(256) 350-5585

Saturday, September 23rd 2017

Hospice of the Valley

HDR-Different

Eligibility Guidelines

  • Ask yourself: "Would I be surprised if this patient died within the next year?" If the answer is "no," then it is time to consider hospice care.
    • Why ask about a year instead of 6 months if guidelines state a life expectancy less than 6 months? Typically life expectancy is over estimated.
  • Children and adults are eligible for hospice care
  • Hospice of the Valley does not only treat cancer patients. Approximately 50% of our patients have cancer and the other 50% have non-cancer diagnosis.

Patients with any terminal diagnosis are eligible. The most common are:

Amyotrophic Lateral Sclerosis (ALS)

The patient meets at least one of the following (1 or 2)

1. Severely impaired breathing capacity with all of the following findings:

  • Dyspnea at rest
  • Vital capacity less then 30%
  • Requirement for supplemental oxygen at rest
  • The patient declines artificial ventilation

OR
2. Rapid disease progression with either a or b below:
Rapid disease progression as evidenced by all of the following in the preceding twelve (12) months:

  • Progression from independent ambulation to wheelchair or bed-bound status
  • Progression from normal to barely intelligible or unintelligible speech
  • Progression from normal to pureed diet
  • Progression from independence in most or all Activities of Daily Living (ADLs) to needing major assistance by caretaker in all ADLs

a. Severe nutritional impairment demonstrated by all of the following in the preceding twelve (12) months:

  • Oral intake of nutrients and fluids insufficient to sustain life
  • Continuing weight loss
  • Dehydration or hypovolemia
  • Absence of artificial feeding methods

OR
b. Life-threatening complications demonstrated by one or more of the following in the preceding twelve (12) months:

  • Recurrent aspiration pneumonia (with or without tube feeding)
  • Upper urinary tract infection (Pyelonephritis)
  • Sepsis
  • Recurrent fever and antibiotic therapy
  • Stage 3 or 4 decubitus ulcer(s)

In the absence of one or more of the above finding, rapid decline or comorbidities may also support eligibility for hospice care.

Cancer

The patient has 1, 2, and 3:
1. Clinical findings of malignancy with widespread, aggressive, or progressive disease as evidenced by increasing symptoms, worsening lab values and/or evidence of metastatic disease.

2. Impaired performance status with a Palliative Performance Score (PPS) <70% p="">

3. Refuses further curative therapy or continues to decline despite definitive therapy. Decline is evidenced by:

  • Hypercalcemia >12.
  • Cachexia or weight loss of 5% in the preceding three months
  • Recurrent disease after surgery/radiation/chemotherapy
  • Refusal to pursue additional curative or prolonging cancer treatment
  • Signs and symptoms of advanced disease (e.g., nausea, anemia, malignant ascites or pleural effusion, etc.)

The following information will be required:
1. Tissue diagnosis or malignancy
OR
2. Reason(s) why a tissue diagnosis is not available

In the absence of one or more of the above findings, rapid decline or comorbidities may also support eligibility for hospice care.

 

Stroke

The patient has both 1 and 2.
1. Poor functional status with Palliative Performance Scale of 40% or less (unable to care for self)
AND
2. Poor nutritional status with inability to maintain sufficient fluid and calorie intake with either:

  •  >10% weight loss over the previous six (6) months
  •  >7.5% weight loss over the previous three (3) months
  •  Serum albumin <2.5 gm="" dl="" --2="" 5--="">
  •  Current history of pulmonary aspiration without effective response to speech language pathology interventions to improve dysphagia and decrease aspiration events

Supporting evidence for hospice eligibility:

  • Coma (any etiology) with three (3) of the following on the third (3rd) day of coma:
  • Abnormal brain stem response
  • Absent verbal responses
  • Absent withdrawal response to pain
  • Serum creatinine > 1.5 gm/dl

In the absence of one or more of these findings, rapid decline or comorbidities may also support eligibility for hospice care.

