Hospice Eligibility

These changes in clinical variables are listed in order of their likelihood to predict poor survival, the most predictive first and the least predictive last. No specific number of variables must be met, but fewer of those listed first (more predictive) and more of those listed last (least predictive) would be expected to predict longevity of six months or less.

Progression of disease as documented by worsening clinical status, symptoms, signs and laboratory results

Clinical Status

Recurrent or intractable infections such as pneumonia, sepsis or upper urinary tract.

Progressive inanition as 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.

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.

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

Laboratory

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

Decline in Karnofsky Performance Status (KPS) or Palliative Performance Score (PPS) from <70% due to progression of disease.

Increasing emergency room visits, hospitalizations, or physician’s visits related to hospice primary diagnosis

Progressive decline in Functional Assessment Staging (FAST) for dementia (from ≥7A on the FAST)

Progression to dependence on assistance with additional activities of daily living

Progressive stage 3-4 pressure ulcers in spite of optimal care

Physiologic impairment of functional status as demonstrated by declining Karnofsky Performance Status (KPS) Palliative Performance Score (PPS)

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

• Feeding

• Ambulation

• Continence

• Transfer

• Bathing

• Dressing

Note: The word “should” in the disease specific guidelines means that on medical review the guideline so identified will be given great weight in making a coverage determination. It does not mean, however, that meeting the guideline is obligatory.

Although not the primary hospice diagnosis, the presence of disease such as the following, 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

Disease with distant metastases at presentation OR

Progression from an earlier stage of disease to metastatic disease with either:

1. a continued decline in spite of therapy

2. patient declines further disease directed therapy

Note: Certain cancers with poor prognoses (e.g. small cell lung cancer, brain cancer and pancreatic cancer) may be hospice eligible without fulfilling the other criteria in this section.

Patients tend to have a constant overall rate of decline, whether rapid or slow:

Critically Impaired Breathing Capacity occurring over the past 12 months with all of the following:

a. Dyspnea at rest

b. Supplemental O2 at rest

c. No ventilator or ventilator only for comfort. A vital capacity < 30% is supportive, if available or

Rapid Progression and Critical Nutritional Impairment with all of the following in the past 12 months:

a. Bed-bound

b. Barely or unintelligible speech

c. Pureed diet

d. Major assist in all ADLs

e. Insufficient oral intake

f. Continuing weight loss

g. Absence of artificial feeding methods, except to relieve hunger

Rapid Progression and Life Threatening Complications with one of the following in the past 12 months:

a. Recurrent aspiration pneumonia

b. Upper UTI

c. Sepsis

d. Recurrent fever in spite of antibiotics

e. Stage 3/4 decubitus ulcers

Dependent in 3/6 ADLs

Urinary or fecal incontinence (intermittent or constant)

FAST 7A- Unable to speak limited to approximately ≤ 6 intelligible different words in an average day or in the course of an intensive interview.

One of the following in the past 12 Months:

a. Aspiration pneumonia

b. UTI

c. Septicemia

d. Stage 3/4 decubitus ulcers

e. Recurrent fever on antibiotics

f. Weight loss > 10% in past six months/ albumin < 3.0

The FAST scale is used to determine the functional and mental status of a patient with Alzheimer’s. To be hospice appropriate, a patient with Alzheimer’s Disease or related disorders must have a FAST of 7A or greater. The presence of co-morbid conditions (Heart disease, Diabetes, COPD, CVA, etc.) will support eligibility.

Functional Assessment Staging Scale (FAST)

No difficulty either subjectively or objectively

Complains of forgetting location of objects. Subjective work difficulties

Decreased job functioning evident to co-workers. Difficulty in traveling to new locations, Decreased organizational capacity

Decreased ability to perform complex tasks (planning dinner for guests, handling personal finances, forgetting to pay bills)

Requires assistance in choosing proper clothing to wear for the day, season or occasion, (e.g. pt may wear the same clothing repeatedly)

Occasionally or more frequently over the past few weeks:

a. Improperly putting on clothes without assistance or cueing

b. Unable to bathe properly (not able to choose proper water temp)

c. Inability to handle mechanics of toileting (e.g., forget to flush the toilet, does not wipe properly or properly dispose of toilet tissue)

d. Urinary incontinence

e. Fecal incontinence

a. Unable to speak limited to approximately ≤ 6 intelligible different words in an average day or in the course of an intensive interview.

b. Speech is limited to the use of a single intelligible word in an average day or in the course of an intensive interview

c. Ambulatory ability is lost (cannot walk without personal assistance or the use of assistive devices)

d. Cannot sit up without assistance (e.g., the individual will fall over if there are not lateral rests [arms] on the chair.)

e. Loss of ability to smile.

f. Loss of ability to hold up head independently

The medical criteria listed below would support a terminal prognosis for individuals with a diagnosis of stroke. Medical criteria 1 and 2 are important indicators of functional and nutritional status respectively, and would thus support a terminal prognosis if met.

