nutritional impairment (within the 12 months preceding hospice admission)

oral intake of nutrients and fluids insufficient to sustain life
continuing weight loss
dehydration or hypovolemia
absence of artificial feeding methods sufficient to sustain life—not for relieving hunger

3. Patient should demonstrate rapid progression of ALS and life-threatening complications

recurrent aspiration pneumonia (with or without tube feedings)
upper urinary tract infection, e.g., pyelonephritis
sepsis
recurrent fever after antibiotic therapy
stage 3 or 4 decubitus ulcer(s)

References: Guidelines Taken from: LCD ID Number L13653; LCD Title: Hospice – Determining Terminal Status; Contractor: Cahaba Government Benefit Administrator; Determination # HOA03-002

Cancer

If you have a patient with Cancer that meets the following criteria, they may be eligible for hospice services:

The patient must meet ALL of the following (1, 2 and 3):

1. Clinical findings of malignancy with widespread, aggressive or progressive disease as evidenced by increasing symptoms, worsening lab values, and/or evidence of metastatic disease.

The following information will be required:

A. Tissue diagnosis of malignancy
B. Reasons why a tissue diagnosis is not available

2. Impaired performance status with a PPS (Palliative Performance Scale) ≤ 70% = at minimum is unable to work; ambulation is reduced and intake may be reduced

3. Refuses further life-prolonging therapy OR continues to decline in spite of definitive therapy

Supporting documentation includes:

Hypercalcemia > 12
Cachexia or weight loss of 5% in the preceding three months
Recurrent disease after surgery/radiation/chemotherapy
Signs and symptoms of advanced disease (e.g., nausea, requirement for transfusions, malignant ascites or pleural effusion, etc.)

In the absence of one or more of these findings, rapid decline or co-morbidities may also support eligibility for hospice care.

Chronic Degenerative Neurologic Disease

If you have a patient with Chronic Degenerative Neurologic Disease (e.g., Muscular Dystrophy, Myasthenia Gravis or Multiple Sclerosis) that meets the following criteria, they may be eligible for hospice services:

The patient must meet at least one of the following criteria (1 or 2A or 2B):

1. Critical impaired breathing capacity with all of the following findings:

Dyspnea at rest
Vital capacity less than 30%
The requirement of supplemental oxygen at rest
The patient declines artificial ventilation

OR

2. Rapid disease progression with either A or B below:

Progression from independent ambulation to wheelchair or bed bound status
Progression from normal to barely intelligible or unintelligible speech
Progression from normal to pureed diet
Progression from independent in most or all activities of daily living (ADLs) to needing major assistance by caretaker in all ADLs

AND

A. Critical nutritional impairment demonstrated by all of the following in the preceding twelve (12) months:

Oral intake of nutrients and fluids insufficient to sustain life
Continuing weight loss
Dehydration of hypovolemia
Absence of artificial feeding methods

OR

B. Life-threatening complications as demonstrated by one or more of the following in the preceding twelve (12) months:

Recurrent aspiration pneumonia (with or without tube feedings)
Upper urinary tract infection (pyelonephritis)
Sepsis
Recurrent fever after antibiotic therapy
Stage 3 or 4 decubitus ulcers

In the absence of one or more of these findings, rapid decline or co-morbidities may also support eligibility for hospice care.

Coma (any etiology)

Indications Determining Eligibility for Medicare Hospice Benefit

Comatose patients with any 3 of the following on day three of coma:

abnormal brain stem response
absent verbal response
absent withdrawal response to pain
serum creatinine >1.5 mg/dl.

Supportive Documentation (not required for hospice eligibility, but helpful)

Medical complications (in the context of progressive clinical decline within the previous 12 months) which support a terminal prognosis:

aspiration pneumonia
upper urinary tract infection (pyelonephritis)
sepsis
refractory stage 3-4 decubitus ulcers
fever recurrent after antibiotics.

In the absence of one or more of these findings, rapid decline or co-morbidities may also support eligibility for hospice care.

References: Guidelines Taken from: LCD ID Number L13653; LCD Title: Hospice – Determining Terminal Status; Contractor: Cahaba Government Benefit Administrator; Determination # HOA03-002

Dementia (Due to Alzheimer’s and Related Disorders)

Selections in both 1 and 2 must be present as evidence of hospice appropriateness.

1. Is the patient severely demented?…………………… The patient should be at or beyond Stage 7 of the Functional Assessment Staging Scale. (Check all that apply – must be at minimum one of the following):

7A- Ability to speak is limited to approximately 6 intelligible words or fewer, in the course of an average day or in the course of an intensive interview
7B- Speech ability is limited to the use of a single intelligible word in an average day or in the course of an intensive interview. (The person may repeat the word over and over)
7C- Ambulatory ability is lost (cannot walk without personal assistance)
7D- Cannot sit up without assistance (e.g., patient will fall over if there are not lateral rests/arms on the chair)
7E- Loss of the ability to smile
7F- Loss of the ability to hold head independently

2. Patient should show ALL of the following characteristics.

Inability to ambulate independently (cannot walk without personal assistance)
Unable to dress without assistance
Unable to bathe without assistance
Incontinence of urine and stool (intermittent or constant)
Unable to speak or communicate meaningfully (see 7A above)

3. Has the patient had one or more of the following medical complications related to Dementia during the past 12 months?…….……………………………Patients should have had one of the following within the past 12 months.