Dementia/Alzheimer's

The patient has both 1 and 2:
1. Stage VII or beyond according to the Functional Assessment Staging Scale with all of the following:

  • Inability to ambulate without assistance
  • Inability to dress without assistance
  • Urinary and fecal incontinence, intermittent or constant
  • No consistent meaningful/ reality based verbal communication; stereotypical phrases or the ability to speak is limited to a few intelligible words

AND

2. Has had at least one (1) of the following conditions within the past twelve (12) months:

  • Aspiration pneumonia
  • Pyelonephritis or other upper urinary tract infection
  • Septicemia
  • Decubitus ulcers, Multiple and/or Stage 2-4
  • Fever, recurrent after antibiotics
  • Inability to maintain sufficient fluid and caloric intake demonstrated by either of the following:

a. 10% weight loss during the previous six (6) months

OR

b. Serum albumin <2.5 gm="" dl="" p="">

In the absence of one or more of these findings, rapid decline or comorbidities may also support eligibility for hospice care.

 

Failure to Thrive – Adults

The patient meets all of the following (1,2, and 3):

1. Palliative Performance Scale equal to or less than 40% (mostly in bed, requires assistance with ADL)

2. Body Mass Index below 22 kg/M

Body Mass Index calculator(BMI) = 703 x (patient's weight in pounds) divided by (patient's height in inches)2

3. The patient declines or is not responding to enteral or parenteral nutritional support

In the absence of one or more of these findings, rapid decline or comorbidities may also support eligibility for hospice care.

Heart Disease

The patient has 1 or 2 and 3.
1. Poor response to (or patient's choice is not to pursue) optimal treatment with diuretics, vasodilators, and/or angiotensin converting enzyme (ACE) inhibitors

OR

2. The patient has angina pectoris at rest resistant to standard nitrate therapy and is not a candidate for invasive procedures and/or has declined revascularization procedures
and

3. New York Heart Association (NYHA) Class IV symptoms with both of the following:

  • The presence of significant symptoms of recurrent Congestive Heart Failure (CHF) and/or angina at rest
  • Inability to carry out even minimal physical activity with symptoms of heart failure (dyspnea and/or angina)

Supporting evidence for hospice eligibility:

  • Echo demonstrating an ejection fraction of 20% or less
  • Treatment resistant symptomatic dysrythmias
  • History of unexplained or cardiac related syncope
  • CVA secondary to cardiac embolism
  • History of cardiac arrest or resuscitation

In the absence of one or more of these findings, rapid decline or comorbidities may also support eligibility for hospice care.

HIV Disease

The patient must have 1a or b, 2 and 3.
1a. CD4 + Count < 25 cells/ mm

OR

1b. Persistant viral load > 100,000 copies/ml from two (2) or more assays at least one (1) month apart

AND

2. At least one (1) of the following conditions:

  • CNS lymphoma
  • Untreated or refractory wasting (loss of >33% lean body mass)
  • Mycobacterium avium complex (MAC) bacteremia, untreated, refractory or treatment refused
  • Progressive multifocal leukoencephalopathy
  • Systemic lymphoma
  • Refractory visceral Kaposi's sarcoma
  • Renal failure in the absence of dialysis
  • Refractory cryptosporidium infection
  • Refractory toxoplasmosis
  • Treatment resistant symptomatic dysrythmias
  • History of unexpected or cardiac related syncope
  • CVA secondary to cardiac embolism
  • History of cardiac arrest or resuscitation

AND

3. Palliative Performance Scale of <50% requires="" considerable="" assistance="" and="" frequent="" medical="" care="" activity="" limited="" mostly="" to="" bed="" or="" chair="" --50="" --="">


Supporting evidence for hospice eligibility:

  • Chronic persistent diarrhea for one year
  • Persistant serum albumin <2.5 --2="" 5--="">
  • Concomitant active substance abuse

In the absence of one or more of these findings, rapid decline and comorbidities may also support eligibility for hospice care.

