Hospice Eligibility Guidelines by Diagnosis

1. Recurrent serious infections
   a. Pneumonia
   b. Sepsis
   c. Pyelonephritis
   d. Clostridium difficile
2. Nutritional impairment
   a. Unintentional weight loss (typically, 10% of body weight or more in preceding six months)
   b. Declining mid-arm circumference and/or mid-calf circumference
   c. Declining albumin
   d. Extremely low cholesterol level
   e. Dysphagia with recurrent aspiration and/or decline in oral intake
3. Worsening signs and symptoms
   a. Dyspnea with tachypnea
   b. Intractable cough
   c. Nausea/vomiting
   d. Diarrhea
   e. Pain requiring increasing opioid doses
   f. Agitation/delirium requiring antipsychotic medications
   g. Hypotension (SBP < 90, or postural hypotension)
   h. Edema
   i. Pleural or pericardial effusion
   j. Weakness to the point of falling or severely limiting activity
   k. Lethargy/somnolence
   l. Chronic or worsening open pressure wounds
4. Laboratory testing
   a. Elevated PCO2
   b. Decreased PO2 or SpO2
   c. Hypercalcemia
   d. Progressive renal failure
   e. Progressive hepatic failure
   f. Increasing tumor markers (PSA, CA-125, CEA, etc)
5. Functional decline
   a. Unable to work or carry on normal activity
   b. Needing increased care due to disease progression
   c. New need for assistance with dressing, bathing, toileting, transferring, hygiene tasks, ambulation or feeding due to disease progression
   d. If associated dementia, requires around the clock care, is incontinent of bowel and bladder, and needing assistance with dressing, bathing and toileting

TIP: What could the patient do 12 months ago that he/she can no longer do? What could the patient do six months ago that he/she can no longer do?

1. Malignancy with poor prognosis at diagnosis    
   Example: glioblastoma, pancreatic cancer
2. Metastatic disease at diagnosis    
   Example: Non-small cell lung cancer metastatic to brain
3. Progression to metastatic cancer despite therapy or patient not receiving therapy
4. Not a candidate for or declines further chemotherapy
5. Not a candidate for or declines further radiation (Note: some hospices will cover limited radiation therapy to palliate symptoms)
6. Not a candidate for or declines surgery to treat cancer
7. Need for assistance with at least two activities of daily living (unless cancer with poor prognosis) ADLs are ambulation, dressing, bathing, toileting, transferring, hygiene and feeding
8. Functional impairment to the point of not being able to work or carry on normal activity (unless cancer with poor prognosis)
9. Poor prognosis supported by presence of comorbid conditions like COPD, CHF, CAD, DM, Parkinson’s, stroke, renal failure, liver disease, dementia or AIDS

1. Should have all of the following:
   a. Disabling shortness of breath at rest with very limited functional capacity and/or spirometry with postbronchodilator FEV1 < 30% predicted
   b. Increasing ER visits, hospitalizations or medical provider visits related to lung infections and/or respiratory failure
   c. Hypoxia at rest on room air with SpO2 ≤ 88%, or PO2 ≤ 55 mmHg OR Hypercapnia with PCO2 ≥ 50 mm Hg
2. Eligibility supported by:
   a. Right heart failure (Cor pulmonale) due to lung disease
   b. Unintentional, progressive weight loss of > 10% body weight in preceding 6 months
   c. Resting tachycardia (HR > 100 beats/min)
   d. Diffusing capacity of the lungs for carbon monoxide corrected for hemoglobin (DLCOcor) < 9 ml/min/mmHg or < 30% predicted
   e. BODE index score ≥ 7 points
   i. Correlates with 18% 4-year survival
   f. Serial decline in post-bronchodilator FEV1 of > 40 mL/year
   g. Declining BMI
   h. Advanced age
   i. Low albumin

1. Maximally treated for heart disease, is not a candidate for further treatment or intervention, or has declined further cardiac interventions
2. NYHA Class IV heart disease
   a. Symptoms of heart failure or angina at rest
   b. Inability to carry on any physical activity without discomfort or symptoms worsen with any physical activity
   c. CHF may be documented by EF ≤ 20% if an echocardiogram has been done
3. Eligibility supported by:
   a. Symptomatic, treatment resistant supraventricular or ventricular arrhythmias
   b. History of cardiac arrest or resuscitation
   c. History of unexplained syncope
   d. Brain embolism of cardiac origin
   e. Comorbid HIV

1. Should show all of the following:
   a. Urinary incontinence
   b. Fecal incontinence
   c. Need for assistance with dressing, bathing and toileting
   d. Unable to walk without extensive assistance, unable to propel wheelchair with hands or feet
   e. No consistently meaningful verbal communication
   i. Speech limited to echoing speech, repetitive phrases or fewer than six intelligible words in a given day or intensive interview
2. Should have had at least one of the following in the 12 months preceding hospice referral:
   a. Aspiration pneumonia
   b. Pyelonephritis or other upper UTI
   c. Sepsis
   d. Multiple open pressure sores
   e. Recurrent fever after antibiotics, or antibiotics are declined
   f. At least 10% unintentional weight loss in the past six months (or 5% in the past three months, etc.)
   g. Albumin < 2.5 g/dL
3. Other Considerations
   a. Patients who have a form of dementia other than Alzheimer’s may have a different pattern of decline
       i. For instance, patients with advanced Lewy Body dementia      may be able to ambulate, but typically have agitation and/or    visual hallucinations
   b. Frequent falls/injuries
   c. Need for two people, EZ stand or Hoyer lift to transfer out of bed
   d. Contractures
   e. Return of primitive reflexes like grasp reflex or glabellar reflex
4. Poor prognosis supported by presence of comorbid conditions like COPD, CHF, CAD, DM, Parkinson’s, stroke, renal failure, liver disease or AIDS

