Hospice Eligibility Guidelines Requirements

Hospice Eligibility Guidelines – Requirements

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When is it time to consider hospice care as an option?

Hospice care may be considered for anyone doctors believe to have a life expectancy of less than six months. Usually at the point, active treatment aimed at recovery stops and hospice care is initiated. Hospice care focuses on producing the best possible quality of life in the patient’s remaining time.

Different diseases and conditions each have their own guidelines for hospice admission. The most common of these diseases or conditions include ALS, cancer, dementia, heart disease, HIV, kidney disease, liver disease, lung disease, Parkinson’s disease, stroke and coma. Sometimes a patient does not “fit” into the guidelines but still has a life expectancy of six months or less and therefore may be eligible for hospice.

In order to be eligible to elect hospice care under Medicare, an individual must be entitled to Part A of Medicare and certified as being terminally ill by a physician and having a prognosis of 6 months or less if the disease runs its normal course.

This is a guideline typically used to determine hospice eligibility. Guideline change. Check with Medicare or your own insurance provider for current guidelines in your area.

AMYOTROPHIC LATERAL SCLEROSIS (ALS):

Patients tend to have a constant overall rate of decline, whether rapid or slow. They should have 1 OR 2 OR 3 below:
1. Critically Impaired Breathing Capacity occurring over the past 12 months with all of the following: a) dyspnea at rest; b) supplemental O2 at rest; c) no ventilator or ventilator only for comfort. A vital capacity < 30% is supportive, if available or
2. Rapid Progression and Critical Nutritional Impairment with all of the following in the past 12 months: a) bed-bound; b) barely or unintelligible speech; c) pureed diet; d) major assist in all ADLs; e) insufficient oral intake; f) continuing weight loss; g) NO ARTIFICIAL NUTRITION except to relieve hunger or
3. Rapid Progression and Life Threatening Complications with one of the following in the past 12 months: a) recurrent aspiration pneumonia; b) upper UTI; c) sepsis; d) recurrent fever in spite of antibiotics; e) stage 3/4 decubitus ulcers

 

CANCER:

Patients should have 1 OR 2
1. DISTANT METASTASES AT DIAGNOSIS OR
2. PROGRESSION FROM EARLIER STAGE TO METASTATIC DISEASE with EITHER: a) failure of treatment; OR b) refusal of further treatment

NOTE: may be eligible on diagnosis of small-cell lung cancer, brain cancer, and pancreatic cancer if treatment is not sought

 

DEMENTIA OF ALZHEIMERS TYPE:

Patients should have 1 AND 2
1. > STAGE 7 on FAST SCALE: a) unable to ambulate and dress and bathe without assistance; b) incontinent of urine and stool; c) 6 or less intelligible words/day AND
2. ONE OF THE FOLLOWING IN THE PAST 12 MONTHS: a) aspiration pneumonia ; OR b) upper UTI; OR c) septicemia; OR d) multiple stage 3/4 decubitus ulcers; OR d) recurrent fever on antibiotics; OR e) weight loss >10% in past 6 months/ albumin <2.5

 

AIDS:

Patients should have 1 and 2:
1. CD4+ < 25 (2 or more assays at least one month apart) or Viral Load > 100,000 and one of the following: a) CNS lymphoma; or b) wasting with weight loss > 10%; or c) MAC, untreated or treatment ineffective or refused; or d) PML; or e) systemic lymphoma with partial chemo response; or f) visceral Kaposi’s sarcoma unresponsive to treatment; or g) renal failure and no dialysis; or h) cryptosporidium; or i) toxoplasmosis unresponsive to treatment and
2. Karnofsky Performance Score (KPS)/Palliative Performance Scale (PPS) < 50

Supportive documentation:
a) diarrhea > 1 year; b) albumin < 2.5; c) ongoing substance abuse; d) age > 50; e) resistance to antiretrovirals or prophylactic RX; f) advance d AIDS dementia; g) toxoplasmosis; h) CHF; i) advanced liver disease

 

