1. Life limiting condition
    2. Pt/family informed condition is life limiting
    3. Pt/family elected palliative care
    4. Documentation of clinical progression of disease as evidenced by:
      • Serial physician assessment
      • Laboratory studies
      • Radiologic or other studies
      • Multiple Emergency Dept. visits
      • Inpatient hospitalizations
      • Home health nursing assessment if patient is home bound


    5. Recent decline in functional status as evidenced by either:
      A. Karnofsky Performance Status
      • 50% Required considerable assistance and frequent medical care
      • 40% Disabled; requires special care and assistance. Unable to care for s elf; disease may be progressing rapidly
      • 30% Severely disabled; although death is not imminent
      • 20% Very sick; active supportive treatment necessary
      • 10% Moribund; fatal processes progressing rapidly


      B. Dependence in 3 of 6 Activities of Daily Living
      • Bathing
      • Dressing
      • Feeding
      • Transfers
      • Continence of urine and stool
      • Ambulation to bathroom


    6. Recent impaired nutritional status as evidenced by:
      • Unintentional, progressive weight loss of 10% over past six months
      • Serum albumin less than 2.5 gm/dl (may be helpful prognostic indicator but should not be used by itself)


  1. Does the patient have symptoms and signs of congestive heart failure at rest?


    • Dyspnea at rest and on exertion
    • Orthopnea
    • Paroxysmal nocturnal dyspnea
    • Edema
    • Syncope
    • Weakness
    • Chest pain


    • Diaphoresis: sweating
    • Cachexia: profound weight loss
    • Jugulovenous distension (JVD)
    • Neck veins distended above clavicle
    • Rales: wet crackles in lungs heard on inspiration
    • Gallop rhythym: S3, S4
    • Liver enlargement
    • Edema, pitting edema
  2. Has the physician verified that the patient is on optimal diuretic and vasodilator therapy?

    Diuretics Patient should be on optimal dose of one of the following:

    • Furosemide (Lasix)
    • Bumetanide (Bumex)
    • Ethacrynic Acid (Edecrin)
    • Torsemide (Demedex)
    • Metolazone (Zaroxolyn, Mykrox)

    Vasodilators Patient should be on optimal dose of one of the following:

    A. Nitrates (e.g., Nitro patch, isosorbide) plus Hydralazine

    B. Angiotensin Converting Enzyme (ACE) Inhibitor:

    • Benazepril (Lotensin)
    • Captopril (Capoten)
    • Enalapril (Vasotec)
    • Fosinopril (Monopril)
    • Lisinopril(Prinvil, Zestril)
    • Quinapril (Accupril)
    • Ramipril (Altace)
  3. Does patient have ejection fraction of < 20% (only if test results available)?
  4. The following factors are further indications of decreased survival time:
    • Symptomatic supraventricular or ventricular arrhythmias resistant to antiarrhythmic therapy
    • History of cardiac arrest and resuscitation in any setting
    • History of syncope of any cause, cardiac or otherwise
    • Cardiogenic brain embolism, i.e. embolic CVA of cardiac origin
    • Concomitant HIV disease



  • Dyspnea at rest and on exertion
  • Housebound, chairbound
  • Oxygen dependent
  • Copious/purulent sputum
  • Recurrent infections
  • Severe cough
  • Pulmonary hyperinflation: barrel-chested
  • Accessory muscles of respiration
  • Retractions
  • Fatigue
  • Cough
  • Poor response to bronchodilators


  • Forced expiratory volume in one second (FEVI) after bronchodilator is less than 30% of predicted (is objective evidence but not necessary)
  • Decrease in FEVI on serial testing of over 40 ml/year is also helpful but not necessary
  • Hypoxemia at rest on room air with declining O2 saturation and/or PaO2 levels and/or increasing PaCO2 levels
  • Increased hospitalizations for pulmonary infections/respiratory failure
  • Unintentional weight loss of >10% of body weight in past 6 months
  • Resting tachycardia (heart rate > 100 b/min)
  • Presence of cor pulmonate or right heart failure due to lung disease as evidence by:
    • Echocardiographic documentation*
    • Electrocardiogram (EKG)
    • Chest x-ray
    • Physical signs of RHF


Both 1 and 2 must be present as evidence of hospice appropriateness.

