FOR CLINICIANS
Diagnosis-based guidelines for Medicare eligibility
HOSPICE REFERENCE GUIDELINES
NOTE: In situations of co-morbidities and/or rapid decline, patients may be hospice-appropriate even without meeting the diagnosis criteria listed below. The presence of two or more conditions within a given diagnosis warrants a hospice consultation.
- General Guidelines – All Diagnoses
General Guidelines – All Diagnoses
- Life-limiting condition(s) /progression of disease(s)
- Karnofsky score ≤ 50%
- Dependence in 3 of 6 ADLs
- Weight loss > 10% over past 6 months
- Serum albumin ≤ 2.5
- BMI < 22kg/m2
- End-stage Heart Disease
End-stage Heart Disease
- Functional Class IV NYHA Assessment
- Symptomatic despite optimal diuretic and vasodilator therapy
- Arrhythmia resistant to treatment
- Ejection fraction ≤ 20%
- History of cardiac arrest
- Cardiogenic embolic disease (e.g. CVA)
- End-stage Lung Disease
End-stage Lung Disease
- Disabling dyspnea at rest or unresponsive to bronchodilators
- Progression of pulmonary disease resulting in recurring infections or respiratory failure
- Hypoxemia at rest on room air. 02 sats. < 88% or P02. < 55 mmHg FEV 1 < 30% after bronchodilator
- Right heart failure due to lung disease
- Resting tachycardia
- Cancer
Cancer
NOTE: Both criteria 1 & 2 as well as either 3 or 4 must be present for hospice eligibility. However, certain cancer patients with poor prognoses may be hospice eligible without fulfilling any of these criteria.
- Palliative Performance Scale 70%
- Dependence in 2 or more ADLs
- Pathology report indicates evidence of malignancy or metastases
- Progression from earlier stage of disease to metastatic disease with either of the following:
- Continued decline despite therapy
- Patient refuses further disease-directed therapy
- End-stage Renal Disease
End-stage Renal Disease
- Not a candidate for dialysis or renal transplant
- Creatine clearance < 10cc/min serum, creatine > 6.0 mg/dl
- Signs of uremia (confusion, nausea, pruritus, restlessness)
- Urine output < 400 cc/24 hrs.
- Hyperkalemia > 7.0
- End-stage Liver Disease
End-stage Liver Disease
- Not a candidate for liver transplant
- PTT > 5 seconds over control
- Ascites despite maximum diuretics
- Serum albumin < 2.5
- Peritonitis spontaneous bacterial
- Cirrhosis or ascites
- Somnolence or coma
- Recurrent variceal bleeding
- End-stage Neurologic Disease/ALS
End-stage Neurologic Disease/ALS
- Unable to walk; needs assistance in all ADLs
- Barely intelligible or unintelligible speech
- Significant dyspnea on 02
- Nutritional status declining
- Medical complications, e.g.: aspiration pneumonia, UTI, decubitus ulcers, recurrent fever
- End-stage Dementia/Alzheimer’s
End-stage Dementia/Alzheimer’s
- FAST score of 7 or below
- Speech limited to 6 words or less
- Unable to sit up, hold head up or smile
- Incontinent
- Requires assistance to dress. bathe and ambulate
- Medical complications, e.g.: recurrent aspiration, pneumonia, UTI, sepsis, decubitus ulcers
- CVA and Coma
CVA and Coma
- Nutritional status declining due to dysphagia; not a candidate for feeding tube
- Poor functional status PPS score < 40%
- Medical complications e.g.: aspiration pneumonia, UTI, decubitus ulcers
- Persistent vegetative state/comatose
- HIV
HIV
- CD4+ count ≤ 25 cells/rnc/L
- Viral load < 100,000 copies/ml. Patient has elected to forego antiretroviral meds
- Any of the following life-threatening complications:
- CNS lymphoma
- Wasting loss of 33% lean body mass
- Renal failure
- Persistent diarrhea & serum albumin < 2.5
- Congestive heart failure
Serenity Hospice provides caring and compassionate hospice care services to patients and families throughout its servicing counties in PA.