Aspiration Pneumonia
Upper Urinary Tract Infection or Pyelonephritis
Septicemia
Decubitus Ulcer(s) multiple, Stage 3-4
Fever, recurrent after antibiotics
Inability or unwillingness to maintain sufficient fluid or caloric intake with a 10% weight loss during previous 6 months or serum albumen

OR

Patients who receive tube feedings must have documented impaired nutritional status as indicated by either:
Unintentional progressive weight loss of greater than 10% over prior 6 month period
Serum albumin less than 2.5 mg/dl (may be prognostic indicator, but should not be used by itself)

Heart Disease

Numbers 1 and 2 should be present factors, from number 3 on add supporting documentation.

1. Is the patient not eligible for surgery or refusing surgery?

2. Does the patient have symptoms and signs of congestive heart failure at rest?

Patient is New York Heart Association (NYHA) Class IV as evidenced by following –Check all that apply:

Symptoms

Dyspnea at rest: short winded or can’t breathe
Dyspnea on exertion: can’t breathe with exercise
Orthopnea: can’t breathe lying down
Paroxysmal nocturnal dyspnea (PND): Waking up at night short of breath
Edema: swollen ankles, feet
Syncope
Weaknes
Chest pain

Signs

Diaphoresis: sweating
Cachexia: profound weight loss
Jugulvenous destination (JVD)
Neck veins distended above clavicle
Rales: wet crackles in lungs heard on inspiration
Gallop rhythm: S3, S4
Liver enlargement

3. Has the physician verified the patient is on optimal diuretic & vasodilator therapy?

Diuretics – patient should be on optimal dose of one of the following. (Check all that apply):

Furosemide (Lasix)
Bumetanide (Bumex)
Metolazone (Zaroxlyne, Mykrox) – may be combined with the above, but not used alone
Ethacrynic Acid (Edecrine)
Torsemide (Demedex)

Vasodilators – patient should be on optimal dose of one of the following. (Check all that apply):

Nitrates (e.g., Nitropatic, Isosorbide) plus Hydralazine
ACE (Angiotension Converting Enzyme) inhibitor:

Other:

Apresoline
Benzepril (Lotensin)
Catopril (Capoten)
Elanapril (Vasotec)
Fosinapril (Monopril)
Lisinopril (Prinvil, Zestril)
Quinapril (Accupril)
Rimipril (Altace)

4. Does the patient have an ejection fraction of less than or equal to 20%

5. The following factors are further indicators of decreased survival time. (Check all that apply):

Symptomatic supraventricular or ventricular arrhythmias resistant to anti-arrhythmic therapy
History of cardiac arrest and resuscitation in any setting
Cardiogenic brain embolism; i.e., embolic CVA or cardiac origin
Concomitant HIV disease

HIV Disease

Numbers 1 and 2 should be present factors, from number 3 on add supporting documentation.

Factors 1 and 2 should be present, from 3 on offer supporting documentation:

1. CD4+ Count 100,000 copies/ml, plus one of the following:

CNS Lymphoma
Wasting – untreated or persistent despite treatment (loss of at least 10% lean body mass)
Mycobacterium avium complex (MAC) bacteremia – untreated, unresponsive to treatment, or treatment refused
Progressive multifocal leukoencephalopathy
Systemic lymphoma, with advanced HIV disease and partial response to chemotherapy
Visceral Kaposi’s sarcoma unresponsive to therapy
Renal failure in the absence of dialysis
Cryptosporidium infection
Toxoplasmosis – unresponsive to therapy

2. Decreased performance status as measured by the Karnofsky Performance Status scale of < 50%

50 = moderately disabled; dependent; requires considerable assistance and frequent care
40 = severely disabled; dependent; requires special care and assistance
30 = severely disabled; hospitalized; death not imminent
20 = very sick; active supportive treatment needed
10 = moribund; fatal processes rapidly progressing

Supportive Documentation (not required for hospice eligibility, but helpful)

3. Chronic persistent diarrhea for one year

4. Persistent serum albumin 50 years

5. Absence of (or resistance to) effective antiretroviral, chemotherapeutic and prophylactic drug therapy related specifically to HIV disease

6. Advanced AIDS dementia complex

7. Toxoplasmosis

8. Congestive heart failure – symptomatic at rest

9. Advanced liver disease

Guidelines Taken from: LCD ID Number L13653; LCD Title: Hospice – Determining Terminal Status; Contractor: Cahaba Government Benefit Administrator; Determination # HOA03-002

End-Stage Liver Disease

The following factors have been shown to correlate with poor short-term survival in advance cirrhosis of the liver due to alcoholism, hepatitis, or uncertain causes (cryptogenic). Their effects are additive, i.e., prognosis worsens with the addition of each one and clinical judgment is vital. The following criteria should be followed and reviewed over time.

1. The patient is not a candidate for a liver transplant.

2. Laboratory indicators of severely impaired liver function should show both of the following:

Prothrombin time prolonged more than 5 sec. over control or INR > 1.5
Serum albumin < 2.5 gm/dl

3. Clinical indicators of end-stage liver disease (patient should show at least one of the following):

Ascites
- Refractory to sodium restriction and diuretics; spironolactone 75-150 mg/day plus furosemide > 40 mg/day
- Patient non-compliant with treatment
Spontaneous bacterial peritonitis (median survival 30% at one year; high mortality even when infection cured intially if liver disease is severe or accompanied by renal disease.)
Hepatorenal syndrome (usually occurs during hospitalization; survival usually days to weeks)
- Patient has cirrhosis and ascites
- Elevated creatinine and BUN
- Oliguria 400 ml/day
- Urine sodium concentration 10mEq/l recurrent
Recurrent variceal bleeding: patient should have re-bled despite therapy which currently includes:
- Injection sclerotherapy or band ligation, if available
- Oral beta blockers
- Transjugular intrahepatic portosystemic shunt (TIPS)
- Patient refused further therapy
Hepatic encephalopathy
- Refractory to protein restriction and Lactulose or neomycin
- Patient non-compliant

4. Other (Check all that apply):

Symptoms

Decreased awareness of environment
Sleep disturbance
Depression
Emotional lability
Somnolence
Slurred speech
Obtundation

Signs

Flapping of asterixis (in earlier stages)
Stupor (late stage)
Coma (late stage)

5. The following factors have been shown to worsen prognosis and should be documented if present:

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

Note: Patients awaiting liver transplant who otherwise fit the above criteria may be certified for hospice, but if a donor organ is procured, the patient should be discharged from hospice.

