VNA Hospice Care

• Life-limiting conditions; prognosis < 6 months if the disease follows its normal progression
• Progressive difficulty in many ADLs (a critical factor in determining prognosis)
• Progression of disease(s) – Need for frequent medical care, hospitalization

• Patients of any age with a BMI < 20 kg/m2 who are ill enough to be hospitalized, regardless of diagnosis, have significant morbidity within 6 months
• Weight loss > 10% over past 6 months (one of the most critical indicators in the elderly)
• Serum albumin < 2.5 g/dl
• Cholesterol < 156 mg/dl
• HCT < 41%
• Two or more comorbid conditions
• Family desires palliative care only
• No longer pursuing aggressive medical treatment

• CD4 < 25/mcl or viral load > 100,000/ml plus 1 of the following:
  1. Weight loss of at least 33% of lean body mass (wasting syndrome)
  2. CNS or systemic lymphoma, unresponsive to treatment
  3. PML (progressive multifocal leukoencephalopathy)
  4. Cryptosporidiosis
  5. MAC (mycobacterium avium complex)
  6. Visceral Kaposi’s Sarcoma, unresponsive to treatment
  7. Renal failure without anticipated dialysis
• Karnofsky Performance Scale 5

• Chronic diarrhea > 1 year
• Persistent serum albumin < 2.5 g/dl
• Advanced AIDS dementia complex
• CHF, symptomatic at rest
• Current substance abuse
• Age > 50
• Absence of antiretroviral, chemotherapeutic, or prophylactic drug therapy specifically for HIV disease

• Progression differs markedly from patient to patient
• The two factors most critical to survival (and prognosis) are ability to breathe, and to a lesser extent, the ability to swallow
• At least one of the following:
  1. Critically impaired breathing capacity- VC < 30% of predicted
     – Dyspnea at rest
     – Requires supplemental oxygen at rest
     – Declines ventilator
  2. Rapid progression of ALS- Wheelchair or bed-bound
     – Barely intelligible speech
     – Requires pureed or liquid diet
     – Requires assistance with all ADLs
  3. Critical nutritional impairment- Oral intake of nutrients and fluids insufficient to sustain life
     – Dehydration or hypovolemia
     – Progressive weight loss
     – Declines feeding tube
  4. Both rapid progression of ALS and life-threatening complications- Life-threatening complications
     a. Recurrent aspiration pneumonia
     b. UTIs/pyelonephritis
     c. Sepsis
     d. Recurrent fever after antibiotic therapy

• Exam by neurologist within 3 months of hospice evaluation

• Certain cancer diagnoses with poor prognosis may be hospice eligible without fulfilling other criteria
  1. Small Cell Lung Cancer
  2. Brain Cancer
  3. Pancreatic Cancer

Other Criteria:

• Patient meets ALL of the following:
  1. Clinical findings of malignany with widespread, aggressive or progressive disease as evidenced by increasing symptoms, worsening lab values and/or evidence of metastatic disease
  2. Palliative Performance Scale (PPS) < 70%
  3. Refuses further life-prolonging therapy or continues to decline in spite of definitive therapy
  4. Karnofsky < 70%

Documentation includes:

• Hypercalcemia > 12 mg/dL
• Cachexia or weight loss of 5% in the past 3 months
• Recurrent disease after surgery, radiation or chemotherapy
• Tissue diagnosis or reason why tissue diagnosis is not available
• Signs of advanced disease (e.g., nausea, requirement for transfusions, malignant ascites or pleural effusion, increased pain, etc.)

