Healthcare Providers

• The patient has a life limiting condition with clinical progression of 6 months or less as determined by the patients attending physician and the hospice medical director
• Weight loss >10% over 6 months, serum albumin <2.5gm/dl Dependence in Activities of Daily Living
• The patient/designated decision maker and the attending physician, who orders hospice care, agrees with a plan of care for palliation and comfort care
• Increasing emergency room visits, hospitalizations, or physician visit related to the hospice diagnosis

• Disease with distant metastases at presentation; or
• 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

Supporting Criteria
Hypercalcemia > 12, cachexia or weight loss of 5% in past 3 months, recurrent disease after surgery/radiation/chemotherapy, signs and sx of advanced disease (e.g. nausea, requirement for transfusions, malignant ascites or pleural effusion, etc.)

• Stage 7 or beyond according to the Functional Assessment Staging Tool (FAST)
• Unable to ambulate without assistance
• Unable to complete ADLs without assistance
• Urinary and fecal incontinence; intermittent or constant
• No consistently meaningful verbal communication; stereotypical phrases only or the ability to speak is limited to six or fewer unintelligible words

Supporting Criteria
Aspiration pneumonia, urinary tract infection, septicemia, multiple decubitus ulcers (stage 3-4), recurrent Fever after antibiotics, serum albumin < 2.5 gm/dl

• Optimally treated with diuretics, vasodilators
• Discomfort with physical activities
• Presence of NYHA Class IV CHF or angina at rest

Supporting Criteria
Ejection fraction is less than 20%, arrhythmias resistant to treatment, history of cardia arrest or resuscitation, unexplained syncope, cardiogenic embolic stroke

• Prothrombin time prolonged more than 5 seconds or INR .1.5
• Serum albumin
• Ascites, refractory to treatment, spontaneous bacterial peritonitis, hepatorenal syndrome, hepatic encephalopathy, refractory to treatment recurrent variceal bleeding

Supporting Criteria
Progressive malnutrition, muscle wasting with reduced strength and endurance, active alcoholism, hepatic carcinoma, hepatitis C refractory to treatment, hepatitis B positivity

• Disabling dyspnea at rest
• Poor or unresponsive bronchodilators
• Progression of disease as evidenced by increasing ED visits, hospitalizations, pulmonary infections or respiratory failure
• Oxygen saturation <88% room air, or PO250mmhg (ABG)

Supporting Criteria
Cor pulmonale, weight loss of greater than 10% of body weight over the preceding 6 months

• The patient is not seeking dialysis or renal transplant
• Serum creatinine > 8.0 mg/dl (> 6.0 mg/dl for diabetics)

Supporting Criteria
Uremia, Serum K>7.0 not responding to treatment, Oliguria 400cc/24 hours, Hepatorenal syndrome, Sepsis, Fluid overload, Nausea, uremia, puritis, sedation, confusion, restlessness, uremic pericarditis

• Coma or persistent vegetative state secondary to stroke, beyond 3 days
• Post anoxic stroke-coma obtundation with myoclonus more than 3 days
• Dysphagia severe enough to prevent the patient from receiving food and fluids to sustain life

Chronic-Phase
Karnofsky score <50%

• Post stroke dementia-unable to do ADLs without assistance
• Poor nutritional states, whether artificial or not; weight loss greater than 10% over 6 months; serum albumin <2.5gm/dl

Supporting Criteria
Medical complications related to debility and progressive clinical decline, aspiration, pneumonia, pyelonephritis, sepsis, refractory stage 3-4 decubitus ulcers, fever recurrent after antibiotics. Documentation of various diagnostic imaging factors which support poor prognosis after stroke.

(chronic degenerative conditions such as ALS, Parkinson’s, Muscular Dystrophy, Myasthenia Gravis or Multiple Sclerosis)

• Significant dyspnea at rest (requiring supplemental oxygen at rest)
• Critical nutritional impairment, rapid disease progression over previous 12 months, wheelchair or bed bound, barely intelligible or unintelligible speech, pureed diet, major assist with ADLs, continued weight loss, insufficient intake, dehydration or hypovolemic
• Life-threatening complications, aspiration pneumonia, urinary tract infection, sepsis, recurrent fever after antibiotic therapy