Multiple Sclerosis

The patient meets at least one of the following criteria (1 or 2):

1. Critically impaired breathing capacity with all of the following findings:

a)Dyspnea at rest
b)Vital capacity less than 30%
c)Requirement for supplemental oxygen at rest
d)The patient declines artificial ventilation

OR

2. Rapid disease progression and either a, or b below:

Rapid disease progression as evidenced by all of the following in the proceeding twelve (12) months:

a) Progression from independent ambulation to wheelchair or bed-bound status
b) Progression from normal to barely intelligible or unintelligible speech
c) Progression from normal to pureed diet
d) Progression from independence in most or all Activities of Daily Living (ADL’S) to needing major assistance by caretaker in all ADL’S

AND

2B. Life threatening complications demonstrated by one or more of the following in the proceeding twelve (12) months:

a) Recurrent aspiration pneumonia (without tube feedings)
b)Pyelonephritis or other upper urinary tract infection
c) Sepsis
d) Recurrent fever after antibiotic therapy
e) Stage 3 or stage 4 decubitus ulcer(s)

In the absence of one or more of the above findings, rapid decline or comorbidities may also support eligibility for hospice care.

Parkinson’s Disease

The patient meets at least one of the following criteria (1 or 2):

1. Critical impaired breathing capacity with all of the following findings:

Dyspnea at rest
Vital capacity less than 30%
Requirement for supplemental oxygen at rest
The patient declines artificial ventilation

OR

2. Rapid disease progression with either A or B below:

Progression from independent ambulation to wheelchair or bed bound status
Progression from normal to barely intelligible or unintelligible speech
Progression from normal to pureed diet
Progression from independent in most or all activities of daily living (ADLs) to needing major assistance by caretaker in all ADLs

AND

A. Critical nutritional impairment demonstrated by all of the following in the preceding twelve (12) months:

Oral intake of nutrients and fluids insufficient to sustain life
Continuing weight loss
Dehydration of hypovolemia
Absence of artificial feeding methods

OR

B. Life-threatening complications as demonstrated by one or more of the following in the preceding twelve (12) months:

Recurrent aspiration pneumonia (with or without tube feedings)
Upper urinary tract infection (pyelonephritis)
Sepsis
Recurrent fever after antibiotic therapy
Stage 3 or stage 4 decubitus ulcer(s)

In the absence of one or more of these findings, rapid decline or co-morbidities may also support eligibility for hospice care.

Pulmonary Disease

1 and 2 should be present; 3, 4 and 5 lend supporting documentation

1. Does the patient have severe chronic lung disease?

If Yes, both A and B must be present:

A. Disabling Dyspnea as evidenced by:

Symptoms

Dyspnea at rest
House-bound, chair-bound
Oxygen dependent
Copious/purulent sputum
Recurrent infections
Severe cough
Poor response to bronchodilators
Forced expiratory volume in one second (FEV1) after bronchodilator; < 30% of predicted*

Signs

Cyanosis: blue fingertips/lips
Pulmonary hyperinflation: barrel-chested
Pursed-lip breathing
Accessory muscles of respiration
Retractions: supraclavicular
Increased expiratory phase: slowed, forced expiration
Liver
Diminished breath sounds
Depressed diaphragm

B. Progression of end-stage Pulmonary Disease as evidenced by: (Check all that apply):

Increased visits to Emergency Room or hospitalizations for pulmonary infections/respiratory failure or increased physician home visits
Decrease in FEV1 on serial testing of > 40 ml/year*

2. Hypoxemia at rest on room air as evidenced by:

pO2, ≤ 55 mm Hg on supplemental O2
O2 saturation ≤ 88% on supplemental O2 (through blood gas reports or O2 sat monitors)
Hypercapnia, as evidenced by pCO2 ≥ 50 mg Hg (within past 3 months)

3. Presence of corpulmonale or right heart failure due to lung disease

4. Unintentional weight loss > 10% of body weight in past 6 months

5. Resting tachycardia (heart rate > per minute)

* These tests are helpful evidence but should not be required if not readily available.

Renal Disease

1 and 2 should be present; 3, 4 and 5 lend supporting documentation

1. Patient is not seeking dialysis or renal transplant or is discontinuing dialysis

2. Laboratory criteria for renal failure (one of the following should be present):

Creatinine clearance of
O2 saSerum creatinine >8.0 mg/dl (>6.0 mg/dl for diabetics)turation ≤ 88% on supplemental O2 (through blood gas reports or O2 sat monitors)
Note: Creatinine clearance may be estimated by using the following formula: Creatinine clearance = (140 – age in years)(body wt. in KG)/72) (serum creatinine in ml/dl) Multiply by 0.85 for women

3. Clinical signs and symptoms associated with renal failure. (Check all which are present):

Uremia: clinical signs of renal failure:
- Confusion, obtundation
- Intractable nausea and vomiting
- Generalized purities
- Restlessness; “restless legs”
Oliguria: urine output < 400 cc/24 hours
Intractable hyperkalemia: persistent serum potassium > 7.0 not responsive to medical management
Uremic pericarditis
Hepatorenal syndrome
Intractable fluid overload, not responsive to treatment

