Resources for Healthcare Professionals

Diagnosis Guidelines

The following Diagnosis Guidelines are for the most common illnesses. The guidelines are not required criteria for admission, but rather are guidelines adopted by the Centers for Medicare and Medicaid Services to assist physicians in determining hospice appropriateness.

Adult Immuno-Deficiency Syndrome
Amyotrophic Lateral Sclerosis
Cancer
Cardiac Disease
Coma
Dementia
Liver Disease
Pulmonary Disease
Renal Disease
Stroke

Adult Immuno-Deficiency Syndrome

Medical criteria for the terminal diagnosis of HIV disease are met if the patient has BOTH 1 and 2, with 3 providing supporting documentation, but not required:

CD4+ Count < 25 cells/mcL or persistent viral load > 100,000 copies/ml; AND ONE OF THE FOLLOWING:

CNS lymphoma
Untreated, or not responsive to treatment, wasting (loss of 33% lean body mass)
Mycobacterium avium complex (MAC) bacteremia, untreated, unresponsive to treatment, or treatment refused
Progressive multifocal leukoencephalopathy
Systemic lymphoma, with advanced HIV disease and partial response to chemotherapy
Visceral Kaposi’s sarcoma unresponsive to therapy
Renal failure in the absence of dialysis
Cryptosporidium infection
Toxoplasmosis, unresponsive to therapy

AND

Decreased performance status, as measured by the Karnofsky Performance Status (KPS) scale, of 50 or less
Documentation of the following factors will support eligibility for hospice care:

Chronic persistent diarrhea for one year
Persistent serum albumin < 2.5
Concomitant substance abuse
Age >50 years
Absence of antiretroviral, chemotherapeutic and prophylactic drug therapy related specifically to HIV disease
Advanced AIDS dementia complex
Congestive heart failure, symptomatic at rest
Chronic persistent diarrhea

If a patient meets the medical criteria above, they are by definition eligible to receive hospice services. Some patients may not meet the criteria, but may still be eligible for hospice care due to comorbidities or rapid functional decline. Contact Allegiance for further information.

Amyotrophic Lateral Sclerosis

Patients will be considered to be in the terminal stage of ALS if they meet the following criteria (should fulfill 1, 2, or 3):

The patient should demonstrate critically impaired breathing capacity with ALL of the following characteristics in the past 12 months preceding initial hospice certification:

Vital capacity (VC) < 30% of normal
Significant dyspnea at rest
Requiring supplemental 02 at rest
Patient declines artificial ventilation

Patient should demonstrate BOTH: Rapid progression of ALS as demonstrated by ALL of the following within the 12 months preceding initial hospice certification:

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 (ADLs) to needing major assistance by caretaker in all ADLs.

AND

Critical nutritional impairment as demonstrated by ALL of the following within 12 months preceding initial hospice certification:

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

BOTH of the following:
Rapid progression of ALS (2.A. above)
AND

Life-threatening complications as demonstrated by ONE of the following within the last 12 months preceding initial hospice certification:

Recurrent aspiration pneumonia (with or without tube feedings)
Upper UTI, e.g. , pyelonephritis
Sepsis
Recurrent fever after antibiotic therapy
Decubitus ulcers, multiple, Stage 3-4
In end-stage ALS, two factors are critical in determining prognosis: ability to breathe, and to a lesser extent, ability to swallow.

Cancer

Patients will be considered to be in the terminal stage of cancer if they meet the following criteria (1 and 2 should be present):

Definitive Diagnosis

Patient has tissue diagnosis of a malignancy that may be metastatic
Patient has received optimal treatment for their cancer or they do not wish further treatment
Patient has been on an investigational protocol or clinical trial and has failed on that protocol or trial and they do not wish further treatment
Patient is not a candidate for any further treatment
Patient has experienced severe complications from their treatment(s), e.g., radiation burns, pain, nausea and vomiting, fatigue/debility, etc. and they do not wish further treatment
Individuals who have chosen care that focuses on symptom management rather than curative treatment
Patient or family has decided to focus on quality vs. quantity of life
Patient or family wishes palliative measures or comfort care

