Counseling patients with advanced and progressive chronic illnesses brings up the difficult discussion regarding goals of care. Physicians play an important role in providing patients with information to help them make informed choices and deciding when to pursue a comfort-oriented approach to providing care for your patients is one of the most difficult decisions you will make.

These end-stage disease indicators may be helpful to physicians discussing care options available to patients. But these are just guidelines so please call Dr. Cynthia Williams, Community Hospices' Medical Director, at 1.866.234.7742 if you have questions about a specific clinical situation.

Hospice Eligibility

Your patients may be eligible for hospice if they meet some or all of these guidelines:

General End-stage Disease Indicators

• Physical decline
• Weight loss not due to reversible cause
• Assistance with at least 2 ADL's
• Multiple comorbities
• Decreasing serum albumin or cholesterol
• Decline in Karnofsky Performance Status (KPS) or Palliative Performance (PPS)
• Dysphagia causing poor intake or recurrent aspiration
• Recurrent or intractable infections

Progression of disease as documented by the following:
Cachexia, increased ER visits or hospitalizations, progressive stage 3 or 4 pressure ulcers in spite of optimal care, decline in SBP<90 mmHg or progressive postural hypotension

Amyotrophic Lateral Sclerosis

Rapid progression of ALS as evidenced by:

• Progression from independent ambulation to wheelchair to 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 ADL's to needing major assistance by caretaker in all ADL's

Intake insufficient to sustain life
Significant dyspnea, on O/2 at rest
Declines artificial ventilation
Medical complications such as pneumonia or sepsis

Coma - Any Etiology

• Abnormal brain stem response
• Absent verbal response
• Absent withdrawal response to pain
• Serum creatinine >1.5 mg/dl

Cancer Diagnoses

Disease with distant metastases at presentation or
Progression from an earlier stage of disease to metastatic disease with either:

1. continued decline in spite of therapy
2. patient declines further disease-directed therapy
3. patients with cancers that have poor prognoses (i.e. small cell lung cancer and pancreatic cancer) may be hospice eligible without fulfilling the other criteria in this section

Dementia

• Unable to walk without assistance, and
• Urinary and fecal incontinence, and
• Unable to bathe and dress without assistance
• No consistent meaningful verbal communication
• Stereotypical phrases only or
• Six or fewer intelligible words

Plus any of other following in the six months prior to certification:

• Inability to maintain fluid and calories intake with 10% weight loss
• Serum albumin <2.5 gm/dl

Or any of the following in the twelve months prior to certification:

• Recurrent fevers
• Aspiration pneumonia
• Pyelonephritis or UTI
• Septicemia
• Multiple stage III or IV decubitus ulcers

Heart Disease - CHF

• NYHA Class IV Disease*
• Symptomatic at rest despite optimal diuretic/vasodilator therapy
• Patient not a candidate for revascularization or declines such procedures

* New York Heart Association (NYHA) Classification:
Class IV: patients who should be at complete rest, confined to bed or chair; any physical activity brings on discomfort and symptoms occur at rest

HIV/AIDS

• CD4 <25 cells/ul or persistent viral load > 100,000 copies/ml, and
• KPS<50, and
• Absence of, or resistance to effective antiretroviral, chemotherapeutic and prophylactic drug therapy related specifically to HIV disease

Plus any one of the following:

• Wasting syndrome
• PML (progressive multifocal leukoencephalopathy)
• Cryptosporidiosis
• MAC (mycobacterium avium complex), unresponsive to treatment
• Visceral Kaposi's sarcoma, unresponsive to treatment
• Toxoplasmosis, unresponsive to treatment
• CNS lymphoma

Liver Disease

• PT > 5 sec above control or INR > 1.5 and
• Serum albumin < 2.5 g/dl

Plus any one of the following:

• Refractory ascites
• Spontaneous bacterial peritonitis
• Hepatorenal syndrome
• Refractory hepatic encephalopathy
• Recurrent variceal bleeding

Pulmonary Disease

• Documented disease progression evidenced by increasing ER visits, hospitalizations or recurrent pulmonary infections
• Disabling dyspnea at rest, poorly or unresponsive to bronchodilators

Plus any one of the following:

• pO2 <55 mmHg on room air
• pCO2 > 50 mmHg
• Sat o2 < 88% (on supplemental oxygen)

Other helpful indicators:

• Right heart failure
• Unintentional weight loss
• Resting tachycardia > 100/min

Stroke - CVA

• Poor nutritional status
• Poor functional status
• Persistent vegetative state
• Post-stroke dementia

Renal Disease

• Patient not seeking dialysis, and
• Patient not a candidate for renal transplant

Plus any one of the following:

• Creatinine clearance < 10 ml/min (without comorbid conditions)
• Creatinine clearance < 15 ml/min (with comorbid diabetes of CHF)
• Creatinine clearance < 20 ml/min (with comorbid diabetes and CHF)
• Serum creatinine > 8.0 mg/dl (> 6.0 mg/dl for diabetes)