4. Comorbid conditions predict early mortality (Check all that apply):

Mechanical ventilation
Malignancy – other organ system
Chronic lung disease
Advanced cardiac disease
Advanced liver disease
Sepsis
Immunosupression/AIDS
Albumen < 3.5 gm/dl
Cachexia
IPlatelet count < 25,000
Age > 75
Disseminated intravascular coagulation
GI bleeding

Stroke

Indications Determining Eligibility for Medicare Hospice Benefit – All following items must be present:

1. <40% decline in Karnofsky Performance Status:

Mechanical ventilation
40 = severely disabled; dependent; requires special care and assistance
30 = severely disabled; hospitalized; death not imminent
20 = very sick; active supportive treatment needed
10 = moribund; fatal processes rapidly progressing

2. Inability to maintain hydration and caloric intake with one of the resulting issues:

Weight loss >10% in the last 6 months or >7.5% in the last 3 months
Serum albumin
Current history of pulmonary aspiration not responsive to speech language pathology intervention
Sequential calorie counts documenting inadequate caloric/fluid intake
Dysphagia severe enough to prevent the patient from receiving food and fluids necessary to sustain life – in a patient who declines or does not receive artificial nutrition and hydration.

Documentation to support eligibility for hospice care:

Non-traumatic hemorrhagic stroke documentation of diagnostic imaging factors which support poor prognosis include:
large-volume hemorrhage on CT:
- A. infratentorial: 20 ml.
- B. supratentorial: 50 ml.
ventricular extension of hemorrhage
surface area of involvement of hemorrhage 30% of cerebrum
midline shift 1.5 cm.

Thrombotic/embolic stroke documentation of diagnostic imaging factors which support poor prognosis include:

large anterior infarcts with both cortical and subcortical involvement
large bihemispheric infarcts
basilar artery occlusion
bilateral vertebral artery occlusion

References: Guidelines Taken from: LCD ID Number L13653; LCD Title: Hospice – Determining Terminal Status; Contractor: Cahaba Government Benefit Administrator; Determination # HOA03-002 Karnofsky Scale developed by Karnofsky, Abelmann, Craver & Burchenal, 1948

Hospice Diagnoses

General Guidelines of Hospice Diagnoses

1. Disease progression – documented by worsening clinical status, symptoms, signs and laboratory results:

A. Clinical Status: Recurrent or intractable infections such as pneumonia, sepsis or upper urinary tract. Progressive inanition documented by:

Weight loss not due to reversible causes such as depression or use of diuretics.
Decreasing anthropomorphic measurements (mid-arm circumference, abdominal girth), not due to reversible causes such as depression or use of diuretics.
Decreasing serum albumen or cholesterol
Dysphagia leading to recurrent aspiration and/or inadequate oral intake documented by decreasing food portion consumption.

B. Symptoms:

Dyspnea with increasing respiratory rate
Cough, intractable
Nausea/vomiting poorly responsive to treatment
Diarrhea, intractable
Pain requiring increasing doses of major analgesics more than briefly

C. Signs:

Decline in systolic blood pressure to below 90 or progressive postural hypotension
Ascites
Venous, arterial or lymphatic obstruction due to local progression or metastatic disease
Edema
Pleural/pericardial effusion
Weakness
Change in level of consciousness

D. Lab Results (if available—not required to establish hospice eligibility):

Increasing pCO2 or decreasing pO2 or decreasing SaO2
Increasing calcium, creatinine or liver function studies
Increasing tumor markers (e.g. CEA, PSA)
Progressively decreasing or increasing serum sodium or increasing serum potassium

2. Decline in Karnofsky Performance Status (KPS) from < 70% due to progression of disease:

100 = normal; no complaints; no evidence of disease; able to work
90 = able to carry on normal activity; minor symptoms; able to work
80 = normal activity with effort; some symptoms; able to work
70 = cares for self; unable to carry on normal activity; independent; not able to work
60 = disabled; dependent; requires occasional assistance; cares for most needs
50 = moderately disabled; dependent; requires considerable assistance and frequent care
40 = severely disabled; dependent; requires special care and assistance
30 = severely disabled; hospitalized; death not imminent
20 = very sick; active supportive treatment needed
10 = moribund; fatal processes rapidly progressing

3. Dependence on assistance for two or more activities of daily living (ADLs):

Feeding
Ambulation
Continence
Transfer
Bathing
Dressing

4. Progressive stage 3-4 pressure ulcers despite optimal care

5. Co morbidities:

Chronic obstructive pulmonary disease
Congestive heart failure
Ischemic heart disease
Diabetes mellitus
Neurologic disease (CVA, ALS, MS, Parkinson’s)
Renal failure
Liver Disease
Neoplasia
Acquired Immune Deficiency Syndrome
Dementia

6. Recent impaired nutritional status

Evidenced by (check all appropriate):

unintentional, progressive weight loss of 10% over past six months
serum albumin less than 2.5gm/dl (may be helpful prognostic indicator but should not be used by itself)

General Guidelines

General Guidelines of Hospice Diagnoses

1. Disease progression – documented by worsening clinical status, symptoms, signs and laboratory results:

A. Clinical Status: Recurrent or intractable infections such as pneumonia, sepsis or upper urinary tract. Progressive inanition documented by:

Weight loss not due to reversible causes such as depression or use of diuretics.
Decreasing anthropomorphic measurements (mid-arm circumference, abdominal girth), not due to reversible causes such as depression or use of diuretics.
Decreasing serum albumen or cholesterol
Dysphagia leading to recurrent aspiration and/or inadequate oral intake documented by decreasing food portion consumption.