Presumptive Diagnosis

Diagnostic work-up by imaging techniques revealed a mass or multiple lesions consistent with a widely spread malignancy
Patient is not a candidate for aggressive chemotherapy or radiation therapy
Patient or family do not wish any treatment(s)
Patient or family wish palliative/symptom management or comfort care

Cardiac Disease

Patients will be considered to be in the terminal stage of cardiac disease if they meet the following criteria (1 and 2 should be present; factors from 3 lend supporting documentation, but are not required):

At the time of initial certification or recertification for hospice:
Patient is already optimally treated with diuretics and vasodilators, which may include Angiotensin-converting enzyme (ACE) inhibitors or the combination of hydrolyzing and nitrates. If side effects, such as hypotension or hyperkalemia, prohibit the use of ACE inhibitors or the combination of hydrolyzing and nitrates, this should be documented in the medical records; OR Patients having angina pectoris, at rest, resistant to standard nitrate therapy and are either not candidates or decline invasive procedures.
AND

Unable to carry on any physical activity without symptoms
Symptoms are present even at rest
If any physical activity is undertaken, symptoms are increased

The patient has significant symptoms of recurrent congestive heart failure (CHF) at rest, and is classified as a New York Heart Association (NYHA) Class IV.

Treatment resistant symptomatic supraventricular or ventricular arrhythmias
History of cardiac arrest or resuscitation
History of unexplained syncope
Brain embolism of cardiac origin
Concomitant HIV disease
Documentation of ejection fraction of 20% or less

Coma

The medical criteria listed below would support a terminal prognosis for individuals with a diagnosis of coma (any etiology). Comatose patients with any 3 of the following on day three of coma are considered terminal:

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

Dementia

Patients will be considered to be in the terminal stage of dementia if they meet the following criteria (BOTH 1 and 2):

Stage 7 on the Functional Assessment Staging (FAST) Scale, described as:

Unable to ambulate without assistance
Unable to dress without assistance
Unable to bathe without assistance
Urinary and fecal incontinence, intermittent or constant
No consistently meaningful verbal communication: stereotypical phrases only or the ability to speak is limited to six or fewer intelligible words

Patients should have had one of the following within the past 12 months:

Aspiration pneumonia
Pyelonephritis or upper urinary tract infection
Septicemia
Decubitus ulcers, multiple, stage 3-4
Fever, recurrent after antibiotics
Inability to maintain sufficient fluid and calorie intake demonstrated by either of the following:
- 10% weight loss during the previous six months OR < 2.5 gm/dl

Liver Disease

Patients will be considered to be in the terminal stage of liver disease if they meet the following criteria (1 and 2 should be present; factors from 3 will lend supporting documentation):

The patient has end stage liver disease as evidenced by BOTH of the following:

Prothrombin time prolonged more than 5 seconds over control, or International Normalized Ratio (INR) > 1.5 AND Serum albumin < 2.5 gm/dl

AND

The patient shows at least ONE of the following:

Ascites, refractory to treatment or patient non-compliant
Spontaneous bacterial peritonitis
Hepatorenal syndrome (elevated creatinine and BUN with oliguria (<400ml/day) and urine sodium concentration < 10 mEq/l)
Hepatic encephalopathy, refractory to treatment, or patient non-compliant
Recurrent variceal bleeding, despite intensive therapy

Documentation of the following factors will support eligibility for hospice care:

Progressive malnutrition
Muscle wasting with reduced strength and endurance
Continued active alcoholism (> 80 gm ethanol/day)
Hepatocellular carcinoma
HBsAg (Hepatitis B) positivity
Hepatitis C refractory to interferon treatment

Patients awaiting liver transplant who otherwise fit the above criteria may be certified for the Medicare hospice benefit, but if a donor organ is procured, the patient should be discharged from hospice.