 

Huntington's Disease

The patient has both 1 and 2:
1. Stage VII or beyond according to the Functional Assessment Staging Scale with all of the following:

  • Inability to ambulate without assistance
  • Inability to dress without assistance
  • Urinary and fecal incontinence, intermittent or constant
  • No consistent meaningful verbal communication

AND

2. Has had at least one (1) of the following conditions within the past twelve (12) months:

  • Aspiration pneumonia
  • Pyelonephritis or other upper urinary tract infection
  • Septicemia
  • Decubitus Ulcers, Multiple, Stage 3-4
  • Toxoplasmosis unresponsive to therapy
  • Fever, recurrent after antibiotics
  • Inability to maintain sufficient fluid and caloric intake with one or more of the following during the preceding twelve (12) months:

a. 10% weight loss during the previous six (6) months

OR

b. Serum albumin <2.5gm dl="" p="">

OR

c. Significant dysphagia with associated aspiration measured objectively (e.g., swallowing test or a history of choking or gagging with feeding)

In the absence of one or more of these findings, rapid decline or comorbidities may also support eligibility for hospice care.

 

Liver Disease

The patient has both 1 and 2.

1. Synthetic failure demonstrated by a or b and c:

a. Prothrombin time (PTT) prolonged more than five (5) seconds over control

OR

b. International Normalized Ratio (INR) >1.5

AND

c. Serum albumin <2.5 gm="" dl="" --2="" 5--="">

AND

2. End-Stage liver disease is present, and the patient has one or more of the following conditions:

  • Ascites, refractory to treatment or patient declines or is non-compliant
  • History of spontaneous bacterial peritonitis
  • Hepatorenal syndrome (elevated creatinine with oliguria [<400 ml="" day="" --400--="">
  • Hepatic encephalopathy, refractory to treatment or patient non-compliant
  • History of recurrent vatical bleeding despite intensive therapy or patient declines therapy

Supporting evidence for hospice eligibility:

  • Progressive malnutrition
  • Muscle wasting with reduced strength
  • Ongoing alcoholism (>80 gm ethanol/day)
  • Hepatocellular carninoma
  • Hepatitis B surface antigen positive
  • Hepatitis C refractory to interferon treatment

In the absence of one or more of these findings, rapid decline or comorbidities may also support eligibility for hospice care.

 

Lung Disease

The patient has severe chronic lung disease as documented by 1, 2, and 3.
1a. Disabling dyspnea at rest

1b. Poor response to bronchodilators

1c. Decreased functional capacity (e.g., bed to chair existence, fatigue and cough).

  • An FEV1 <30% is="" objective="" evidence="" for="" disabling="" dyspnea="" but="" not="" required="" --30="" --="">

AND

2. Progression of disease as evidenced by a recent history of increased visits to MD office, home or emergency room and/or hospitalizations for pulmonary infections and/or respiratory failure

AND

3. Documentation within the past three (3) months of a or b or both:

a. Hypoxemia at rest (pO2<55 mghg="" by="" abg="" or="" oxygen="" saturation="" 88="" p="">

b. Hypercapnia evidenced by pCO2>50mm Hg

Supporting evidence for hospice eligibility:

  • Cor pulmondale and right heart failure secondary to pulmonary disease
  • Unintentional progressive weight loss >10% over the preceding six (6) months
  • Resting tachycardia >100bpm

In the absence of one or more of these findings, rapid decline or comorbidities may also support eligibility for hospice care.

 

Multiple Sclerosis

The patient must meet at least one of the following criteria (1 or 2):
1. Severely impaired breathing capacity with all of the following findings:

  • Dyspnea at rest
  • Vital capacity less than 30%
  • The requirement of supplemental oxygen at rest
  • The patient declines artificial ventilation

OR

2. Rapid disease progression and either a or b below:
Rapid disease progression as evidenced by all of the following in the preceding twelve (12) months:

  • Progression from independent ambulation to wheelchair or bed-bound status
  • Progression from normal to barely intelligible or unintelligible speech
  • Progression from normal to pureed diet
  • Progression from independence in most or all Acitivities of Daily Living (ADL) to needing mayo assistance by caretaker in all ADL

