Criteria for Determining Hospice Appropriateness

The patient should meet the following criteria:

1. Cancer diagnosis is confirmed through pathology or radiology.
2. Patient is no longer receiving curative treatment.
3. There is evidence of end-stage disease and / or metastasis.
4. Lab / diagnostic studies have been done recently to support disease progression.
5. Karnofsky Performance Score of ≤ 70%. (See Karnofsky Scale below)
6. Modified ADL score of ≤ 18. (See Modified ADL Scale below)
7. Descriptive score of ≤ 25. (See Descriptive Scale below)

Patients with dementia must show all of the following characteristics:

1. Stage seven or beyond according to the Functional Assessment Staging Scale (FAST). (See the Functional Assessment Staging (FAST)¹ below).
2. Unable to ambulate without assistance.
3. Unable to dress without assistance.
4. Unable to bathe without assistance.
5. Urinary and fecal incontinence, intermittent or consistent.
6. No meaningful verbal communication, stereotypical phrases only, or ability to speak is limited to six or fewer intelligible words.
7. Patients must have one of the following within the past 12 months:
   • Aspiration pneumonia
   • Pyelonephritis or other upper urinary tract infection
   • Septicemia
   • Decubitus ulcers, multiple, stages 3-4
   • Fever, recurrent after antibiotics
   • Inability to maintain sufficient fluid and caloric intake with 10% weight loss during the previous six months or serum albumin < 2.5 gm/dl.

Factors 1 and 2 must be present; factors from 3 will add supporting documentation:

1. At the time of certification and re-certification, the patient is already optimally treated with diuretics and vasodilators, usually angiotensin-converting enzyme (ACE) inhibitors. (Optimally treated means that patients who are not on vasodilators have a medical reason for refusing these drugs, e.g., hypotension or renal disease.)
2. The patient has significant symptoms of recurrent congestive heart failure (CHF) at rest, and is classified as New York Heart Association (NYHA) Class IV. (Class IV patients with heart disease have an inability to carry on any physical activity without discomfort. Symptoms of heart failure or of the angina syndrome may be present even at rest. If any physical activity is undertaken, discomfort in increased.) Significant congestive heart failure may be documented by an ejection fraction of ≤ 20%, but is not required if not readily available.
3. Documentation of the following factors will support eligibility determination.
   • Treatment resistant symptomatic supraventricular or ventricular arrhythmia’s.
   • History of cardiac arrest or resuscitation
   • History of unexplained syncope
   • Brain embolism of cardiac origin
   • Concomitant HIV disease

Specific Guidelines for Determining Prognosis
Factors 1 and 2 must be present; factors from 3 will add supporting documentation:

1. CD4+ < 25 cells/mcL or persistent viral load > 100,000 copies/ml, plus one of the following:
   • CNS lymphoma
   • Untreated, or not responsive to treatment, wasting (loss of 35% lean body mass)
   • Mycobacterium avium complex (MAC) bacterium, untreated, unresponsive to treatment, or
     treatment refused.
   • Progressive multifocal leukoencephalopathy.
   • Systemic lymphoma, with an advanced HIV disease and partial response to chemotherapy.
   • Visceral Kaposi’s sarcoma unresponsive to therapy.
   • Cryptosporidium infection.
   • Toxoplasmosis, unresponsive to therapy.
2. Decreased performance status, as measured by the Karnofsky Performance Status (KPS) scale, of ≤ 50%. (See the Karnofsky Scale and Descriptive Scale below).
3. Documentation of the following factors will support eligibility determination.
   • Chronic persistent diarrhea for one year;
   • Persistent serum albumin < 2.5;
   • Concomitant, active substance abuse;
   • Age > 50 years;
   • Absence of antiretroviral, chemotherapeutic and prophylactic drug therapy related to HIV disease;
   • Advanced AIDS dementia complex;
   • Congestive heart failure, symptomatic at rest.

Specific Guidelines for Determining Prognosis
Factors 1 and 2 must be present; documentation of factor 3 will add supporting documentation:

1. The patient should show BOTH a and b.
   • Prothrombin time prolonged more than 5 seconds over control, or international Normalized
     Ration (INR) > 1.5;
   • Serum albumin < 2.5 gm/dl.
2. End-stage liver disease is present and the patient shows AT LEAST ONE of the following:
   • Ascites, refractory to treatment or patient non-compliant;
   • Spontaneous bacterial peritonitis;
   • Hepatorenal syndrome (elevated creatine and BUN with oliguria <400 ml/day and urine sodium
     concentration < 10 mEq/1;
   • Hepatic encephalopathy, refractory to treatment, or patient non-compliant;
   • Recurrent variceal bleeding, despite intensive therapy.
3. Documentation of the following factors will support eligibility for hospice care.
   • Progressive malnutrition
   • Muscle wasting with reduced strength and endurance
   • Continued active alcoholism (>80 gm Ethanol/day)
   • Hepatocellular carcinoma
   • HBsAg (hepatitis B) positivity
   • Hepatitis C refractory to interferon treatment.

NOTE: Patients awaiting liver transplant who otherwise fit the above criteria may be certified for the Medicare Hospice Benefit, but if a donor organ is procured, the patient must be discharged from hospice.

