hospice-eligibility-criteria.pdf

Palliative Performance Scale (PPS)

Hospice Eligibility Criteria

Patient has a terminal illness with a life

expectancy of 6 months or less

CANCER

Pt meets ALL of the following:

1. Clinical findings of malignancy with widespread,

aggressive or progressive disease as evidenced by

increasing sx, worsening lab values and/or

evidence of metastatic disease

2. PPS <70%

3. Refuses further life-prolonging therapy

Continues to decline in spite of definitive therapy

Supporting documentation includes:

Hypercalcemia >12

Cachexia or weight loss > 5% in past 3 months

Recurrent disease after surgery/radiation/chemo

Signs/sxs of advanced disease (e.g. nausea,

requirement for transfusions, malignant ascites or

pleural effusion, etc.)

DEMENTIA

Stage 7C or beyond according to FAST Scale

AND

One or more in the 12 months:

Aspiration pneumonia

Pyelonephritis

Septicemia

Multiple pressure ulcers (stage 3-4)

Recurrent Fever

Inability to maintain sufficient fluid and calorie

intake in past 6 months (10% weight loss or

albumin <2.5)

Other significant condition that suggests limited

prognosis

RENAL FAILURE

Pt refuses dialysis or renal transplant (or requests to

discontinue dialysis)

AND

Creatinine clearance is <10 (<15 for diabetics)

AND

Serum creatinine >8 (> 6 for diabetics)

Supporting documentation for CRF:

Uremia, oliguria (urine output <400cc/24hrs),

intractable hyperkalemia (>7), uremic pericarditis,

hepatorenal syndrome, intractable fluid overload

Supporting documentation for ARF:

Mechanical ventilation, malignancy (other organ

system), chronic lung disease, advanced cardiac

disease, advanced liver disease

HEART DISEASE

CHF NYHA Class IV --> Significant

sxs at rest

AND

Inability to carry out minimal physical

activity without dyspnea or angina

AND

Optimally treated: diuretics,

vasodilators, ACEI, hydralazine, nitrates

Angina at rest, resistant to standard nitrate tx, and

either not a candidate for/or declined invasive

procedures

Supporting documentation:

20%, treatment resistant symptomatic

dysrhythmias

h/o cardiac related syncope, CVA 2/2 cardiac

embolism

H/o cardiac resuscitation, concomitant HIV disease

HIV/AIDS

CD4+ <25 OR Viral load >100,000

AND

At least 1: CNS lymphoma, untreated or refractory

wasting (loss of >33% lean body mass), MAC

bacteremia, PML, systemic lymphoma, visceral ICS,

RF on no HD, cyptosporidium infection, refractory

toxoplasmosis

AND

PPS <50%

LIVER DISEASE

ESLD as demonstrated by:

PT> 5 sec OR INR > 1.5

AND

Serum albumin <2.5

AND

One or more of the following:

Refractory ascites, h/o SBP, hepatorenal

syndrome, refractory hepatic

encephalopathy, h/o recurrent variceal bleeding

Supporting Documentation:

Progressive malnutrition, muscle wasting with dec.

strength, ongoing alcoholism (>80 gm

ethanol/day), hepatocellular CA HBsAg positive,

Hep. C refractory to treatment

PULMONARY DISEASE

Patient has ALL of the following:

Disabling dyspnea at rest

Little/no response to bronchodilators

Decreased functional capacity -->

bed to chair existence, fatigue,

cough

AND

Progression of disease --> recent

increasing office, home, ED visits and/or

hospitalizations for pulmonary infection and/or

respiratory failure

AND

Documentation within past 3 months:

RA hypoxemia at rest (p02 <55 by ABG)

or 02 sat <88%

or hypercapnia pC02 >50

Supporting documentation:

Cor pulmonale and right heart failure, unintentional

progressive weight loss

NEUROLOGIC DISEASE:

Chronic degenerative conditions such as ALS,

Parkinson’s, Muscular Dystrophy, Myasthenia Gravis or

Multiple Sclerosis)

Critically impaired breathing capacity, with all:

Dyspnea at rest, vital capacity <30%, needs O2 at rest, refuses

artificial ventilation

Rapid disease progression with progression from:

Independent ambulation to wheelchair or bed-bound status

Normal to barely intelligible or unintelligible speech

Normal to pureed diet

Independence in most ADLs to needing major assistance in all

ADLs

AND

Critical nutritional impairment demonstrated by all of the

following in the preceding 12 months:

Oral intake of nutrients/fluids insufficient to sustain life

Continuing weight loss

Dehydration or hypovolemia

Absence of artificial feeding methods

Life-threatening complications in the past 12 months

Recurrent aspiration pneumonia, pyelonephritis, sepsis,

recurrent fever, stage 3 or 4 pressure ulcers

STROKE OR COMA

PPS

40%

AND

Poor nutritional status with inability to maintain sufficient fluid

and calorie intake with

1 of the following:

10% weight loss in past 6 months

7.5% weight loss in past 3 months

Serum albumin <2.5

Current history of pulmonary aspiration without effective

response to speech therapy interventions to improve

dysphagia and decrease aspiration events

Supporting documentation includes:

Coma (any etiology) with 3 of the following on the 3rd day of

coma:

Abnormal brain stem response

Absent verbal responses

Absent withdrawal response to pain

Post anoxic stroke

Serum creatinine > 1.5

***Other Terminal Illness

If pt does not meet any of the above guidelines, pt may still be

eligible if documentation strongly supports a prognosis of less

than 6 months

ie. Sepsis, Severe limb-threatening ischemia due to PVD

*Adult Failure to Thrive cannot be used as a principal dx

***Inpatient Unit (IPU) - Eligibility

Symptoms that cannot be managed in any other setting (i.e. pt

requires IV pain medications/anti-emetics, uncontrolled

dyspnea, frequent suctioning, intensive wound care)

Documentation of ongoing IPU eligibility required daily

Intended to be short-term

Imminent death - only if skilled nursing needs

Inpatient facilities ABQ, NM - Kindred Hospice and Presbyterian

Hospice