1. Not seeking dialysis or renal transplant OR discontinuing dialysis
   Should have at least one of the following:
   a. Creatinine clearance < 10 mL/min
   b. Creatinine clearance < 15 mL/min if diabetes or CHF
   c. Creatinine clearance < 20 mL/min if both diabetes and CHF
   d. Creatinine > 8 mg/dL
   e. Creatinine > 6 mg/dL if diabetes
2. Eligibility supported by comorbidities:
   a. Mechanical ventilation
   b. Malignancy (other than renal)
   c. Chronic lung disease
   d. Advanced cardiac disease
   e. Advanced liver disease
   f. Sepsis
   g. AIDS or other immunosuppression
   h. Malnutrition (cachexia and/or albumin < 3.5 g/dL)
   i. Thrombocytopenia (platelet count <25,000)
   j. DIC
   k. GI bleeding
3. Eligibility supported by signs/symptoms
   a. Oliguria (< 400 mL urine in 24 hours)
   b. Uremia
   c. Refractory hyperkalemia (K > 7 mg/dL)
   d. Uremic pericarditis
   e. Hepatorenal syndrome
   f. Refractory ascites and/or edema

1. Should have both:
   a. Coagulopathy
       i. PT > 5 seconds over control
      ii. INR > 1.5
   b. Albumin < 2.5 g/dL
2. Should have end-stage liver disease
   a. MELD score ≥ 30 corresponds to
      i. 40% six-month survival, 37% one-year survival
   b. Child-Turcotte-Pugh score ≥ 10 (Class C) corresponds to
      i. 45% median 1-year survival, 38% median 2-year survival
3. At least one of the following:
   a. Refractory ascites
   b. Spontaneous bacterial peritonitis
   c. Hepatorenal syndrome
   d. Refractory hepatic encephalopathy
   e. Recurrent variceal bleeding
4. Eligibility supported by:
   a. Progressive malnutrition
   b. Muscle wasting with objective reduced strength/endurance
   c. Active alcoholism
   d. Hepatocellular carcinoma
   e. Hepatitis B
   f. Hepatitis C
5. Can receive hospice services while on liver transplant list, but would not continue with hospice if undergoes transplant.

1. All of the following should be present:
   a. Need for around-the-clock care with significant disability
   b. Unable to maintain nutritional status based on at least one of the following:
       i. Unintentional weight loss of >10% body weight in preceding     six months, or > 7.5% in preceding three months
       ii. Albumin < 2.5 g/dL
       iii. Currently aspirating despite dietary interventions/     modifications
       vi. Serial calorie counts documenting inadequate calorie/fluid     intake
       v. Dysphagia to the point that the patient cannot receive food     and fluid needed to sustain life, and no artificial     nutrition/hydration
2. If coma, should have any of the following on day three of the coma:
   a. Abnormal brain stem response
   b. No verbal response (cont.)
   c. No withdrawal to pain
   d. Creatinine > 1.5 mg/dL
3. Eligibility supported by the following signs/symptoms in the preceding 12 months:
   a. Aspiration pneumonia
   b. Pyelonephritis
   c. Sepsis
   d. Chronic open pressure wounds
   e. Recurrent fever
4. Imaging findings that support eligibility
   a. Non-traumatic hemorrhagic stroke
       i. Head CT showing large-volume hemorrhage ≥ 20 mL     infratentorial ≥ 50 mL supratentorial
       ii. Extension of hemorrhage into ventricle(s)
       iii. Hemorrhage involving at least 30% of cerebrum iv. ≥ 1.5 cm     midline shift
       v. Obstructive hydrocephalus and no VP shunt
   b. Embolic or thrombotic stroke
       i. Large anterior infarct with cortical and subcortical     involvement
       ii. Large infarct involving both hemispheres
       iii. Occlusion of basilar artery
       iv. Occlusion of bilateral vertebral arteries

1. Difficulty breathing despite artificial ventilation (CPAP, BiPAP, ventilator, etc) or declines artificial ventilation
2. Inability to swallow effectively with nutritional impairment despite artificial nutrition (TPN, enteral feeding) or declines artificial nutrition
3. Widespread muscle denervation – weakness, fasciculations, etc.
4. Recurrent aspiration and/or aspiration pneumonia
5. Ideally, poor prognosis is supported by Neurologist evaluation within three months of hospice referral
6. Need for assistance with at least two activities of daily living
   a. ADLs are ambulation, dressing, bathing, toileting, transferring, hygiene and feeding
7. Functional impairment to the point of not being able to work or carry on normal activity
8. Poor prognosis supported by presence of comorbid conditions like COPD, CHF, CAD, DM, Parkinson’s, stroke, renal failure, liver disease, dementia or AIDS