  1. Is patient severely demented?
    Patient should be at or beyond Stage 7 of the Functional Assessment Staging Scale.
    • 7A - Ability to speak is limited to approximately 6 intelligible words or fewer, in the course of an average day or in the course of an intensive interview
    • 7B - Speech ability is limited to the use of a single intelligible word in an average day or in the course of an intensive interview (the person may repeat the word over and over)
    • 7C - Ambulatory ability is lost (cannot walk without personal assistance)
    • 7D - Cannot sit up without assistance (e.g., patient will fall over if there are not lateral rests (arm) on the chair).
    • 7E - Loss of ability to smile
    • 7F - Loss of ability to hold up head independently

    Patient should show ALL of the following characteristics:

    • Unable to bathe properly
    • Incontinence of urine and stool (occasionally or more frequently)
    • Unable to speak or communicate meaningfully
    • Unable to ambulate independently
    • Unable to dress without assistance
  2. Has the patient had one or more of the following medical complications related to dementia during the past year?
    • Aspiration pneumonia
    • Upper urinary tract infection
    • Septicemia
    • Decubitus ulcers, multiple, stage 3-4
    • Fever recurrent after antibiotics
    • Inability or unwillingness to take food or fluids sufficient to sustain life; not a candidate for feeding tube or parenteral nutrition

Patients who ARE receiving tube feedings must have documented impaired nutritional status as indicated by either:

  • Unintentional, progressive weight loss of greater than 10% over a period of 6 months, or
  • Serum albumin less than 2.5 g/dL


CD4+ count

  • Measured during a period when patient is relatively free of acute illness
  • Observed disease progression and decline in functional status


Viral load

    • >100,000 copies/ml persistently high as evidenced by 2 or more assays at least 1 month apart


  • patient has elected to forego antiretroviral and prophylactic medication
  • functional status is declining


Patient is experiencing complications including::

  • CNS lymphoma
  • Progressive multifocal leukoencephalopathy
  • Cryptosporidiosis
  • Wasting
  • MAC bacteremia, untreated
  • Visceral Kaposi's Sarcoma unresponsive to therapy
  • Renal failure, refuses or fails dialysis
  • AIDS dementia complex
  • Toxoplasmosis
  • Chronic persistent diarrhea for one year, regardless of etiology
  • Persistent serum albumin
  • Concomitant substance abuse
  • Congestive heart failure, symptomatic at rest


  1. Laboratory indicator of severely impaired liver function (patient should show both of the following):
    • Prothrombin time prolonged more than 5 seconds over control
    • Serum albumin < 2.5 g/dL
  2. Clinical indicators of end-stage liver disease (patient should show at least one of the following):
    • Ascites refractory to sodium restriction and diuretics or patient noncompliant with medication
    • Spontaneous bacterial peritonitis
    • Hepatic encephalopathy refractory to treatment or patient noncompliant
    • Recurrent variceal bleeding despite treatment or patient refuses treatment
    • Hepatorenal syndrome
    • Elevated creatinine and BUN
    • Oliguria
    • Urine sodium concentration < 10 mEq/l


  • Decreased awareness of environment
  • Somnolence
  • Slurred speech
  • Obtundation


  • Coma
  • Progressive malnutrition
  • Muscle wasting with reduced strength and endurance
  • Continued, active alcoholism
  • Hepatocellular carcinoma
  • HBsAg positivity
  • Hepatitis C refractory to interferon treatment


Absent of other co-morbid conditions, the patient should not be seeking dialysis or renal transplant. Patients who do refuse dialysis or transplant are generally appropriate for hospice services if they fit dialysis criteria.
  1. Laboratory criteria for renal failure (one must be present)
    • Creatinine clearance of
    • Serum creatinine >8.0 mg/dl (>6.0 Mg/dl for diabetics)
    • Estimated Glomerular Filtration Rate (GFR)
    • If the patient has co-morbid CHF then Creatinine Clearance of
  2. Clinical signs and syndromes associated with renal failure
    • Uremia
    • Oliguria
    • Intractable hyperkalemia unresponsive to treatment
    • Uremic pericarditis
    • Hepatorenal syndrome
    • Intractable fluid overload


