Hospice Criteria Checklist

Identify the condition that is the main contributor to the person's terminal prognosis. Non-specific diagnoses such as Debility or Adult Failure to Thrive (AFTT) may no longer be listed as a principal terminal diagnosis. Debility and AFTT can & should be listed as secondary (related) conditions to support prognosis if indicated.

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HEART DISEASE: The patient has 1 & 2 or 3

1) CHF with NYHA Class IV symptoms and both:

1a) Significant symptoms at rest

1b) Inability to carry out minimal physical activity without dysonea or angina

2) Patient is optimally treated (i.e. diuretics, vasodilators, ACEI or hydralazine and nitrates)

3) Patient has angina pectoris at rest, resistant to standard nitrate therapy and is either not a candidate for/or has declined invasive procedures

Supporting Documentation for HEART DISEASE includes:

EF less than or equal to 20%

Treatment resistant symptomatic dysrhythmias h/o cardiac related syncope

CVA 2/2 cardiac embolism h/o cardiac resuscitation

Contaminant HIV disease

LIVER DISEASE: The patient has both 1 & 2

1) End-stage liver disease as demonstrated by A or B & C:

1a) PT>5 sec.

1b) INR>1.5 AND

1c) Serum albumin <2.5gm/dl

2) One or more of the following conditions: Refractory Ascites, h/o spontaneous bacterial peritonitis, Hepatorenal syndrome, refractory hepatic encephalopathy, h/o recurrent variceal bleeding.

Supporting documentation for LIVER DISEASE includes:

Progressive malnutrition

Muscle wasting with decreased strength

Ongoing alcoholism (>80gm ethanol/day)

Hepatocellular CA HBsAg positive

Hep. C refractory to treatment

PULMONARY DISEASE: Severe chronic lung disease as documented by 1-3

1) The patient has all of the following:

1a) Disabling dyspnea at rest

1b) Little or no response to bronchodilators

1c) Decreased functional capacity

2) Progression of disease as evidence by a recent h/o increasing office, home or ED visits and/or hospitalizations for pulmonary infection and/or respiratory failure.

3) Documentation within the last 3 months ≥ 1:

3a) Hypoxemia at rest on room air (p02 < 55mmHg by ABG)

3b) Oxygen saturation 50mmHg

Supporting documentation for PULMONARY DISEASE includes:

Cor Pulmonale and right heart failure

Unintentional, progressive weight loss

RENAL FAILURE: The patient has 1, 2 & 3

1) Patient is not seeking dialysis or renal transplant

2) Creatinine clearance is <10cc/min (<15 for diabetics)

3) Serum creatinine >8.0mg/dl (>6.0mg/dl for diabetics)

Supporting documentation for CHRONIC RENAL FAILURE:

Uremia

Oliguria (urine output <400cc in 24 hours)

Intractable Hyperkalemia

Uremic Pericarditis

Hepatorenal Syndrome

Intractable Fluid Overload

Supporting documentation for ACUTE RENAL FAILURE:

Mechanical ventilation

Malignancy (other organ system)

Chronic Lung Disease

Advanced Cardiac Disease

CANCER: Patient meets ALL of the below:

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

Palliative Performance Scale (PPS) ≤70%

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

Supporting documentation for CANCER includes:

Hypercalcemia >12

Cachexia or weight loss of 5% in the past 3 months

Recurrent disease after surgery/radiation/chemotherapy

Signs and sx of advance disease (ex. nausea, requirement for transfusions, malignant ascites or pleural effusion, etc.)

STROKE or COMA: Patient has both 1 & 2

1) Poor functional status PPS ≤ 40%

2) Poor nutritional status with inability to maintain sufficient fluid and calorie intake with ≥ one of the following:

2a) ≥ 10% weight loss in the past 6 months

2b) ≥ 7.5% weight loss in the past 3 months

2c) Serum albumin < 2.5gm/dl

Current history of pulmonary aspiration without effective response to speech therapy interventions to improve dysphagia and decrease aspiration events.

Supporting documentation for STROKE or COMA:

Coma (any etiology) with 3 of the following on the 3rd day of the coma:

a) Abnormal brain stem response

b) Absent verbal response

c) Absent withdrawal response to pain

d) Serum creatinine > 1.5gm/dl

NEUROLOGIC DISEASE: Patient must meet at least one of the following criteria (1 or 2A or 2B):

1) Critically impaired breathing capacity with all:

- Dyspnea at rest

- Vital capacity < 30%

- Need O2 at rest

- Patient refuses artificial ventilation

2) Rapid disease progression with either A or B below: Progression from:

- Independent ambulation to wheelchair of bedbound status

- Normal to barely intelligible or unintelligible speech

- Normal to pureed diet

- Independence in most ADLs to needing major assistance in all ADLs

2A) Critical nutritional impairment demonstrated by ALL of the following in the preceding 12 months:

- Oral intake of nutrients and fluids insufficient to sustain life

- Continuing weight loss

- Dehydration or hypovolemia

- Absence of artificial feeding methods

2B) Life-threatening complications in the past 12 months as demonstrated by ≥ 1:

- Recurrent aspiration pneumonia

- Pyelonephritis

- Spesis

- Recurrent fever

- Stage 3 or 4 pressure ulcer(s)

(Criteria are very similar for chronic degenerative conditions such as ALS, Parkinson's, Muscular Dystrophy, Myasthenia, Gravis or Multiple Sclerosis)

TERMINAL ILLNESS: GENERAL (NON-SPECIFIC):

a) Terminal condition not attributed to a single, specific illness AND

b) Rapid decline as of the past 3-6 months as evidence by:

- Progression of disease as evidence by sx, signs and test results

- Decline in PPS to ≤ 50%

- Involuntary weight loss > 10% and/or Albumin < 2.5

ADDITIONAL COMMENTS: