Patient has BOTH 1 and 2:

1. Stage VII or beyond according to the Functional Assessment Staging Scale* with all of the following:

• Inabiltiy 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 3-4
• 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

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 than 30%
• Requirement for supplemental oxygen at rest
• The patient declines artifical 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 staus
• 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-threathing 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 (Pyelonephritid)
• Sepsis
• Recurrent fever after antibiotic therapy
• Stage 3 0r Stage 4 decubitus ulcer(s)

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

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%.

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.d., nausea, anemia, malignant ascites or pleural effusion, etc.)

The following information will be required:

1. Tissure diagnosis of 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.

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 caloris 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
• Current history of pulmonary aspiration without effective response to speech-language pathology interventions to improve dysphasia 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.

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 paient 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 without 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 arrhythmias
• History of unexplained or cardiac-related syncope
• CVA secondary to cardiac embolism
• History of cardiac arrest or resuscitation 

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

The patient must have 1a or b, 2 and 3.

1a. CD4 + Count <25 cells/mm³

OR

1b. Persistent 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 arrhythmias
• 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)

Supporting evidence for hospice eligibility:

• Chronic persistent diarrhea for one year
• Persistent serum albumin <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.

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:

The patient has both 1 and 2.

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

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

OR

b. International Normalized Ratio (INR) >1.5

AND

c. Serum albumin <2.5gm/dl

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])
• Hepatic encephalopathy refractory to treatment or patient non-compliant
• History of recurrent variceal 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 carcinoma
• 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.

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 existense, fatigue and cough).

• An FEV1 <30% is objective evidence for disabling dyspnea but is not required

AND

2. Progression of disease as evidenced by a recent history of increased visitsto 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%

b. Hypercapnia evidence by pCO2>50mm Hg

Supporting evidence for hospice eligibility:

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

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

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 artifical 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.

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 artifical 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.

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 artifical 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 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 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.

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 artifical 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.

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/min for diabetics)

Creatinine Clearance Calculation for men

CrCl = ([140-age] × weight in kg)/(serum creatinine in mg/dl × 72)

Creatinine Clearance Calculation for women

CrCl = ([140-age] × weight in kg)/(serum creatinine in mg/dl × 72) × 0.85

OR

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

Supporting evidence for hospice eligibility:

• Uremis
• 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.