AND

a. Severe nutritional impairment demonstrated by all of the following in the preceding twelve (12) months:

  • Oral intake of nutrients and fluids insufficient to sustain life
  • Continuing weight loss
  • Dehydration or hypovolemia
  • Absence of artificial feeding

OR

b. Life-threatening complications demonstrated by one or more of the following in the preceding twelve (12) months:

  • Recurrent aspiration pneumonia (with or without tube feedings)
  • Upper urinary tract infections (e.g., Pyelonephritis)
  • Sepsis
  • Recurrent fever after antibiotic therapy
  • Stage 3 or 4 decubitus ulcer(s)

In the absence of one or more of these findings, rapid decline or comorbidities may also support eligibility for hospice care.

Muscular Dystrophy

The patient must meet at least one of the following criteria (1 or 2);
1. Severely impaired breathing capacity with all of the following findings:

  • Dyspnea at rest
  • Vital capacity less than 30%
  • The requirement of supplemental oxygen at rest
  • The patient declines artificial ventilation

OR

2. Rapid disease progression and either a or b below:

Rapid disease progression as evidenced by all of the following in the preceding twelve (12) months:

  • Progression from independent ambulation to wheelchair or bed-bound status
  • Progression from normal to barely intelligible or unintelligible speech
  • Progression from normal to pureed diet
  • Progression from independence in most or all Activities of Daily Living (ADL) to needing major assistance by caretaker in all ADL

AND

a. Severe nutritional impairment demonstrated by all of the following in the preceding twelve (12) months:

  • Oral intake of nutrients and fluids insufficient to sustain life
  • Continuing weight loss
  • Dehydration or hypovolemia
  • Absence of artificial feeding

OR

b. Life-threatening complications demonstrated by one or more of the following in the preceding twelve (12) months:

  • Recurrent aspiration pneumonia (with or without tube feedings)
  • Upper urinary tract infections (e.g., Pyelonephritis)
  • Sepsis
  • Recurrent fever after antibiotic therapy
  • Stage 3 or 4 decubitus ulcer(s)

In the absence of one or more of these findings, rapid decline or comorbidities may also support eligibility for hospice care.

Myasthenia Gravis

The patient must meet at least one of the the following criteria (1 or 2):
1. Severely impaired breathing capacity with all of the following findings:

  • Dyspnea at rest
  • Vital capacity less than 30%
  • The requirement of supplemental oxygen at rest
  • The patient declines artificial ventilation

OR

2. Rapid disease progression and either a or b below:
Rapid disease progression as evidenced by all of the following in the preceding twelve (12) months:

  • Progression from independent ambulation to wheelchair or bed-bound status
  • Progression from normal to barely intelligible or unintelligible speech
  • Progression from normal to pureed dieta
  • Progression from independence in most or all Activities of Daily Living (ADL) to needing major assistance by caretaker in all ADL

AND

a. Severe nutritional impairment demonstrated by all of the following in the preceding twelve months (12) months:

  • Oral intake of nutrients and fluids insufficient to sustain life
  • Continuing weight loss
  • Dehydration or hypovolemia
  • Absence of artificial feeding methods

OR

b. Life-threatening complications demonstrated by one or more of the following in the preceding twelve (12) months:

  • Recurrent aspiration pneumonia (with or without tube feedings)
  • Upper urinary tract infection (e.g., Pyelonephritis)
  • Sepsis
  • Recurrent fever after antibiotic therapy
  • Stage 3 or 4 decubitus ulcer(s)

In the absence of one or more of these findings, rapid decline or comorbidities may also support eligibility for hospice care.

Non-Specific Terminal Illness

The patient has a non-specific terminal medical condition that cannot be attributed to a single specific illness. The physician believes there is a limited life expectancy of six (6) months or less based on a combination of signs, symptoms, test results and/or overall clinical decline.