Specific Guidelines for Determining Prognosis
The distinguishing feature of this patient population is that no single, anatomically defined disease is
sufficiently dominant so as to warrant, by itself, designation as the terminal diagnosis. Rather it is the
cumulative frailties of multiple intercurrent co-morbidities that renders the patient’s condition terminal. Patients will be considered to be in decline of their health status (life expectancy of six months or less) if changes in status in the following clinical variables are documented:

1. Progression of disease as documented by symptoms, signs and test results.
2. Decline in Karnofsky Performance Status of Palliative Performance Score/Adapted Karnofsky. (See
   the Karnofsky Scale and Descriptive Scale below).
3. Weight loss, decreasing anthropomorphic measurements, such as, mid-arm circumference or abdominal
   girth (not due to reversible causes as depression or use of diuretics), and decreasing serum albumin or
   cholesterol.
4. Dependence on assistance for two or more ADLs (feeding, ambulation, continence, transfer, bathing,
   dressing). (See the Modified ADL Scale below.)
5. Dysphagia leading to inadequate intake or recurrent aspiration.
6. Decline in systolic blood pressure to below 90 or progressive postural hypotension.
7. Increasing ER visits or hospitalizations related to the hospice primary diagnosis.
8. Decline in Functional Assessment Staging (FAST) for dementia. (See the Functional Assessment Staging (FAST)¹ below.)
9. Progressive stage 3-4 pressure ulcer in spite of optimal care.

These changes in clinical variables apply to patients whose decline is not considered to be reversible due to intercurrent illness or condition. The clinical variables are listed in order of their power to predict poor survival, the most predictive first and the least predictive last. No specific number of the above criteria must be met, but fewer of those listed first (more predictive) and more of those listed last (less predictive) would be expected to predict the longevity of six months or less.

Specific Guidelines for Determining Prognosis
Factors 1 and 2 must be present; documentation of 3, 4 and/or 5 will add supporting documentation:

1. Severe chronic lung disease as documented by both A and B:
   • Disabling dyspnea at rest, poorly or unresponsive to bronchodilators, resulting in decreased
     functional capacity, e.g., bed to chair existence, fatigue, and cough. (Documentation of CForced
     Expiratory Volume in one second [FEV1], after bronchodilator, less than 30% of predicted is
     objective evidence for disabling dyspnea but is not necessary to obtain.)
   • Progression of end-stage pulmonary disease, as evidenced by increasing visits to the ER or
     hospitalizations for pulmonary infections and/or respiratory failure. (Documentation of serial
     decrease of FEV1>40 ml/year is objective evidence for disease progression, but is not necessary
     to obtain.)
2. Hypoxemia at rest on room air, as evidenced by p0₂≤55 mmHg and oxygen saturation ≤88% on
   supplemental oxygen. Or hyercapnia, as evidenced by pCO₂≥50 mmHg. (These values may be obtained
   from recent hospital records.)
3. Cor Pulmonale and right heart failure (RHF) secondary to pulmonary disease (e.g., not secondary to left
   heart disease or valvulopathy)
4. Unintentional progressive weight loss of greater than 10% of body weight over the preceding six
   months.
5. Resting tachycardia > 100/min.

Specific Guidelines for Determining Prognosis
Acute Renal Failure (1 and either 2 or 3 must be present. Factors from 4 will lend supporting documentation).

1. The patient is not seeking dialysis or renal transplant;
2. Creatinine clearance < 10 cc/min (<15 cc/min for diabetics); OR < 15 cc/min (<20 cc/min for diabetics)
   with comorbidity of congestive heart failure;
3. Serum creatinine > 8.0 mg/dl (>6.0 mg/dl for diabetics);
4. Comorbid conditions:
   • Mechanical ventilation;
   • Malignancy (other organ system);
   • Chronic lung disease;
   • Advanced cardiac disease;
   • Advanced liver disease;
   • Sepsis;
   • Immunosuppression/AIDS;
   • Albumin < 3.5 gm/dl;
   • Cachexia;
   • Platelet count < 25,000;
   • Disseminated intravascular coagulation;
   • Gastrointestinal bleeding.

Chronic Renal Failure (1 and either 2 or 3 must be present as outlined above. Factors from 5 will lend
supporting documentation.)

1. Signs and symptoms of renal failure:
   • Uremia;
   • Oliguria (< 400 cc/24 hours);
   • Intractable hyperkalemia (> 7.0) not responsive to treatment;
   • Uremic pericarditis;
   • Hepatorenal syndrome;
   • Intractable fluid overload, not responsive to treatment.

Specific Guidelines for Determining Prognosis
Acute phase of hemorrhagic or ischemic stroke: Factors 1, 2 or 3 must be present.

1. Coma or persistent vegetative state secondary to stroke, beyond three days duration.
2. In post anoxic stroke, coma or severe obtundation, accompanied by severe myoclonus, persisting
   beyond three days past the anoxic event.
3. Dysphagia which prevents sufficient intake of food and fluids to sustain life in a patient who does not
   receive artificial nutrition and hydration.

Chronic phase of hemorrhagic or ischemic stroke: Factors 1, 2, or 3 must be present.

1. Post stroke dementia (all of the following):
   • Stage seven or beyond according to the Functional Assessment Staging Scale (FAST) (See Functional Assessment Staging (FAST)¹ below.)
   • Unable to ambulate without assistance;
   • Unable to dress without assistance;
   • Unable to bathe without assistance;
   • Urinary and fecal incontinence, intermittent or constant;
   • Ability to speak is limited to six or fewer intelligible words.
2. Poor functional status with Karnofsky score of 40% or less. (See the Karnofsky Scale and Descriptive Scale below.)
3. Poor nutritional status whether on artificial nutrition or not, with the inability to maintain sufficient fluid
   and calorie intake with ≥10% weight loss during the previous six months or serum albumin < 2.5 gm/dl.
   Coma (any etiology): Any of the following are present on day three of coma.
   • Abnormal brain stem response.
   • Absent verbal response.
   • Absent withdrawal response to pain.
   • Serum creatinine > 1.5 mg/dl.