If 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 metastic disease.

2. Impaired performance status with a Palliative Performance Scale – 70% or less

3. Refuses further curative therapy or continues to decline in spite of definitive therapy Supportive criteria incluyde:

     1. Hypercalcaemia -12 or higher
     2. Cachexia or weight loss of 5% in the preceding three months
     3. Recurrent disease after surgery/ radiation/ chemotherapy
     4. Declines to pursue additional curative or prolonging cancer treatment
     5. Signs and symptoms of advanced disease (e.g., nausea, requirement for transfusions, malignant ascites or pleural effusion, etc.)

The following information will be required:

1. Tissue diagnosis of malignancy
2. Reasons 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 care.

The patient has 1 and 2:

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

     a) Inability to ambulate without assistance
     b) Inability to dress without assistance
     c) Urinary and fecal incontinence, intermittent or constant
     d) 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 a least one (1) of the following conditions within the past twelve (12) months:

     a) Aspiration precautions
     b) Pyelonephrits or other upper urinary tract infection
     c) Septicemia
     d) Decubitus ulcers, multiple, stage 3-4
     e) Fever, recurrent after antibiotics
     f) Inability to maintain sufficient fluid and calorie intake demonstrated by the following:

     10% weight loss during the previous six (6) months

OR

Serum albumin; 2.5gm/dl

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

The patient meets all of the following 1, 2, and 3:

1. Palliative Performance Scale equal to or less than 40% (mainly in bed, requires assistance with ADL’S)

2. Body Mass Index below 22kg/m (body mass index + 703 multiplied by the patients weight in pounds divided by height in inches)

3. The patient declines or is not responding to eternal or parenteral nutritional support.

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

The patient meets 1 or 2 and 3:

1. Poor response to (or patient’s choice not to purse) optimal treatment with diuretics, vasodilators, and/or angiotensin converting enzyme (ACE) inhibitors

AND

2. The patient has angina pectoris at rest resistant to standard nitrate therapy and is not a candidate for invasive procedures and/ or has declined revascularization

3. New York heart association (NYHA) class IV symptoms with both of the following

     a) The presence of significant symptoms of recurrent congestive heart failure (CHF) and/ or angina at rest
     b) Inability to carry out even minimal physical activity without symptoms of heart failure (dyspnea) or angina

OR

4. Documentation to support eligibility

     a) Echo demonstrating an ejection fraction of 20% or less
     b) Treatment resistant symptomatic dysrhytmias
     c) History of unexplained cardiac related syncope
     d) CVA secondary to cardiac embolism
     e) History of cardiac arrest or resuscitation

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

The patient must have 1-a or 1-b, 2 and 3. Number 4 provides supporting documentation:

1-a. CD4 + count, 25 cells mcl

OR

1-b. Persistent viral load >100,000 copies/ml from two (2) or more assays at least one month apart.

AND

2. At least one (1) of the following conditions

     a) CNS lymphoma
     b) Untreated or refractory wasting (loss of > 33% lean body mass)
     c) Mycobacterium avium complex (MAC) bacteremia, untreated refractory or treatment refused
     d) Progressive multifocal leukoencephalopathy
     e) Systemic lymphoma
      f) Refractory visceral kaposi’s sarcoma
     g) Renal failure in the absence of dialysis
     h) Refractory cryptosporidum infection
      i) Refractory toxoplasmosis

AND

3. Palliative performance scale of = 50% (requires considerable assistance and frequent medical care, activity limited mostly to bed or chair)

4. Supporting factors: chronic persistent diarrhea for one year, persistent serum albumin <2.5, concomitant active substance abuse.