The clinical impression of six (6) months or less is  based on the following:

1. Rapid decline over the past 3-6 months evidenced by:

  • Progression of disease evidenced by symptoms, signs, and test results
  • Decline in Palliative Performance Scale
  • Weight loss not due to reversible causes and/or declining serum albumin levels
  • Dependence on assistance for two or more ADLs: feeding, ambulation, continence, transfer, bathings, or dressing

2. Dysphagia leading to inadequate nutritional intake or recurrent aspiration

3. Decline in systolic blood pressure

4. Increasing emergency visits, hospitalizations, or physician follow-up

5. Decline in Functional Assessment Staging (FAST) for dementia

6. Multiple progressive Stage 3-4 pressure ulcers in spite of optimal care


In the absence of one or more of these findings, rapid decline or comorbidities may also support eligibility for hospice care.

Parkinson's Disease

The patient must meet at least one of the following criteria (1 or 2):
1. Severely impaired breathing capacity with all of the following findings:

  • Dyspnea at rest
  • Vital capacity less than 30%
  • The requirement of supplemental oxygen at rest
  • The patient declines artificial ventilation

OR

2. Rapid disease progression and either a or b below:

  • Progression from independent ambulation to wheelchair or bed-bound status
  • Progression from normal to barely intelligible or unintelligible speech
  • Progression from normal to pureed diet
  • Progression from independence in most or all Activities of Daily Living (ADL) to needing major assistance by caretaker in all ADL

AND

a. Severe nutritional impairment demonstrated by all of the following in the preceding twelve (12) months:

  • Oral intake of nutrients and fluids insufficient to sustain life
  • Continuing weight loss
  • Dehydration or hypovolemia
  • Absence of artificial feeding

OR

b. Life-threatening complications demonstrated by one or more of the following in the preceding twelve (12) months:

  • Recurrent aspiration pneumonia (with or without tube feedings)
  • Upper urinary tract infection (e.g., Pyelonephritis)
  • Sepsis
  • Recurrent fever after antibiotic therapy
  • Stage 3 or 4 decubitus ulcer(s)

In the absence of one or more of these findings, rapid decline or comorbidities may also support eligibility for hospice care.

Renal Failure

The patient has 1 and either 2 or 3.
1. The patient is not seeking dialysis or transplant

AND

2. Creatinine clearance* <10cc min="" 15cc="" for="" diabetics="" p="">

OR

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

Supporting evidence for hospice eligibility:

  • Uremia
  • Oliguria (urine output is less than 400cc in 24 hours)
  • Intractable hyperkalemia (greater than 7.0) not responsive to treatment
  • Uremic pericarditis
  • Hepatorenal syndrome
  • Immunosuppression/ AIDS
  • Intractable fluid overload, not responsive to treatment

In the absence of one or more of these findings, rapid decline or comorbidities may also support eligibility for hospice care.

 

General Criteria for Palliative Care Support:  When is a patient appropriate for PCS?

Has a life-limiting illness

  • Patient and family needs help understanding health care options related to illness.
  • Has prolonged hospital stay
  • Has had two or more admissions in past six months and/or multiple emergency room visits.
  • Complex case with multiple physicians
  • Need help with symptom management
  • Need help with medication managment
  • Family/patient request
  • May be hospice appropriate but not emotionally ready or choosing to seek curative therapies.

Palliative Care Support services may be provided in the home or assisted/independent living facility.  Requires a physician order.  Services offered on a sliding scale fee.

General Criteria for Hospice Care

  • The patient has a prognosis of less than 6 months if the disease runs its normal course. (Guidelines for Hospice Admission handbook available, see below).
  • The patient's physician and the hospice physician confirm that prognosis.
  • The patient and family choose to focus on comfort, rather than curative treatments.

Hospice of the Valley provides a unique tool for physicians to assist in evaluating a patient's appropriateness. If you would like a copy of our Guidelines for Hospice Admission handbook and the convenient pocket guide, please call or email us at (256) 350-5585 or This email address is being protected from spambots. You need JavaScript enabled to view it.