B. Symptoms:

Dyspnea with increasing respiratory rate
Cough, intractable
Nausea/vomiting poorly responsive to treatment
Diarrhea, intractable
Pain requiring increasing doses of major analgesics more than briefly

C. Signs:

Decline in systolic blood pressure to below 90 or progressive postural hypotension
Ascites
Venous, arterial or lymphatic obstruction due to local progression or metastatic disease
Edema
Pleural/pericardial effusion
Weakness
Change in level of consciousness

D. Lab Results (if available—not required to establish hospice eligibility):

Increasing pCO2 or decreasing pO2 or decreasing SaO2
Increasing calcium, creatinine or liver function studies
Increasing tumor markers (e.g. CEA, PSA)
Progressively decreasing or increasing serum sodium or increasing serum potassium

2. Decline in Karnofsky Performance Status (KPS) from < 70% due to progression of disease:

100 = normal; no complaints; no evidence of disease; able to work
90 = able to carry on normal activity; minor symptoms; able to work
80 = normal activity with effort; some symptoms; able to work
70 = cares for self; unable to carry on normal activity; independent; not able to work
60 = disabled; dependent; requires occasional assistance; cares for most needs
50 = moderately disabled; dependent; requires considerable assistance and frequent care
40 = severely disabled; dependent; requires special care and assistance
30 = severely disabled; hospitalized; death not imminent
20 = very sick; active supportive treatment needed
10 = moribund; fatal processes rapidly progressing

3. Dependence on assistance for two or more activities of daily living (ADLs):

Feeding
Ambulation
Continence
Transfer
Bathing
Dressing

4. Progressive stage 3-4 pressure ulcers despite optimal care

5. Co morbidities:

Chronic obstructive pulmonary disease
Congestive heart failure
Ischemic heart disease
Diabetes mellitus
Neurologic disease (CVA, ALS, MS, Parkinson’s)
Renal failure
Liver Disease
Neoplasia
Acquired Immune Deficiency Syndrome
Dementia

6. Recent impaired nutritional status

Evidenced by (check all appropriate):

unintentional, progressive weight loss of 10% over past six months
serum albumin less than 2.5gm/dl (may be helpful prognostic indicator but should not be used by itself)

Adult Failure to Thrive

The patient must meet ALL of the following (1, 2 and 3):

1. < 40% decline in Karnofsky Performance Status:

40 = severely disabled; dependent; requires special care and assistance
30 = severely disabled; hospitalized; death not imminent
20 = very sick; active supportive treatment needed
10 = moribund; fatal processes rapidly progressing

2. Unexplained weight loss resulting in:

Body Mass Index below 22 kg/m²
Body Mass Index = 703 x (patient’s weight in pounds) ÷ (height in inches)²

3. The patient is refusing enteral or parenteral nutritional support or has not responded to such nutritional support, despite adequate caloric intake.

Accepted ICD-9-CM Codes for Failure to Thrive:

783.7 Failure to Thrive
799.3 Debility Unspecified
799.9 Other unknown and unspecified causes of morbidity and mortality

In the absence of one or more of these findings, rapid decline or co-morbidities may also support eligibility for hospice care.

Advanced End Stage Senescence or Debility

The patient has:

Karnofsky Performance Status < 50%:

40 = severely disabled; dependent; requires special care and assistance
30 = severely disabled; hospitalized; death not imminent
20 = very sick; active supportive treatment needed
10 = moribund; fatal processes rapidly progressing

AND

At least one of the following conditions within the past 12 months:

Aspiration Pneumonia
Pyelonephritis or other upper urinary tract infection
Speticemia
Decubitus ulcers, multiple, stage 3-4
Fever, recurrent after antibiotics
Inability to maintain sufficient fluid and caloric intake with > 10% weight loss during the previous six months

OR

A serum albumin of < 2.5 gm/dl
Significant dysphagia with associated aspiration measured objectively (e.g., swallowing test or a history of choking/gagging with feeding)

In the absence of one or more of these findings, rapid decline or co-morbidities may also support eligibility for hospice care.

Amyotrophic Lateral Sclerosis

Patients should fulfill 1, 2 or 3:

1. Critically impaired breathing capacity (within the 12 months preceding hospice admission)

Vital capacity (VC) < 30% of normal (if available)
Dyspnea at rest
Patient declines mechanical ventilation, with external ventilation used for comfort measures only

2. Rapid ALS progression (within the 12 months preceding hospice admission)

from independent ambulation, to wheelchair, to bed bound status
from normal to barely intelligible or unintelligible speech
from normal to pureed diet
from independence in most or all activities of daily living (ADLs) to needing major assistance in all ADL’s by caretaker

Critical nutritional impairment (within the 12 months preceding hospice admission)

oral intake of nutrients and fluids insufficient to sustain life
continuing weight loss
dehydration or hypovolemia
absence of artificial feeding methods sufficient to sustain life—not for relieving hunger

3. Patient should demonstrate rapid progression of ALS and life-threatening complications

recurrent aspiration pneumonia (with or without tube feedings)
upper urinary tract infection, e.g., pyelonephritis
sepsis
recurrent fever after antibiotic therapy
stage 3 or 4 decubitus ulcer(s)

References: Guidelines Taken from: LCD ID Number L13653; LCD Title: Hospice – Determining Terminal Status; Contractor: Cahaba Government Benefit Administrator; Determination # HOA03-002

Cancer

If you have a patient with Cancer that meets the following criteria, they may be eligible for hospice services:

The patient must meet ALL of the following (1, 2 and 3):

1. Clinical findings of malignancy with widespread, aggressive or progressive disease as evidenced by increasing symptoms, worsening lab values, and/or evidence of metastatic disease.