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

The patient has end-stage Huntington’s disease with both 1 and 2:

1. Stage VII or beyond according to the functional assessment staging scale with all of the following:

     a) Inability to ambulate without assistance
     b) Inability to dress without assistance
     c) Urinary and fecal incontinence, intermittent or constant
     d) No consistent meaningful verbal communication

AND

2. Had at least one (1) of the following conditions within the past twelve (12) months:

     a) Aspiration pneumonia
     b) Pyelonephritis or other upper urinary tract infection
     c) Septicemia
     d) Decubitus ulcers, multiple, stage 3-4
     e) Toxoplasmosis unresponsive to therapy
     f) Fever, recurrent after antibiotics
     g) Inability to maintain sufficient fluid and calorie intake with one or more of the following during the preceding twelve (12) months:

          10% weight loss during the previous six (6) months

OR

A serum albumin, 2.5 gm/dl

Significant dysphagia with associated aspiration measured objectively (e.g., swallowing test or a history of choking or gagging with feeding)

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

The patient has both 1 and 2. Number 3 adds support:

1. Synthetic failure demonstrated by a, b and c.

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

OR

     b) International normalized ratio (INR) 1.5

AND

     c) Serum albumin 2.5 gm/dl

AND

2. End stage liver disease is present, has one or more of the following conditions:

     a) Ascites, refractory to treatment or patient declines or is non-compliant
     b) History of spontaneous bacterial peritonitis
     c) Hepatic syndrome (elevated creatinine with oliguria 400nl/day) d) Hepatic encephalopathy, refractory to treatment or patient non-compliant e) History of recurrent variceal bleeding despite intensive therapy or patient declines sclerosing therapy. 3. Supporting conditions include: progressive malnutrition, muscle wasting with reduced strength, ongoing alcoholism (80gm ethanol/day), hepatocellular carcinoma, and hepatitis b surface antigen positive, hepatitis c refractory to interferon treatment.

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

The patient meets at least one of the following criteria (1 or 2):

1. Critically impaired breathing capacity with all of the following findings:

     a) Dyspnea at rest
     b) Vital capacity less than 30%
     c) Requirement for supplemental oxygen at rest
     d) The patient declines artificial ventilation

OR

2. Rapid disease progression and either a, or b below:

Rapid disease progression as evidenced by all of the following in the proceeding twelve (12) months:

     a) Progression from independent ambulation to wheelchair or bed-bound status
     b) Progression from normal to barely intelligible or unintelligible speech
     c) Progression from normal to pureed diet
     d) Progression from independence in most or all Activities of Daily Living (ADL’S) to needing major assistance by caretaker in all ADL’S

AND

    2A. Critical nutritional impairment demonstrated by all of the following in the proceeding twelve (12) months:

           a) Oral intake of nutrients and fluids insufficient to sustain life
           b) Continuing weight loss
           c) Dehydration or hypovolemia
           d) Absence of artificial feeding methods

OR

     2B. Life threatening complications demonstrated by one or more of the following in the proceeding twelve (12) months:

           a) Recurrent aspiration pneumonia (without tube feedings)
           b) Pyelonephritis or other upper urinary tract infection
           c) Sepsis
           d) Recurrent fever after antibiotic therapy
           e) Stage 3 or stage 4 decubitus ulcer(s)

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

The patient must meet at least one of the following criteria (1 or2):

1. Critically impaired breathing capacity with all of the following findings;

     a) Dyspnea at rest
     b) Vital capacity less than 30%
     c) Requirement for supplemental oxygen at rest
     d) The patient declines artificial ventilation

OR

2. Rapid disease progression with either 2A, or 2B below.

Rapid disease progression as evidenced by all of the following in the proceeding twelve (12) months:

     a) Progression from independent ambulation to wheelchair or bed-bound status.
     b) Progression from normal to barely intelligible or unintelligible speech
     c) Progression from independence in most or all Activities of Daily Living (ADL’S) to needing major assistance by caretaker in all ADL’S

AND

     2A. Critical nutritional impairment demonstrated by all of the following in the Proceeding twelve (12) months:

           a) Oral intake of nutrients and fluids insufficient to sustain life
           b) Continuing weight loss
           c) Dehydration or hypovolemia
           d) Absence of artificial feeding methods

