Physician / Referral Sources

Attention Physicians

The following excerpts were taken from a directive letter written for Physicians from the Director of CMS (Center for Medicare and Medicaid Services) regarding hospice care

    Should I recommend Hospice Care?
  • “Physicians, hospitals and skilled nursing facilities are urged to recommend hospice care to beneficiaries when it is determined that the patient has six (6) months or less to live and may benefit from it.”
    Who Makes the Decision on Terminality and How?
  • “The certification of terminal illness of an individual who elects hospice shall be based on the physician’s or medical director’s clinical judgment regarding the normal course of the individual’s illness.”
    What if the Patient lives longer than six months?
  • “The Medicare Program recognizes that terminal illnesses do not have predictable courses; therefore the benefit is available for extended periods of time beyond six (6) months provided that proper certification is made at the start of each coverage period.”
    Identification of Hospice Appropriate Patients
  • Patient has a life limiting illness with prognosis measured in months
  • Weight loss of 10% or more in six months or less
  • Recurrent infections in last six months
  • Frequent hospitalizations in last six months
  • Patient or family refuses PEG placement (Prior PEG does not exclude patient)
  • Patient refuses hospitalization or other aggressive treatments
  • Patient has optimal treatment, but continues to exacerbate
  • Significant decline in overall health due to multiple medical and functional problems

Guidelines for Non-Cancer Diagnoses

These guidelines are not meant to be inclusive. They are examples of criteria requirements set forth by the National Hospice Organization. A consultation would be necessary to make a definitive determination regarding hospice appropriateness.

    End-Stage Cardiovascular Disease
  • Recurrent, persistent symptoms of CHF despite optimal/maximal treatments, including optimal therapy with diuretics and ACE inhibitors.
  • Recent episode of cardiac arrest, syncope, respiratory arrest
  • May or may not be oxygen dependent
  • Multiple hospitalizations related to a severe cardiac condition
  • Inability to perform physical activity of any kind without discomfort, pain, or shortness of breath
  • CVA if cardiac origin, such as an embolism
  • Ejection Fraction of < 20%
  • Unstable weight
  • Uncontrolled edema
    End-Stage Pulmonary Disease
  • Dyspnea at rest
  • Functional activity is limited so much that patient experiences a “bed-to-chair” existence, disabling dyspnea
  • Signs of right-sided heart failure
  • FEVI < 30% of predicted value, post bronchodilator therapy
  • Multiple ER visits/hospitalizations for pulmonary infections or failure
  • Weight loss greater than 10% of body weight in last 3-6 months
  • Hypoxemia at rest (02 Sat < 88% on room air)
  • Frequent steroid and/or antibiotic use
  • Resting pulse rate > 100 beats/min
  • Progressive cough and fatigue
  • Previous requirement of a ventilator secondary to respiratory failure/infection
    End-Stage Renal Disease
  • Candidate for dialysis, but refuses
  • Stops dialysis to choose palliative care
  • Creatinine clearance < 10ml/min (< 15ml/min if diabetic)
  • Serum creatinine > 8.0mg/dl (> 6.0mg/dl if diabetic)
  • Hepatorenal Syndrome
  • Uremia
  • Oliguria (UO < 400ml/24 hrs)
  • Intractable hyperkalemia (> 7.0) not responsive to treatment
    End-Stage Liver Disease
  • Prothrombin time > 5 seconds over control and serum albumin < 2.5 mg/dl, with at least one of the following:
  • Recurrent bleeding or esophageal varices
  • Ascites
  • Hepatorenal syndrome (as evidenced by elevated BUN and Creatinine)
  • Hepatic encephalopathy and/or coma (very late stage)
    End-Stage HIV Disease
  • Chronic persistent diarrhea for one year, regardless of etiology
  • Persistent serum albumin < 2.5g/dl
  • Concomitant substance abuse
  • Decisions to forego antiretroviral, chemotherapeutic, and prophylactic drug therapy related specifically to HIV disease
  • Congestive heart failure, symptomatic at rest
  • CD4+ count below 25 cells/mcl
  • Persistent HIV RNA (Viral load) of > 100,000 copies/ml
  • Opportunistic diseases such as CNS lymphoma, progressive multifocal leaukoencephalopathy, cryptosporidiosis, wasting, MAC bacteremia, visceral Kaposi’s sarcoma, renal failure, AIDS dementia complex or toxoplasmosis.
    End-Stage ALS (Amyotrophic Lateral Sclerosis)
  • Rapid progression of ALS in last six months, as evidenced by: progression from ambulation or wheelchair to being bed bound, from normal to pureed diet, from independent or partial-assist to total assistance with ADL’s, no longer speaks intelligibly.
  • Must exhibit one of the following: Impaired breathing ability as evidenced by respiratory infections or failure, nutritional impairment responsible for >10% loss of body weight in <6 months, or life-threatening complications like pneumonia, urosepsis, etc.
    End-Stage Dementia; Alzheimer’s/Multi-infarct
  • Exhibits all the following: Unable to ambulate, dress, or bathe without assistance; unable to converse meaningfully with others, incontinent of urine and stool.
  • Cannot sit upright in geri-chair or wheelchair without support
  • Difficulty swallowing food, liquids or medications
  • No longer smiling or interacting with caregivers
  • History of frequent UTI’s, urosepsis, pneumonia, septicemia
  • Multiple decubiti
  • Weight Loss
    End-Stage Stroke, CVA
  • Dysphagia may or may not be a candidate for artificial nutrition/hydration
  • Age >70 years
  • Greater than 10% weight loss despite enteral feeding
  • Comorbid conditions such as aspiration pneumonia, multiple decubiti, septicemia, urosepsis, or frequent UTIs
  • Unable to communicate meaningfully