HEART DISEASE:

Patients should have 1 AND 2
1. OPTIMAL TREATMENT AND EITHER NOT A CANDIDATE FOR /OR REFUSE SURGERY AND
2. NYHA CLASS IV (DISCOMFORT WITH ANY PHYSICAL ACTIVITY; SYMPTOMS OF CHF/ ANGINA AT REST). (EF =/< 20% if available)

SUPPORTIVE: a) symptomatic arrhythmias resistant to treatment; b)previous arrest/CPR; c) unexplained syncope; d) brain embolus from heart; e) HIV

 

LIVER DISEASE:

Patients should have 1 AND 2
1. PT > 5 SEC. OVER CONTROL OR INR. 1.5 AND ALBUMIN < 2.5 AND
2. ONE OF THE FOLLOWING: a) refractory ascites or non-compliance; OR b) spontaneous bacterial peritonitis; OR c) hepato-renal syndrome; OR d) refractory encephalopathy or non-compliance; OR e) recurrent esophageal variceal bleeding despite treatment

SUPPORTIVE: a) weight loss>10%; b) muscle wasting/loss of strength; c) continued alcohol consumption; d) hepatocellular cancer; e) HBsAg positive; or f) hepatitis C refractory to treatment

 

LUNG DISEASE:

Patients should have 1 AND 2
1. DYSPNEA AT REST AND MINIMAL EXERCISE TOLERANCE (with FEV1 <30% IF AVAILABLE) AND PROGRESSION OF DISEASE WITH INCREASED ER VISITS, HOSPITALIZATIONS OR MD HOME VISITS (documented serial decrease in FEV1 40 ml/year if available) AND
2. PO2 <55 mmHg ON ROOM AIR OR O2 SAT < 88 ON O2 OR Pco2 >50 mm Hg

SUPPORTIVE: a) cor pulmonale; b) weight loss.10% in past 6 months; c) HR > 100/min at rest

 

KIDNEY DISEASE:

Patients should have 1 AND EITHER 2 OR 3
1. NOT SEEKING DIALYSIS OR TRANSPLANT OR STOPPING DIALYSIS AND
2. CREATININE CLEARANCE < 10 cc/min (<15 FOR DIABETICS) OR LESS THAN 15 cc/min WITH CHF (< 20 cc/min FOR DIABETICS) OR
3. CREATININE > 8 mg/dl (> 6 FOR DIABETICS)
SUPPORTIVE FOR ACUTE RENAL FAILURE: a) mechanical ventilation; b) cancer; c) chronic lung disease; d) advanced heart disease; e) advanced liver disease; f) sepsis; g) AIDS; h) albumin < 3.5; i) cachexia; j) platelet ct < 25,000; k) DIC; l) GI bleeding

SUPPORTIVE FOR CHRONIC RENAL FAILURE: a) uremia b) oliguria (< 400cc/day); c) K+ > 7 with treatment; d) pericarditis; e)hepatorenal syndrome; f) intractable fluid overload

 

STROKE:

Patients should have 1 AND 2
1. Karnofsky Performance Score KPS/PPS < 40 AND
2. INADEQUATE NUTRITION WITH ONE OF THE FOLLOWING: a) weight loss > 10% in 6 months or 7.5% in 3 months; OR b) albumin < 2,5; OR c) aspiration pneumonia not responsive to speech therapy intervention; OR d) inadequate caloric intake counts; OR e) severe dysphagia and NO artificial feeding

SUPPORTIVE: any of the following in the previous 12 months: a) aspiration pneumonia; b) upper UTI; c) sepsis; d) refractory decubitus ulcer 3/4; e) recurrent fever on antibiotics
Note: specific CT findings on hemorrhagic or embolic strokes may support poor prognosis

 

COMA:

Patients with ANY 3 of the following on DAY 3 of coma:
1. Abnormal brain stem response
2. No verbal response
3. No withdrawal response to pain
4. Creatinine > 1.5.

For supportive factors see “SUPPORTIVE” under stroke

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