1.  AMYOTROPHIC LATERAL SCLEROSIS (ALS)

Critically impaired breathing capacity, meaning ALL of:

Vital capacity less than 30% of normal

Shortness of breath at rest

Needs supplemental oxygen at rest

Declines artificial ventilation; external ventilation used for comfort only

OR

Rapid ALS progression and critical nutritional impairment, ALL of:

Independent walking to bed bound in the last 12 months

Normal to barely intelligible speech in last 12 months

Normal to puree diet in last 12 months

Independence in ADLs to major assistance in last 12 months

Oral intake of nutrients and fluids insufficient to sustain life

Continuing weight loss

Dehydration

Absence of artificial feeding methods, sufficient to sustain life but not for relieving hunger

OR

Rapid ALS progression and life-threatening complications, ONE of:

Rapid progression per above

Recurrent aspiration pneumonia

Kidney infection

Sepsis (blood infection)

Recurrent fever after antibiotic therapy

2.  LIVER DISEASE

ALL OF:

Prothrombin time > 5 sec over control, or INR > 1.5, AND

Serum albumin < 2.5 mg%, AND

Ascites OR spontaneous bacterial peritonitis OR hepatorenal syndrome OR hepatic encephalopathy, OR variceal bleeding

Not required but lend weight to diagnosis:

- Progressive malnutrition
- Muscle wasting, reduced strength/endurance
- Continued active alcoholism (>80gm EtOH/d)
- Hepatocellular carcinoma
- HBsAg positive
- Hepatitis C refractive to interferon

 3.  HEART DISEASE

• HEART FAILURE DEFINITION:

There is an abnormality of heart structure (how the heart is built) or function (how the heart works). The heart therefore cannot fill with enough blood or send it to the body fast enough to meet the oxygen needs of the living tissues of the body.

• HEART DISEASE:
  • Patient already optimally treated, is not surgical candidate, or who has refused surgery
  • Has Class IV disease (means inability to do physical activity without discomfort – symptoms of heart failure-fatigue, SOB- or angina) 
  • Supportive findings (not required): treatment resistant symptomatic arrhythmia; history of cardiac arrest; unexplained syncope (passing out); brain embolism (clot); HIV disease.

4.   DEMENTIA

ALL of:

Stage 7 or more FAST score

Cannot walk without assistance

Cannot dress without assistance

Cannot bathe without assistance

Urinary & fecal incontinence (occ or constant)

No consistently meaningful verbal communication; stereotypical phrases only, or the ability to speak is limited to 6 or fewer intelligible words.     

SHOULD* have one of the following in past 12 months:

Aspiration pneumonia

Pyelonephritis or other upper UTI

Septicemia

Decubitus ulcers, multiple, stage 3-4

Fever, recurrent, after antibiotics

10% wt loss over 6 mo or albumin <2.5 mg%

NOTE: *SHOULD= “given great weight”, but not needed

FAST SCORE

Functional Assessment Staging (FAST)

• Check Highest Consecutive Level of Disability
• Hospice Appropriate if FAST score 6 or 7

*Occasionally or more frequently over the past weeks

1	No difficulty either subjectively or objectively.
2	Complains of forgetting location of objects Subjective work difficulties
3	Decreased job functioning evident to co-workers Difficulty in traveling to new locations Decreased organization capacity *
4	Decreased ability to perform complex tasks such as: * Planning dinner for guests Handling personal finances (e.g. forgetting to pay bills) Difficulty shopping, etc.
5	Requires assistance in choosing proper clothing to wear for the day, season or occasion* Repeatedly, observed wearing the same clothing, unless supervised
6	Improperly putting on clothes without assistance or cueing* (e.g. may put street clothes on overnight clothes, put shoes on wrong feet, have          difficulty buttoning clothing) Unable to bathe properly (e.g. difficulty adjusting bath – water temperature)* Unable to handle mechanics of toileting  Unable to handle mechanics of toileting (e.g. forgets to flush toilet, does not wipe properly or properly dispose of toilet tissue)* Urinary incontinence* Fecal incontinence*
7	Limited ability to speak < 6 intelligible different words in an average day or interview* Speech ability is limited to the use of a single intelligible word in a normal interaction. Repetitive actions. * Ambulatory ability lost (cannot walk without personal assistance) Cannot sit up without assistance Individual falls over if no lateral arm rests on chair* Loss of ability to smile* Loss of ability to hold up head independently*