OR

     2B. Life-threatening complications demonstrated by one or more of the following

In the proceeding twelve (12) months:

           a) Recurrent aspiration pneumonia (with or without tube feedings)
           b) Pyelonephritis or other upper urinary tract infections
           c) Sepsis
           d) Recurrent fever after antibiotic therapy
           e) Stage 3 or stage 4 decubitus ulcer(s)

In the absence of one or more of the above 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. Critically impaired breathing capacity with all of the following findings:

     a) Dyspnea at rest
     b) Vital capacity less than 30%
     c) Requirement for supplemental oxygen at rest
     d) The patient declines artificial ventilation

OR

2. Rapid disease progression with either 2A or 2B below.
Rapid disease progression as evidenced by all of the following in the proceeding twelve (12) months:

     a) Progression from independent ambulation to wheelchair or bed-bound status.
     b) Progression from normal to barely intelligible or unintelligible speech.
     c) Progression from independence in most or all Activities of Daily Living (ADL’S) to needing major assistance by caretaker in all ADL’S

AND

         2A. Critical nutritional impairment demonstrated by all of the following in the Proceeding twelve (12) months:

               a) Oral intake of nutrients and fluids insufficient to sustain life
               b) Continuing weight loss
               c) Dehydration or hypovolemia
               d) Absence of artificial feeding methods

OR

         2B. Life-threatening complications demonstrated by one or more of the following in the proceeding twelve (12) months:

               a) Recurrent aspiration pneumonia (with or without tube feedings)
               b) Pyelonephritis or other upper urinary tract infections
               c) Sepsis
               d) Recurrent fever after antibiotic therapy
               e) Stage 3 or stage 4 decubitus ulcer(s)

In the absence of one or more of the above findings, rapid decline or co morbidities may also support eligibility for hospice care.

The patient has a terminal medical condition that cannot be attributed to a single specific illness. The physician believes there is a limited diagnosis of six (6) months or less based on a constellation of signs, symptoms, test results and/or clinical decline.

The clinical impression of six (6) months or less is based on the following:

1. Rapid decline over the past 3-6 months by symptoms, signs and test results.

     a) Progression of disease evidenced by symptoms, signs and test results
     b) Decline in palliative performance scale
     c) Weight loss not due to reversible causes and/or declining serum albumin levels
     d) Dependence on assistance for two (2) or more ADL’S; feeding, ambulation, continence, transfer, bathing and dressing.

2. Dysphagia leading to inadequate nutritional intake or recurrent aspiration

3. Decline in systolic blood pressure to be below 90, systolic or progressive postural hypotension

4. Increasing emergency visits. Hospitalizations, or physician follow-up

5. Decline in functional assessment staging (FAST) for dementia

6. Multiple progressive stage 3-4 pressure ulcers in spite of optimal care

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

The patient must meet at least one of the following criteria (1 or2):

1. Critically impaired breathing capacity with all of the following findings:

     a) Dyspnea at rest
     b) Vital capacity less than 30%
     c) Requirement for supplemental oxygen at rest
     d) The patient declines artificial ventilation

OR

2. Rapid disease progression with either 2A or 2B below.
Rapid disease progression as evidenced by all of the following in the proceeding twelve (12) months:

     a) Progression from independent ambulation to wheelchair or bed-bound status.
     b) Progression from normal to barely intelligible or unintelligible speech.
     c) Progression from independence in most or all Activities of Daily Living (ADL’S) to needing major assistance by caretaker in all ADL’S

AND

     2A. Critical nutritional impairment demonstrated by all of the following in the Proceeding twelve (12) months:

            a) Oral intake of nutrients and fluids insufficient to sustain life
            b) Continuing weight loss
            c) Dehydration or hypovolemia
            e) Absence of artificial feeding methods

OR

     2B. Life-threatening complications demonstrated by one or more of the following in the proceeding twelve (12) months:

            a) Recurrent aspiration pneumonia (with or without tube feedings)
            b) Pyelonephritis or other upper urinary tract infections
            c) Sepsis
            d) Recurrent fever after antibiotic therapy
            e) Stage 3 or stage 4 decubitus ulcer(s)

In the absence of one or more of the above 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. 4 provide supporting data:

1.

     a) Disabling dyspnea at rest
     b) Poor response to bronchodilators
     c) Decreased functional capacity (e.g. bed to chair existence, fatigue and Cough)

An FEVI  30% is objective evidence for disabling dyspnea but is not required.