Pulmonary Disease

Patients will be considered to be in the terminal stage of pulmonary disease if they meet the following criteria (1 and 2 should be present; factors 3, 4 and/or 5 provide supporting documentation):

Severe chronic lung disease as documented by both:

Disabling dyspnea at rest, poorly or unresponsive to bronchodilators, resulting in decreased functional capacity, e.g., bed to chair existence, fatigue, and cough [documentation of Forced Expiratory Volume in one second (FEV1), after bronchodilator, less than 30% of predicted is objective to obtain].
Progression of end stage pulmonary disease, as evidenced by increasing visits to the emergency department or hospitalizations for pulmonary infections and/or respiratory failure (documentation of serial decrease in FEV1 of greater than 40 ml/year is objective evidence for disease progression, but is not necessary to obtain).

Hypoxemia, as evidenced by:
Oxygen saturation of 88% or less on room air
O2 < = 55 mm Hg
(These values may be obtained from recent hospital records.)

Documentation of the following factors may provide additional support for end stage pulmonary disease.

Cor pulmonale or right heart failure (RHF) secondary to pulmonary disease (e.g., not secondary to left heart disease or valvulopathy).
Unintentional progressive weight loss of greater than 10% of body weight over the preceding six months.
Resting tachycardia > 100/min.

Renal Disease

Patients will be considered to be in the terminal stage of renal disease if they meet the following criteria:

Acute Renal Failure (1, 2 AND 3 should be present; factors from 4 will lend supporting documentation):

The patient is not seeking dialysis or renal transplant.
AND
Creatinine clearance < 10 cc/min (< 15 cc/min. for diabetes)
AND
Serum creatinine > 8.0 mg/dl (> 6.0 mg/dl for diabetes)
Supporting documentation of comorbidities:
- History of mechanical ventilation
- Malignancy (other organ system)
- Chronic lung disease
- Advanced cardiac disease
- Advanced liver disease
- Sepsis
- Immunosuppression/AIDS
- Albumin < 3.5 gm/d
- Cachexia
- Platelet count < 25,000
- Disseminated intravascular coagulation
- Gastrointestinal bleeding

Chronic Renal Failure (1, 2, and 3 should be present; factors from 4 will lend supporting documentation):

The patient is not seeking dialysis or renal transplant.
AND
Creatinine clearance < 10 cc/min (< 15 cc/min. for diabetes)
AND
Serum creatinine > 8.0 mg/dl (> 6.0 mg/dl for diabetes)
Supporting documentation of comorbidities:
- Uremia
- Urine output < 400 cc/day
- Intractable hyperkalemia (> 7.0) not responsive to treatment
- Uremic pericarditis
- Hepatorenal syndrome
- Intractable fluid overload, not responsive to treatment

Stroke

Poor functional status with a Palliative Performance Scale (PPS) of 40 or less. All criteria in number 1 should be met:

Mainly bed-bound
Unable to do work
Requires maximal assistance to perform self-care
Food/fluid intake are normal/reduced
Either fully conscious or drowsy/confused

AND

Inability to maintain hydration and caloric intake with ONE of the following:

Weight loss > 10% during previous 6 months
Weight loss > 7.5% in previous 3 months
Serum albumin < 2.5 gm/dl
Current history of pulmonary aspiration without effective response to speech language pathology interventions to improve dysphagia and decrease aspiration events
Calorie counts documenting inadequate caloric/fluid intake
Dysphagia severe enough to prevent the patient from receiving food/fluids that is necessary to sustain life in a patient who does not receive artificial nutrition/hydration

Documentation of medical complications within the previous 12 months, in the context of progressive clinical decline, will help support eligibility for hospice care.

Recurrent or intractable infections such as pneumonia or other URI
Urinary tract infection
Sepsis
Refractory stage 3-4 decubitus ulcers
Fever recurrent after antibiotics

Clinical Reference Scales

The following reference scales are used by healthcare professionals in various settings. These scales are incorporated in the Diagnosis Guidelines and are often documented by our clinical staff in the care of our patients.

New York Heart Association (NYHA) Functional Classification

Palliative Performance Scale (PPS)

Functional Assessment Staging Tool (FAST)

Body Mass Index (BMI) Reference Chart

FLACC Pain Scale

Pain Assessment Scales