5.   PULMONARY DISEASE

ALL OF:

• Disabling dyspnea at rest, poorly responsive to bronchodilators, decreased ability, ex “bed to chair existence”, fatigue, cough [FEV1<30% but don’t need to document]
• Increasing visits to ER or hospital for infection/failure
• Hypoxemia at rest –O2sat = or <88% on O2

Supporting documentation:

• Right heart failure secondary to pulmonary disease
• Unintentional weight loss >10% over 6 months
• Resting tachycardia >100/mi

6.  CANCER

• Karnofsky < 70% AND\
• Dependence on assistance for 2 or more ADLs: Feeding, Ambulation, Continence, Transfer, Bathing, Dressing AND
• Disease with distant metastases at presentation OR
• Metastatic disease with either continued decline despite therapy OR patient declines therapy  

CANCER – One More Note

Certain cancers with poor prognoses (for example small cell lung cancer, brain cancer and pancreatic cancer) may be hospice eligible without fulfilling the other criteria.

KARNOFSKY

Table 10. Karnofsky Performance Status Scale²⁴

Definition	% Score	Criteria
Able to carry on normal activity and work; no special care needed	100 90 80	Normal; no complaints; no evidence of disease Able to carry on normal activity; minor signs or symptoms of disease Normal activity with effort; some signs or symptoms of disease
Unable to work; able to live at home and care for most personal needs; varying amount of assistance needed	70 50	Able to care for self; unable to carry on normal activity or do active work Requires considerable assistance and frequent medical care
Unable to care for self; requires equivalent of institutional or hospital care; disease may be progressing rapidly	40 30 20 10    0	Disabled; requires special care and assistance Severely disabled; hospitalization indicated although death not imminent Very sick; hospital admission necessary; active supportive treatment necessary Moribund; fatal processes progressing rapidly Dead

Note: The National Hospice Study reported that, in the absence of treatment, the Karnofsky Performance Scale (KPS) is the best predictor of a patient’s length of survival.  Patients with a KPPS of 40 lived on average less than 50 days, while those with a KPS of 20 lived only 10-20 days. 25 Karnofsky DA, Albelman WH, Craver LP, Burchenal JH.  The Use of Nitrogen Mustards in the Palliative Treatment of Carcinoma.  Cancer, 1948; 1:634-656.  Reprinted with permission form Lippincott Williams and Wilkins.

7.  STROKE

• Karnofsky of 40% or less AND
• Inability to maintain hydration and caloric intake with one of the following:
  • Weight loss > 10% past 6 months or > 7.5% past 3 months OR
  • Albumin < 2.5 gm/dl OR
  • “Current history” of aspiration unresponsive to speech language pathology intervention OR
  • Sequential calorie counts showing inadequate calories/fluids OR
  • Dysphagia (difficulty swallowing) severe enough to prevent the patient from receiving food and fluids necessary to sustain life, in a patient who declines or does not receive artificial nutrition and hydration.

STROKE – Diagnostic Imaging Factors for Poor Prognosis

Non traumatic hemorrhagic stroke

Large volume hemorrhage on CT

Ventricular extension of hemorrhage

Surface area > or = 30% of cerebrum

Midline shift > or = 1.5 cm   

Obstructive hydrocephalus in-patient who declines OR is not candidate for ventriculoperitoneal shunt

Thromboembolic stroke

• Large anterior infarcts with both cortical and sub cortical involvement
• Large bihemispheric infarcts
• Basilar artery occlusion
• Basilar vertebral artery occlusion

8.  COMA

Comatose patient with any 3 of the following on day 3 of coma:

• Abnormal brain stem response
• Absent verbal response
• Absent withdrawal response to pain
• Serum creatinine > 1.5 mg/dl

Supportive of hospice care need in the past 12 months               

• Aspiration pneumonia
• Upper urinary tract infection (kidneys)
• Sepsis
• Refractory stage 3-4 decubitus ulcers
• Fever recurrent after antibiotics