AND

2. Progression of disease as evidenced by a recent history of increasing office, home or emergency visits 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= 55mgHG by ABG) or oxygen saturation = 88%

     b) Hypercapnia evidenced by pCO2  50mmHG

4. Supporting conditions include: Cor Pulmonale and right heart failure secondary to pulmonary disease, unintentional progressive weight loss  10 % over the preceding six (6) months, resting tachycardia 100bpm

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

The patient has 1 and either 2 or 3. Number 3 supports hospice eligibility:

1. The patient is not seeking dialysis or transplant

AND

2. Creatinine clearance 10cc/min ( 15 cc/min for diabetics )

AND

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

4. Supporting evidence:

     a) Albumin 3.5gm/dl
     b) Platelet count 25,000
     c) Mechanical ventilation
     d) Malignancy (other organ system)
     e) Chronic Lung disease
     f) Sepsis
     g) Immunosuppression / AIDS
     h) Cachexia
     i) Disseminated intravascular coagulation
     j) Advanced liver disease
     k) Gastrointestinal bleeding

Creatine Clearance Calculation (140- age) x (weight) / 72x (serum creatinine in mg/dl) multiply by 0.85 for women (age in year, weight in Kg)

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

The patient has 1 and either 2 or 3. Number 4 supports hospice eligibility:

1. The patient is not seeking dialysis or transplant

AND

2. Creatine clearance  10cc/min ( 15 cc/min for diabetics)

AND

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

4. Supporting evidence:

     a) Uremia
     b) Oliguria (urine output in less than 400 cc in 24hrs.)
     c) Intractable hyperkalemia (greater than 7.0) not responsive to treatment
     d) Uremic pericarditis
     e) Hepatorenal syndrome
     f) Immunosuppression / AIDS
     g) Intractable fluid overload, not responsive to treatment.

Creatine Clearance Calculation (140- age) x (weight) / 72x (serum creatinine in mg/dl) multiply by 0.85 for women (age in year, weight in Kg)

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

The patient has:

1. Palliative Performance Scale  50 % (requires considerable assistance and frequent medical care.)

AND

2. At least on e (1) of the following conditions within the past twelve (12) months:

     a) Aspiration

     b) Pneumonia

     c) Pyelonephritis or other upper urinary tract infections

     d) Sepsis

3. Recurrent fever after antibiotic therapy

4. Decubitus ulcers, multiple, stage 3-4

5. Fever, recurrent after antibiotics

6. Inability to maintain sufficient fluid and calorie intake with

     a) 10 % weight loss during the previous six (6) months

OR

     b) A declining serum albumin

OR

     c) Significant dysphagia with associated aspiration measured objectively (e.g., swallowing test or a history of

choking/gagging with feeding)

By definition, these finding support the diagnosis of advanced senescence to the extent indicating hospice care.

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

The patient has both 1 and 2. Number 3 supports eligibility:

1. Poor functional status with palliative performance scale of 40% or less (unable To care for self)

OR

2. Poor nutritional status with inability to maintain sufficient fluid and calorie intake with either:

     a) 10 % weight loss over the previous six (6) months
     b) 7.5% weight loss over the previous three (3) months
     c) Serum albumin  2.5 gm/dl

     d) Current history of pulmonary aspiration without effective response to speech language pathology interventions to improve dysphagia and decrease aspiration events Supporting Documentation:

3. Coma. (Any etiology) with three (3) of the following on the third (3rd) day of coma:

     a) Abnormal brain stem response

     b) Absent verbal responses

     c) Absent withdrawal response to pain d) Serum creatinine   1.5gm/dl

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