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Eligibility

Hospice is provided to patients who have a terminal illness. Below oare the medical requirements to cover hospice:

  1. Physician's order
  2. Estimate of six months or less to live if the disease follows its normal progression
  3. Patient must agree to palliative care for the terminal diagnosis rather than curative care

GENERAL CONSIDERATIONS MEDICAL PROFESSIONALS USE TO DETERMINE THE NEED FOR HOSPICE:

  • The patient has a life-limiting condition
  • The patient and family have been informed the condition is life-limiting
  • There is documentation of clinical progression of the disease
  • There is a recent decline in functional status

VNA HOSPICE CARE GENERAL GUIDELINES

Life-limiting conditions; prognosis < 6 months if the disease follows its normal progression

Progressive difficulty in many ADLs (a critical factor in determining prognosis)*

Weight loss > 10% over past 6 months (one of the most critical indicators in the elderly)*

Patients of any age with a BMI < 20kg/m2 who are ill enough to be hospitalized, regardless of diagnosis, have significant morbidity within 6 months

Progression of disease(s)
- Need for frequent medical care

Serum Albumin < 2.5 g/dl

Cholesterol < 156 mg/dl

HCT < 41%

Two or more comorbid conditions

Family desires palliative care only

AIDS / HIV

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 ≤ 50*

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

Amyotrophic Lateral Sclerosis (ALS)

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 O2 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

    • Rapid progression, see 2 above
    • Life-threatening complications
      1. Recurrent aspiration pneumonia
      2. URIs/pyelonephritis
      3. Sepsis
      4. Recurrent fever after antibiotic therapy

Exam by neurologist within 3 months of hospice evaluation

Cancer

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

Signs of advanced disease (e.g., nausea, requirement for transfusions, malignant ascites or pleural effusion, etc.)

CVA and Coma

Acute Phase
Had at least one of the following:*

  1. Myoclonus and/or persistent vegetative state persists 3 days post anoxic event
  2. Decreased level of consciousness or coma which = 3 of the following:

    • 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
  2. Post CVA dementia

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

End-Stage Dementia / Alzheimer's

Multi-Infarct

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

End-Stage Heart Disease

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

End-Stage Liver Disease

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 diureticsc
  2. Peritonitis
  3.  
  4. Hepatorenal syndrome
  5.  
  6. Encephalopathy with asterixis, somnolence, coma
  7.  
  8. Recurrent variceal bleeding
  9.  

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

End-Stage Lung Disease

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

End-Stage Parkinson's Disease

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 evaluation

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

End-Stage Renal Disease

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

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