9.  KIDNEY DISEASE

Acute = recent

Chronic = longstanding

KIDNEY FAILURE - ACUTE

• Patient not seeking dialysis or kidney transplant, or is discontinuing dialysis AND
• Creatinine clearance < 10 cc/min OR
• Creatinine > 8 mg/dl (less for diabetic

KIDNEY FAILURE – CHRONIC

• Patient not seeking dialysis or kidney transplant, or is discontinuing dialysis AND
• Creatinine clearance < 10 cc/min OR
• Creatinine > 8 mg/dl (less for diabetic)

“Co-morbid conditions”

Acute kidney failure: mechanical ventilation, malignancy, chronic lung disease, advanced cardiac disease, advanced liver disease, sepsis, immunosuppression, AIDS, albumin < 3.5 gm/dl, cachexia, platelet count < 25,000, DIC, GI bleed

Chronic kidney failure: uremia, oliguria (< 400 cc/24 hours), intractable hyperkalemia (>7) not responsive to treatment, uremic pericarditis, hepatorenal syndrome, and intractable fluid overload not responsive to treatment.

10.  HUMAN IMMUNODEFICIENCY VIRUS

 

HIV DISEASE:

• CD4+ Count of < 25 cells/mcl OR persistent viral load > 100,000 copies/ml AND one of the following: CNS lymphoma, wasting, MAC bacteremia, progressive multifocal leukoencephalopathy, systemic lymphoma, visceral Kaposi’s sarcoma, renal failure, Cryptosporidium infection, unresponsive Toxoplasmosis, Karnofsky of 50% or less

• Supportive: persistent diarrhea for 1 year; persistent albumin <2.5; active substance abuse; > 50 years old; not taking or resistant to antiretrovirals; advanced AIDS dementia; toxoplasmosis; CHF symptomatic at rest; advanced liver disease

 

11.  DECLINE IN CLINICAL STATUS

Last but Important Category – for Patients Who Are Ill and Failing But Who Don’t Meet a Specific Disease.

 

Life expectancy of 6 months or less is likely if guidelines below met.

Decline is not considered reversible

Criteria listed in order of likelihood to predict poor survival (most likely first)

No specific number of variables must be met

 

CATEGORIES:

• Progression of Disease
  • Clinical Status
  • Symptoms
  • Signs
  • Laboratory
• Decline in Kanjorski
• Increasing Medical Visits
• Decline in FAST for Dementia
• ADL changes
• Pressure Ulcers
  • Recurrent/intractable infections
  • Weight loss not reversible
  • Decreasing anthropometrics not reversible
  • Decreasing serum albumin or cholesterol
  • Dysphasia (trouble eating) causing recurrent aspiration and/or inadequate oral intake

SYMPTOMS:

Symptoms = What the Patient Says

Progression of Disease – Symptoms

 

Dispend (trouble breathing) with increasing respiratory rate

Cough, intractable (won’t quit)

Nausea/Vomiting poorly responsive

Diarrhea, intractable

Pain requiring increasing doses of analgesics

 

SIGNS:

Signs – How the patient looks

• Decline in systolic BP to below 90 or progressive postural hypotension
• Ascots
• Venous, arterial or lymphatic obstruction due to local progression or metastasis disease
• Edema
• Pleural/pericardial effusion
• Weakness
• Change in level of consciousness

LABORATORY:

• NOT REQUIRED TO ESTABLISH HOSPICE ELIGIBILITY
• Increasing pCO2 or decreasing pO2 or SaO2
• Increasing calcium, creatinine, or liver function studies
• Increasing tumor markers (eg. CEA, PSA)
• Increasing or decreasing sodium or potassium

KARNOFSKY: Decline in Karnofsky from <70% due to progression of disease

MEDICAL VISITS: Increasing emergency room visits; hospitalizations, or physician’s visits related to hospice primary diagnosis

“FAST”: Progressive decline in Functional Assessment Staging (FAST) for dementia (from greater than or equal to 7A on the FAST)

ADLs: Dependence on assistance for two or more activities of daily living (ADLs)

• Feeding
• Ambulation
• Continence
• Transfer
• Bathing
• Dressing

ULCERS: Progressive stage 3-4 pressure ulcers in spite of optimal care