  1. Rapid progression of ALS. Most of disability should have developed in past 12 months.
    • Progression from independent ambulation to wheelchair or bed-bound
    • Progression from normal to barely intelligible or unintelligible speech
    • Progression from normal to blenderized diet
    • Progression from independence in all or most ADLs to requiring assistance in all ADLs
  2. In the end stages of ALS there are two factors that are critical for consideration of prognosis: the ability to breathe and the ability to swallow. A and/or B should be present to demonstrate end stage disease.
    A. FVC (forced vital capacity)
    (2 or more of the following):
    • Dyspnea at rest
    • Orthopnea
    • Use of accessory respiratory musculature
    • Paradoxical abdominal motion
    • Respiratory rate >20
    • Reduced speech/vocal volume
    • Weakened cough
    • Symptoms of sleep disordered breathing
    • Frequent awakening
    • Daytime somnolence/excessive daytime sleepiness
    • Unexplained headaches
    • Unexplained confusion
    • Unexplained anxiety
    • Unexplained nausea

    If patient is unable to perform the FVC test, patients meet this criteria if they manifest 3 or more of the above signs/symptoms

    B. Dysphagia with progressive weight loss of at least 5% of body weight.
    Patient may or may not have elected for gastrostomy tube insertion.


Patients who are post stroke should have evidence of reduced functional ability and an inability to maintain appropriate nutrition or hydration as evidenced by both factors listed below.
  1. Have decreased performance status, as measured by the Palliative Performance Status (PPS) scale, of
  2. Inability to maintain hydration and caloric intake with one of the following:
    • Weight loss >10% in the last 6 months or >7.5% in the last 3 months
    • Serum albumin
    • Current history of pulmonary aspiration not responsive to speech language pathology intervention
    • Sequential calorie counts documenting inadequate caloric/fluid intake
    • Dysphagia severe enough to prevent patient from continuing fluids/foods necessary to sustain life and absence of artificial nutrition and hydration (tube feeding, IV fluids)

COMA (any etiology)

Comatose patients who have any 3 of the following criteria on Day 3 of a coma is an indication of poor prognosis:
  • Abnormal brain stem response
  • Absent verbal response
  • Absent withdrawal response to pain
  • Serum creatinine >1.5 mg/dL
Additional information that may aid in supporting a hospice diagnosis is any of the following:
  • Aspiration pneumonia
  • Fever recurrent after antibiotics
  • Pyelonephritis (upper urinary tract infection)
  • Refractory stage 3-4 decubitus ulcers
If available diagnostic imaging may support poor prognosis as evidenced by:
  • Large volume hemorrhage on CT
  • Ventricular extension of hemorrhage
  • Midline shift
  • Obstructive hydrocephalus on patients who are declining or are not candidate for shunt
  • Large anterior infarcts with cortical and subcortical involvement
  • Large bihemispheric infarcts
  • Basilar artery occlusion
  • Bilateral vertebral artery occlusion


The patient should meet the following criteria:
  1. The patient should be showing decreased performance status (Palliative Performance Status of
  2. A and/or B must be present
    • A. Disease with distant metastases at presentation AND/OR
    • B. Aggressive or progressive disease as evidenced by increasing symptoms, worsening lab values, and or evidence of metastatic disease

    NOTE: Certain cancers with poor prognosis like small cell lung cancer, brain cancer, and pancreatic cancer may be hospice eligible without fulfilling other criteria in this section.

  3. Refuses further life prolonging therapy OR continues to decline despite definitive therapy

Additional supporting factors for Cancer

  • Hypercalcemia >12
  • Chachexia or weight loss of 5% on past 3 months
  • Recurrent disease after surgery/radiation/chemotherapy
  • Other signs of advanced disease including nausea, anemia, ascites, pleural effusions


Copyright © 2013 Hospice of the Carolina Foothills