The following information will be required:

A. Tissue diagnosis of malignancy
B. Reasons why a tissue diagnosis is not available

2. Impaired performance status with a PPS (Palliative Performance Scale) ≤ 70% = at minimum is unable to work; ambulation is reduced and intake may be reduced

3. Refuses further life-prolonging therapy OR continues to decline in spite of definitive therapy

Supporting documentation includes:

Hypercalcemia > 12
Cachexia or weight loss of 5% in the preceding three months
Recurrent disease after surgery/radiation/chemotherapy
Signs and symptoms of advanced disease (e.g., nausea, requirement for transfusions, malignant ascites or pleural effusion, etc.)

In the absence of one or more of these findings, rapid decline or co-morbidities may also support eligibility for hospice care.

Chronic Degenerative Neurologic Disease

The patient must meet at least one of the following criteria (1 or 2A or 2B):

1. Critical impaired breathing capacity with all of the following findings:

Dyspnea at rest
Vital capacity less than 30%
The requirement of supplemental oxygen at rest
The patient declines artificial ventilation

OR

2. Rapid disease progression with either A or B below:

Progression from independent ambulation to wheelchair or bed bound status
Progression from normal to barely intelligible or unintelligible speech
Progression from normal to pureed diet
Progression from independent in most or all activities of daily living (ADLs) to needing major assistance by caretaker in all ADLs

AND

A. Critical nutritional impairment demonstrated by all of the following in the preceding twelve (12) months:

Oral intake of nutrients and fluids insufficient to sustain life
Continuing weight loss
Dehydration of hypovolemia
Absence of artificial feeding methods

OR

B. Life-threatening complications as demonstrated by one or more of the following in the preceding twelve (12) months:

Recurrent aspiration pneumonia (with or without tube feedings)
Upper urinary tract infection (pyelonephritis)
Sepsis
Recurrent fever after antibiotic therapy
Stage 3 or 4 decubitus ulcers

In the absence of one or more of these findings, rapid decline or co-morbidities may also support eligibility for hospice care.

Coma (any etiology)

Indications Determining Eligibility for Medicare Hospice Benefit

Comatose patients with any 3 of the following on day three of coma:

abnormal brain stem response
absent verbal response
absent withdrawal response to pain
serum creatinine >1.5 mg/dl.

Supportive Documentation (not required for hospice eligibility, but helpful)

Medical complications (in the context of progressive clinical decline within the previous 12 months) which support a terminal prognosis:

aspiration pneumonia
upper urinary tract infection (pyelonephritis)
sepsis
refractory stage 3-4 decubitus ulcers
fever recurrent after antibiotics.

In the absence of one or more of these findings, rapid decline or co-morbidities may also support eligibility for hospice care.

References: Guidelines Taken from: LCD ID Number L13653; LCD Title: Hospice – Determining Terminal Status; Contractor: Cahaba Government Benefit Administrator; Determination # HOA03-002

Dementia (Due to Alzheimer’s and Related Disorders)

Selections in both 1 and 2 must be present as evidence of hospice appropriateness.

7A- Ability to speak is limited to approximately 6 intelligible words or fewer, in the course of an average day or in the course of an intensive interview
7B- Speech ability is limited to the use of a single intelligible word in an average day or in the course of an intensive interview. (The person may repeat the word over and over)
7C- Ambulatory ability is lost (cannot walk without personal assistance)
7D- Cannot sit up without assistance (e.g., patient will fall over if there are not lateral rests/arms on the chair)
7E- Loss of the ability to smile
7F- Loss of the ability to hold head independently

2. Patient should show ALL of the following characteristics.

Inability to ambulate independently (cannot walk without personal assistance)
Unable to dress without assistance
Unable to bathe without assistance
Incontinence of urine and stool (intermittent or constant)
Unable to speak or communicate meaningfully (see 7A above)

Aspiration Pneumonia
Upper Urinary Tract Infection or Pyelonephritis
Septicemia
Decubitus Ulcer(s) multiple, Stage 3-4
Fever, recurrent after antibiotics
Inability or unwillingness to maintain sufficient fluid or caloric intake with a 10% weight loss during previous 6 months or serum albumen

OR

Patients who receive tube feedings must have documented impaired nutritional status as indicated by either:
Unintentional progressive weight loss of greater than 10% over prior 6 month period
Serum albumin less than 2.5 mg/dl (may be prognostic indicator, but should not be used by itself)

Heart Disease

Numbers 1 and 2 should be present factors, from number 3 on add supporting documentation.

1. Is the patient not eligible for surgery or refusing surgery?

2. Does the patient have symptoms and signs of congestive heart failure at rest?

Patient is New York Heart Association (NYHA) Class IV as evidenced by following –Check all that apply:

Symptoms

Dyspnea at rest: short winded or can’t breathe
Dyspnea on exertion: can’t breathe with exercise
Orthopnea: can’t breathe lying down
Paroxysmal nocturnal dyspnea (PND): Waking up at night short of breath
Edema: swollen ankles, feet
Syncope
Weaknes
Chest pain

Signs

Diaphoresis: sweating
Cachexia: profound weight loss
Jugulvenous destination (JVD)
Neck veins distended above clavicle
Rales: wet crackles in lungs heard on inspiration
Gallop rhythm: S3, S4
Liver enlargement

3. Has the physician verified the patient is on optimal diuretic & vasodilator therapy?

Diuretics – patient should be on optimal dose of one of the following. (Check all that apply):

Furosemide (Lasix)
Bumetanide (Bumex)
Metolazone (Zaroxlyne, Mykrox) – may be combined with the above, but not used alone
Ethacrynic Acid (Edecrine)
Torsemide (Demedex)

