Reliance Hospice & Palliative Caree | Hospice Criteria
15081
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Hospice Criteria

Admission Criteria

Two or more items in any category should generate a hospice referral.

 

Please call our office at 877-659-5998 or fill out our secure online referral form.

General Guidelines

  • Life-limiting condition
  • Patient/family focus on symptom relief rather than cure
  • Progression of disease(s)
  • Evidence of weight loss; serum albumin < 2.5g/dl
  • Symptoms & signs that paint a picture of decline
  • Karnofsky or Palliative Performance Scale score < 50%
  • Dependence in at least 2 ADLs
  • Need for frequent hospitalization, office or ER visits
  • Progressive/unhealing stage III or IV pressure ulcers

Cancer

  • Clinical findings of malignancy with widespread, aggressive or progressive disease as evidenced by increasing symptoms, worsening lab values and/or evidence of metastatic disease
  • Impaired performance on Palliative Performance Scale of <70%
  • Refuses further curative therapy or continues to decline despite definitive therapy. Decline evidenced by:
    • Hypercalcemia > or = 12
    • Cachexia or weight loss of 5% in the preceding 3 months
    • Recurrent disease after surgery/radiation/chemotherapy
    • Refusal to pursue additional curative or prolonging cancer treatment
    • Signs and symptoms of adcanced diesease (nausea, anemia, malignant ascites or pleural effusion, etc.)

Pulmonary Disease

  • Severe chronic lung disease
    • Disabling dyspnea at rest, poorly responsive to bronchodilators
    • FEV1 after bronchodilator < 30%
  • Progression of end-stage pulmonary disease
    • Recurrent pulmonary infections
  • Hypoxemia at rest, on room air: pO2 < 55mmHg – or O2 sat < 88%
  • Right heart failure secondary to pulmonary disease
  • Unintentional progressive weight loss >10%
  • Persistent resting tachycardia

Stroke and Coma

  • Karnofsky Performance < 40%
  • Inability to maintain nutrition/hydration
    • Weight loss > 10%, serum albumin < 2.5 gm/dl, pulmonary
  • aspiration, severe dysphagia
  • Coma 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

Cardiac Disease

  • Symptomatic despite optimal treatment with diuretics and vasodilators
  • Recurrent CHF
    • Ejection fraction < 20%
  • New York Heart Association Class IV
  • Supporting factors
    • Arrhythmias are resistant to treatment
    • History of cardiac arrest or resuscitation
    • History of unexplained syncope
    • Cardiogenic embolic disease (e.g., CVA)

Renal Disease – Acute Renal Failure

  • Patient is not seeking dialysis or transplant
    • Creatinine > 8mg/dl (> 6mg/dl for diabetics)
  • GFR < 10ml/min
    • Creatinine clearance <10cc/min (<15cc/min for diabetics)
  • Co-morbid conditions

Renal Disease – Chronic Renal Failure

  • Patient is not seeking dialysis or transplant
  • Creatinine clearance <10cc/min (<15cc/min for diabetics)
    • Creatinine > 8mg/dl (> 6mg/dl for diabetics); GFR < 10ml/min
  • Symptoms: uremia; oliguria; confusion; nausea; vomiting; pruritus; restlessness; hyperkalemia > 7.0, not responsive to treatment; intractable fluid overload, not responsive to treatment

Liver Disease

  • PTT > 5 seconds over control
  • Serum Albumin < 2.5gm/dl
  • End-stage liver disease
    • Ascites refractory to treatment
    • Spontaneous bacterial peritonitis
    • Hepatorenal syndrome
    • Hepatic encephalopathy, refractory to treatment
  • Supportive factors
    • Progressive malnutrition
    • Continued alcoholism
    • Hepatocellular carcinoma

Dementia

  • Functional Assessment score = 7
    • Unable to ambulate without assist
    • Unable to dress or bathe without assist
    • Urinary and fecal incontinence, intermittent or constant
    • No consistently meaningful verbal communication
  • Complications such as aspiration pneumonia, UTI, septicemia, recurrent fevers
  • Decubitus ulcers stage 3 or 4
  • Weight loss of >10% over last six months

ALS

  • Critically impaired respiratory function
    • Dyspnea at rest
    • Use of accessory muscles
    • Respiratory rate > 20
    • Reduced speech / vocal volume
    • Unexplained headaches, anxiety or nausea
  • Severe nutritional insufficiency
    • Progressive weight loss of at least 5% of body weight
  • With or without gastrostomy tube insertion

HIV

  • CD4 count < 25 cells/mcl or persistent viral load >100,000 copies/ml
  • Decreased performance status
  • Supporting factors
    • Chronic persistent diarrhea
    • Persistent serum albumin < 2.5
    • Concomitant substance abuse
    • Age > 50
    • Advanced AIDS dementia complex
    • CHF or advanced liver disease

Source: Current CMS and NHPCO guidelines