FOR CLINICIANS

Diagnosis-based guidelines for Medicare eligibility

HOSPICE REFERENCE GUIDELINES

NOTE: In situations of co-morbidities and/or rapid decline, patients may be hospice-appropriate even without meeting the diagnosis criteria listed below. The presence of two or more conditions within a given diagnosis warrants a hospice consultation.

  • General Guidelines – All Diagnoses
General Guidelines – All Diagnoses
  • Life-limiting condition(s) /progression of disease(s)
  • Karnofsky score 50%
  • Dependence in 3 of 6 ADLs
  • Weight loss > 10% over past 6 months
  • Serum albumin ≤ 2.5
  • BMI < 22kg/m2
  • End-stage Heart Disease
End-stage Heart Disease
  • Functional Class IV NYHA Assessment
  • Symptomatic despite optimal diuretic and vasodilator therapy
  • Arrhythmia resistant to treatment
  • Ejection fraction ≤ 20%
  • History of cardiac arrest
  • Cardiogenic embolic disease (e.g. CVA)
  • End-stage Lung Disease
End-stage Lung Disease
  • Disabling dyspnea at rest or unresponsive to bronchodilators
  • Progression of pulmonary disease resulting in recurring infections or respiratory failure
  • Hypoxemia at rest on room air. 02 sats. < 88% or P02. < 55 mmHg FEV 1 < 30% after bronchodilator
  • Right heart failure due to lung disease
  • Resting tachycardia
  • Cancer
Cancer

NOTE: Both criteria 1 & 2 as well as either 3 or 4 must be present for hospice eligibility. However, certain cancer patients with poor prognoses may be hospice eligible without fulfilling any of these criteria.

  1. Palliative Performance Scale 70%
  2. Dependence in 2 or more ADLs
  3. Pathology report indicates evidence of malignancy or metastases
  4. Progression from earlier stage of disease to metastatic disease with either of the following:
    • Continued decline despite therapy
    • Patient refuses further disease-directed therapy
  • End-stage Renal Disease
End-stage Renal Disease
  • Not a candidate for dialysis or renal transplant
  • Creatine clearance < 10cc/min serum, creatine > 6.0 mg/dl
  • Signs of uremia (confusion, nausea, pruritus, restlessness)
  • Urine output < 400 cc/24 hrs.
  • Hyperkalemia > 7.0
  • End-stage Liver Disease
End-stage Liver Disease
  • Not a candidate for liver transplant
  • PTT > 5 seconds over control
  • Ascites despite maximum diuretics
  • Serum albumin < 2.5
  • Peritonitis spontaneous bacterial
  • Cirrhosis or ascites
  • Somnolence or coma
  • Recurrent variceal bleeding
  • End-stage Neurologic Disease/ALS
End-stage Neurologic Disease/ALS
  • Unable to walk; needs assistance in all ADLs
  • Barely intelligible or unintelligible speech
  • Significant dyspnea on 02
  • Nutritional status declining
  • Medical complications, e.g.: aspiration pneumonia, UTI, decubitus ulcers, recurrent fever
  • End-stage Dementia/Alzheimer’s
End-stage Dementia/Alzheimer’s
  • FAST score of 7 or below
  • Speech limited to 6 words or less
  • Unable to sit up, hold head up or smile
  • Incontinent
  • Requires assistance to dress. bathe and ambulate
  • Medical complications, e.g.: recurrent aspiration, pneumonia, UTI, sepsis, decubitus ulcers
  • CVA and Coma
CVA and Coma
  • Nutritional status declining due to dysphagia; not a candidate for feeding tube
  • Poor functional status PPS score < 40%
  • Medical complications e.g.: aspiration pneumonia, UTI, decubitus ulcers
  • Persistent vegetative state/comatose
  • HIV
HIV
  • CD4+ count 25 cells/rnc/L
  • Viral load < 100,000 copies/ml. Patient has elected to forego antiretroviral meds
  • Any of the following life-threatening complications:
    • CNS lymphoma
    • Wasting loss of 33% lean body mass
    • Renal failure
    • Persistent diarrhea & serum albumin < 2.5
    • Congestive heart failure

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