Vasodilators – patient should be on optimal dose of one of the following. (Check all that apply):

Nitrates (e.g., Nitropatic, Isosorbide) plus Hydralazine
ACE (Angiotension Converting Enzyme) inhibitor:

Other:

Apresoline
Benzepril (Lotensin)
Catopril (Capoten)
Elanapril (Vasotec)
Fosinapril (Monopril)
Lisinopril (Prinvil, Zestril)
Quinapril (Accupril)
Rimipril (Altace)

4. Does the patient have an ejection fraction of less than or equal to 20%

5. The following factors are further indicators of decreased survival time. (Check all that apply):

Symptomatic supraventricular or ventricular arrhythmias resistant to anti-arrhythmic therapy
History of cardiac arrest and resuscitation in any setting
Cardiogenic brain embolism; i.e., embolic CVA or cardiac origin
Concomitant HIV disease

HIV Disease

Numbers 1 and 2 should be present factors, from number 3 on add supporting documentation.

Factors 1 and 2 should be present, from 3 on offer supporting documentation:

1. CD4+ Count 100,000 copies/ml, plus one of the following:

CNS Lymphoma
Wasting – untreated or persistent despite treatment (loss of at least 10% lean body mass)
Mycobacterium avium complex (MAC) bacteremia – untreated, unresponsive to treatment, or treatment refused
Progressive multifocal leukoencephalopathy
Systemic lymphoma, with advanced HIV disease and partial response to chemotherapy
Visceral Kaposi’s sarcoma unresponsive to therapy
Renal failure in the absence of dialysis
Cryptosporidium infection
Toxoplasmosis – unresponsive to therapy

2. Decreased performance status as measured by the Karnofsky Performance Status scale of < 50%

50 = moderately disabled; dependent; requires considerable assistance and frequent care
40 = severely disabled; dependent; requires special care and assistance
30 = severely disabled; hospitalized; death not imminent
20 = very sick; active supportive treatment needed
10 = moribund; fatal processes rapidly progressing

Supportive Documentation (not required for hospice eligibility, but helpful)

3. Chronic persistent diarrhea for one year

4. Persistent serum albumin 50 years

5. Absence of (or resistance to) effective antiretroviral, chemotherapeutic and prophylactic drug therapy related specifically to HIV disease

6. Advanced AIDS dementia complex

7. Toxoplasmosis

8. Congestive heart failure – symptomatic at rest

9. Advanced liver disease

Guidelines Taken from: LCD ID Number L13653; LCD Title: Hospice – Determining Terminal Status; Contractor: Cahaba Government Benefit Administrator; Determination # HOA03-002

End-Stage Liver Disease

1. The patient is not a candidate for a liver transplant.

2. Laboratory indicators of severely impaired liver function should show both of the following:

Prothrombin time prolonged more than 5 sec. over control or INR > 1.5
Serum albumin < 2.5 gm/dl

3. Clinical indicators of end-stage liver disease (patient should show at least one of the following):

Ascites
- Refractory to sodium restriction and diuretics; spironolactone 75-150 mg/day plus furosemide > 40 mg/day
- Patient non-compliant with treatment
Spontaneous bacterial peritonitis (median survival 30% at one year; high mortality even when infection cured intially if liver disease is severe or accompanied by renal disease.)
Hepatorenal syndrome (usually occurs during hospitalization; survival usually days to weeks)
- Patient has cirrhosis and ascites
- Elevated creatinine and BUN
- Oliguria 400 ml/day
- Urine sodium concentration 10mEq/l recurrent
Recurrent variceal bleeding: patient should have re-bled despite therapy which currently includes:
- Injection sclerotherapy or band ligation, if available
- Oral beta blockers
- Transjugular intrahepatic portosystemic shunt (TIPS)
- Patient refused further therapy
Hepatic encephalopathy
- Refractory to protein restriction and Lactulose or neomycin
- Patient non-compliant

4. Other (Check all that apply):

Symptoms

Decreased awareness of environment
Sleep disturbance
Depression
Emotional lability
Somnolence
Slurred speech
Obtundation

Signs

Flapping of asterixis (in earlier stages)
Stupor (late stage)
Coma (late stage)

5. The following factors have been shown to worsen prognosis and should be documented if present:

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

Note: Patients awaiting liver transplant who otherwise fit the above criteria may be certified for hospice, but if a donor organ is procured, the patient should be discharged from hospice.

Multiple Sclerosis

The patient meets at least one of the following criteria (1 or 2):

1. Critically impaired breathing capacity with all of the following findings:

a)Dyspnea at rest
b)Vital capacity less than 30%
c)Requirement for supplemental oxygen at rest
d)The patient declines artificial ventilation

OR

2. Rapid disease progression and either a, or b below:

Rapid disease progression as evidenced by all of the following in the proceeding twelve (12) months:

a) Progression from independent ambulation to wheelchair or bed-bound status
b) Progression from normal to barely intelligible or unintelligible speech
c) Progression from normal to pureed diet
d) Progression from independence in most or all Activities of Daily Living (ADL’S) to needing major assistance by caretaker in all ADL’S

AND

2B. Life threatening complications demonstrated by one or more of the following in the proceeding twelve (12) months:

a) Recurrent aspiration pneumonia (without tube feedings)
b)Pyelonephritis or other upper urinary tract infection
c) Sepsis
d) Recurrent fever after antibiotic therapy
e) Stage 3 or stage 4 decubitus ulcer(s)

In the absence of one or more of the above findings, rapid decline or comorbidities may also support eligibility for hospice care.