PPS equal to or less than 40%

Inability to maintain hydration and caloric intake with one of the following:

a. Weight loss greater than 10% during the previous 6 months or 7.5% in the last 3 months

b. Serum albumin less than 2.5

c. Current history of pulmonary aspiration not responsive to speech therapy intervention

d. Dysphagia that prevents the patient from receiving adequate food and fluid necessary to sustain life in a patient who does not receive artificial nutrition or hydration

e. Sequential caloric counts documenting inadequate calorie and fluid intake

Supportive documentation:

• Aspiration pneumonia

• UTIdfd

• Sepsis

• Decubitus ulcers stage 3-4

• Recurrent fever despite antibiotics

The medical criteria listed below would support a terminal prognosis for individuals with a diagnosis of coma (any etiology):

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

 Abnormal brain stem response

Absent verbal response

Absent withdrawal response to pain

The medical criteria listed below would support a terminal prognosis for individuals with a diagnosis of heart disease. Medical criteria 1 and 2 are important indications of the severity of heart disease and would thus support a terminal prognosis if met:

1. Optimally treated with diuretics, vasodilators, ace inhibitors. If not explain why (hypotension or renal disease) OR Patient is either not a candidate for or declines surgical procedures AND
2. Class IV of NYHA (Physical activity causes discomfort, symptoms are present at rest)

Supportive documentation:

• Orthopnea

• Paroxysmal nocturnal dyspn

• Dependent pitting edema

• Syncope

• Weakness

• Chest pain

• Diaphoresis

• Cachexia

• Jugular vein distention

• Rales

• Liver Enlargement

• History of cardiac arrest or resuscitation

• Arrhythmias

• Brain embolism from cardiac origin (CVA)

• Significant congestive heart failure may be documented by an ejection fraction of ≤20%, but is not required if not available.

Patients will be considered to be in the terminal stage of pulmonary disease (life expectancy of six months or less) if they meet the following criteria.

1. Dyspnea at Rest and Minimal Exercise Tolerance (with FEV1 < 30% if available) AND
2. Progression of Disease with Increased ER Visits, Hospitalizations or MD Home Visits (documented serial decrease in FEV1 40 ml/year if available) AND
3. PO2 < 55 mm Hg ON ROOM AIR or O2 SAT < 88 ON O2 or Pco2 > 50 mm Hg

Supportive documentation:

• Cor pulmonale

• Weight loss, 10% in past six months

• HR > 100/min at rest

Patients will be considered to be in the terminal stage of liver disease (life expectancy of six months or less) if they meet the following criteria:

1. PT > 5 sec. over control or INR 1.5 and albumin < 2.5
2. One of the following:

a. Refractory ascites or non-compliance

b. Spontaneous bacterial peritonitis

c. Hepato-renal syndrome

d. Refractory encephalopathy or non-compliance

e. Recurrent esophageal variceal bleeding despite treatment

Supportive documentation:

• Weight loss > 10%

• Muscle wasting/loss of strength

• Continued alcohol consumption

• Hepatocellular cancer

• HBsAg positive

• Hepatitis C refractory to treatment

Patients will be considered to be in the terminal stage of renal disease (life expectancy of six months or less) if they meet the following criteria.

Acute renal failure

1. The patient is not seeking dialysis or renal transplant
2. Creatinine clearance
3. Serum creatinine >8.0 mg/dl (>6.9 mg/dl for diabetes)

Supportive documentation

• Mechanical ventilation

• Malignancy (other organ system)

• Chronic lung disease

• Advanced cardiac disease

• Advanced liver disease

• Sepsis

• Immunosuppression/AIDS

• Albumin

• Cachexia

• Platelet count <25,000

• Disseminated intravascular coagulation

• Gastrointestinal bleeding

Chronic renal failure

1. The patient is not seeking dialysis or renal transplant
2. Creatinine clearance
3. Serum creatinine >8.0 mg/dl (>6.9 mg/dl for diabetes)

Supportive documentation

• Uremia

• Oliguria (

• Intractable hyperkalemia (>7.0) not responsive to treatment

• Uremic pericarditis

• Hepatorenal syndrome

• Intractable fluid overload, not responsive to treatment

Patients will be considered to be in the terminal stage the illness (life expectancy of six months or less) if they meet the following criteria (1 and 2 must be present)

1. Decreased performance status, as measured by the PPS scale, of greater than or equal to 50%
2. Viral load > 100,000 copies/ml AND/OR
3. CD4 < 25 cells/mm with functional status mainly sitting/lying plus progressive disease (HIV dementia, 10% weight loss in 6 months, opportunistic infections, HIV-related cancer)

Supportive documentation

• Chronic persistent diarrhea for one year

• Persistent serum albumin <2.5

• Concomitant, active substance abuse

• Age >50 years

• Absence of antiretroviral, chemotherapeutic and prophylactic drug therapy

• Advance AIDS dementia complex

• Toxoplasmosis

• Congestive heart failure

Observable and documented deterioration in overall clinical condition in the past 6 months as evidenced by any of the following:

1. Multiple physician assessments documenting deterioration
2. Multiple hospital/ER visits
3. Progressive decubitus ulcers
4. Decline in functioning status with a PPS of less than 40%
5. Systolic BP less than 90
6. Progressive dependence of ADLs
7. Persistent nausea and vomiting
8. Recent impaired nutritional status
9. Progressive weight loss
10. Decreasing serum albumin—less than 3.0
11. Malnutrition with declining BMI
12. Requires oxygen at rest
13. Declines artificial ventilation
14. A combination of disease processes which, when reviewed together, present a picture of structural and functional impairment.