Acute Phase

• Had at least one of the following:
  1. Myoclonus and/or persistent vegetative state persists 3 days post anoxic event– Abnormal brain stem response
     – Absent speech or meaningful verbal response
     – 6 intelligible words in 24 hours
     – Absent pain response
     – Serum creatinine > 1.5 mg/dl
     – Bed-bound, unable to care for self

Chronic Phase
Both of the following or documentation of severe comorbidities and rapid decline:

• FAST Scale ≥ Stage 7 or Karnofsky ≤ 40
  1. Dependence in most ADLs, paralysis, incontinence, aphasia
• Inability to maintain hydration and nutrition
  1. Decreased nutritional status despite tube feeding, if present
  2. Weight loss > 7.5% in past 3 months
  3. Serum albumin < 2.5 g/dl
  4. Current history of pulmonary aspiration without effective response to speech therapy

• Increased medical complications
• Diagnostic imaging supports poor prognosis

• Functional Assessment Staging Scale 7 (does not affect the impact of comorbid conditions)
• Unable to walk, bathe, dress without assistance
• Dual incontinence
• Speaks 6 spontaneous words/day
• Had at least one of the following in the past 12 months:
  1. Medical complications (aspiration pneumonia or other URI, UTI, sepsis, Multiple Stage 3-4 decubiti)
  2. Dysphagia
  3. Poor nutritional status (despite tube feedings, if present)
  4. Fever, recurrent after antibiotics

• Weight loss > 10% during previous 6 months

• NYHA Class IV:
  1. Symptomatic at rest despite maximum therapy and not pursuing therapy
  2. Angina at rest
  3. Ejection fraction < 20%
• Recurrent CHF and/or angina

• Increased discomfort with minimal activity
• Arrhythmias resistant to treatment
• History of cardiac arrest
• Cardiogenic embolic CVA
• Concomitant HIV disease
• Hx unexplained syncope
• Oxygen dependent

• PTT > 5 sec above control or PT/INR > 1.5 sec
• Serum albumin < 2.5 g/dl
• One or more of the following:
  1. Ascites despite optimum diuretics
  2. Peritonitis
  3. Hepatorenal syndrome
  4. Encephalopathy with asterixis, somnolence, coma
  5. Recurrent variceal bleeding

• Liver transplant either not anticipated or would discharge from hospice if it is scheduled
• Progressive malnutrition, muscle wasting, reduced strength and endurance
• Active ETOH abuse
• Hepatocellular carcinoma
• + for Hepatitis B
• Hepatitis C refractory to treatment

• Disabling dyspnea at rest, unresponsive to bronchodilators
• Recurrent pulmonary infections and/or respiratory failure
• Frequent ER visits, hospitalizations
• pO2 < 55 mg Hg or O2 sat < 88% on O2 or pCO2 50 mm Hg

• FEV 1 < 30% after bronchodilators
• Cor Pulmonale/right heart failure not secondary to left heart failure
• Weight loss > 10% in 6 months
• Resting tachycardia > 100/min
• Age > 70

• Progression differs markedly from patient to patient
• Severely impaired breathing capacity such as:
  1. Dsypnea at rest
  2. Requires supplemental oxygen at rest
  3. The patient declines artificial ventilation
• Rapid disease progression and (one of the below):
  1. Progression from independent ambulation to w/ chair or bed-bound
  2. Severe muscle weakness affecting speech, chewing or swallowing
  3. Progression from independence in most or all ADLs to needing major assistance
• Severe nutritional impairment evidenced by:
  1. Weight loss > 10%
  2. Dehydration or hypovolemia
  3. No desire to implement artificial feedings
  4. Poor nutritional status (despite tube feedings, if present)

• Life-threatening complications demonstrated by one or more of the following:
  1. Recurrent aspiration pneumonia
  2. Upper UTI
  3. Sepsis
  4. Recurrent fever after antibiotic therapy

• Exam by neurologist within 3-6 months of hospice evaluationIn the absence of one or more of the above findings, rapid decline or comorbidities may also support eligibility for hospice care.

• Creatinine clearance < 10 cc/min (< 15 cc/min if diabetic)
• Creatinine > 8 mg/dl ( > 6 mg/dl if diabetic)
• Not seeking dialysis or renal transplant

• Signs of uremia (confusion, nausea, pruritus, restlessness, pericarditis)
• Oliguria < 400 cc / 24 hrs
• Uremic pancreatitis
• Hepatorenal syndrome
• Hyperkalemia > 7 mEq/L
• Intractable fluid overload, not responsive to treatment
• Weight loss
• Decline in ADLs