Parkinson’s Disease

The patient meets at least one of the following criteria (1 or 2):

1. Critical impaired breathing capacity with all of the following findings:

Dyspnea at rest
Vital capacity less than 30%
Requirement for supplemental oxygen at rest
The patient declines artificial ventilation

OR

2. Rapid disease progression with either A or B below:

Progression from independent ambulation to wheelchair or bed bound status
Progression from normal to barely intelligible or unintelligible speech
Progression from normal to pureed diet
Progression from independent in most or all activities of daily living (ADLs) to needing major assistance by caretaker in all ADLs

AND

A. Critical nutritional impairment demonstrated by all of the following in the preceding twelve (12) months:

Oral intake of nutrients and fluids insufficient to sustain life
Continuing weight loss
Dehydration of hypovolemia
Absence of artificial feeding methods

OR

B. Life-threatening complications as demonstrated by one or more of the following in the preceding twelve (12) months:

Recurrent aspiration pneumonia (with or without tube feedings)
Upper urinary tract infection (pyelonephritis)
Sepsis
Recurrent fever after antibiotic therapy
Stage 3 or stage 4 decubitus ulcer(s)

In the absence of one or more of these findings, rapid decline or co-morbidities may also support eligibility for hospice care.

Pulmonary Disease

1 and 2 should be present; 3, 4 and 5 lend supporting documentation

1. Does the patient have severe chronic lung disease?

If Yes, both A and B must be present:

A. Disabling Dyspnea as evidenced by:

Symptoms

Dyspnea at rest
House-bound, chair-bound
Oxygen dependent
Copious/purulent sputum
Recurrent infections
Severe cough
Poor response to bronchodilators
Forced expiratory volume in one second (FEV1) after bronchodilator; < 30% of predicted*

Signs

Cyanosis: blue fingertips/lips
Pulmonary hyperinflation: barrel-chested
Pursed-lip breathing
Accessory muscles of respiration
Retractions: supraclavicular
Increased expiratory phase: slowed, forced expiration
Liver
Diminished breath sounds
Depressed diaphragm

B. Progression of end-stage Pulmonary Disease as evidenced by: (Check all that apply):

Increased visits to Emergency Room or hospitalizations for pulmonary infections/respiratory failure or increased physician home visits
Decrease in FEV1 on serial testing of > 40 ml/year*

2. Hypoxemia at rest on room air as evidenced by:

pO2, ≤ 55 mm Hg on supplemental O2
O2 saturation ≤ 88% on supplemental O2 (through blood gas reports or O2 sat monitors)
Hypercapnia, as evidenced by pCO2 ≥ 50 mg Hg (within past 3 months)

3. Presence of corpulmonale or right heart failure due to lung disease

4. Unintentional weight loss > 10% of body weight in past 6 months

5. Resting tachycardia (heart rate > per minute)

* These tests are helpful evidence but should not be required if not readily available.

Renal Disease

1 and 2 should be present; 3, 4 and 5 lend supporting documentation

1. Patient is not seeking dialysis or renal transplant or is discontinuing dialysis

2. Laboratory criteria for renal failure (one of the following should be present):

Creatinine clearance of
O2 saSerum creatinine >8.0 mg/dl (>6.0 mg/dl for diabetics)turation ≤ 88% on supplemental O2 (through blood gas reports or O2 sat monitors)
Note: Creatinine clearance may be estimated by using the following formula: Creatinine clearance = (140 – age in years)(body wt. in KG)/72) (serum creatinine in ml/dl) Multiply by 0.85 for women

3. Clinical signs and symptoms associated with renal failure. (Check all which are present):

Uremia: clinical signs of renal failure:
- Confusion, obtundation
- Intractable nausea and vomiting
- Generalized purities
- Restlessness; “restless legs”
Oliguria: urine output < 400 cc/24 hours
Intractable hyperkalemia: persistent serum potassium > 7.0 not responsive to medical management
Uremic pericarditis
Hepatorenal syndrome
Intractable fluid overload, not responsive to treatment

4. Comorbid conditions predict early mortality (Check all that apply):

Mechanical ventilation
Malignancy – other organ system
Chronic lung disease
Advanced cardiac disease
Advanced liver disease
Sepsis
Immunosupression/AIDS
Albumen < 3.5 gm/dl
Cachexia
IPlatelet count < 25,000
Age > 75
Disseminated intravascular coagulation
GI bleeding

Stroke

Indications Determining Eligibility for Medicare Hospice Benefit – All following items must be present:

1. <40% decline in Karnofsky Performance Status:

Mechanical ventilation
40 = severely disabled; dependent; requires special care and assistance
30 = severely disabled; hospitalized; death not imminent
20 = very sick; active supportive treatment needed
10 = moribund; fatal processes rapidly progressing

2. Inability to maintain hydration and caloric intake with one of the resulting issues:

Weight loss >10% in the last 6 months or >7.5% in the last 3 months
Serum albumin
Current history of pulmonary aspiration not responsive to speech language pathology intervention
Sequential calorie counts documenting inadequate caloric/fluid intake
Dysphagia severe enough to prevent the patient from receiving food and fluids necessary to sustain life – in a patient who declines or does not receive artificial nutrition and hydration.

Documentation to support eligibility for hospice care:

Non-traumatic hemorrhagic stroke documentation of diagnostic imaging factors which support poor prognosis include:
large-volume hemorrhage on CT:
- A. infratentorial: 20 ml.
- B. supratentorial: 50 ml.
ventricular extension of hemorrhage
surface area of involvement of hemorrhage 30% of cerebrum
midline shift 1.5 cm.

Thrombotic/embolic stroke documentation of diagnostic imaging factors which support poor prognosis include:

large anterior infarcts with both cortical and subcortical involvement
large bihemispheric infarcts
basilar artery occlusion
bilateral vertebral artery occlusion