Diagnosis Guidelines, Prognosis & Eligibility

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Northern Illinois Hospice cares for patients who have terminal diagnoses, including cancer, heart disease, ALS, pulmonary disease, stroke, liver disease and dementia, with a prognosis of six months or less. Guidelines, prognosis and eligibility requirements are detailed below to help determine if your patient is ready for hospice.

To refer a patient to Northern Illinois Hospice, click on the link on the right.

All Diagnoses

  • A life-limiting condition must exist with expected life span of 6 months or less if the illness runs its normal course
  • Progression of disease as documented by worsening clinical status, symptoms, signs and laboratory results
    • By disease specific markers – physical examination, labs, imaging
    • Lab testing is not required to establish hospice eligibility but markers may include:
      • Increasing pCO2 or decreasing pO2 or decreasing Sa02
      • Increasing calcium, creatinine or liver function studies
      • Increasing tumor markers (e.g., CEA, PSA)
      • Progressively decreasing or increasing serum sodium or increasing serum potassium
    • History of increasing ER visits, hospitalizations, or physician visits related to the hospice primary diagnosis
    • Decline in functional status
    • Dependence in 3 or more activities of daily living (ADLs):
      • Ambulation
      • Continence
      • Transfer
      • Dressing
      • Feeding
      • Palliative Performance Scale (PPS) <50%. (Note: several disease specific guidelines establish a lower qualifying PPS)
  • Impaired nutritional status
    • Weight loss 10% over past 6 months not due to reversible causes such as depression or use of diuretics
    • Decreasing anthropomorphic measurements (mid-arm circumference, abdominal girth), not due to reversible causes such as depression or use of diuretics
    • Observation of ill-fitting clothes, decrease in skin turgor, increasing skin folds or other observation of weight loss in a patient
    • Decreasing serum albumin or cholesterol (serum albumin

Alzheimer’s Disease and Related Disorders

  • Fast Scale Stage #7: Loss of speech, locomotion and consciousness:
    • Ability to speak limited (1 to 5 words a day)
    • All intelligible vocabulary lost
    • Non-ambulatory
    • Unable to sit up independently
    • Unable to smile
    • Unable to hold head up
  • Specific secondary and co-morbid conditions also support eligibility for hospice care
    • Co-morbid Conditions Impacting Prognosis (e.g., CHD, COPD) along with structural/functional impairment – together with limitation in activity-related to the co-morbid condition
    • Secondary Conditions Impacting Prognosis (e.g., Delirium, pressure ulcers) along with structural/functional impairment – together with limitation in activity – related to the secondary condition

Cancer

  • Patient meets the following criteria:
    • Progression from an earlier stage disease to a metastatic disease with continued decline in spite of therapy
    • Clinical findings of malignancy or reasons not available
    • Tissue diagnosis of malignancy or reasons not available
    • Palliative Performance Scale (PPS) value less than or equal to 70%
    • Continues to decline in spite of definitive therapy
  • Rapid decline and/or specific secondary and co-morbid conditions
    • Co-morbid Conditions Impacting Prognosis (e.g., Cerebrovascular, CHF, COPD, Diabetes, PVD, Coronary Heart, Renal)
    • Secondary Conditions Impacting Prognosis (e.g., pressure ulcers, joint contractures, UTI, depression)
  • Supporting Documentation
    • Hypercalcmia > or = 12
    • Cachexia or weight loss or 5% in the preceding three months
    • Recurrent disease after surgery/radiation/chemotherapy
    • Signs and symptoms of advanced disease (e.g., nausea, requirement for transfusions, malignant ascites, pleural effusion, etc.)

Cardiopulmonary

  • Patient with:
    • Sufficient clinical information including specific structural/functional impairments and relevant activity limitations and other documentation to support the life expectancy of 6 or fewer months if the illness runs its normal course.
    • Use of the International Classification of Functioning. Disability and Health (ICF) to help identify and document the unique and document the unique services of individuals with cardiopulmonary conditions is suggested but not required. The ICF contains domains (e.g., structures of cardiovascular and respiratory systems, functions of the cardiovascular and respiratory system, communication, mobility and self care) that allow for a comprehensive description of an individual’s health status and service needs.
  • Specific secondary and co-morbid conditions also support eligibility for hospice care
    • Secondary Conditions Impacting Prognosis (e.g., Delirium, pneumonia, stasis ulcers and pressure ulcers)
    • Co-morbid Conditions Impacting Prognosis (e.g., ESRD)

End Stage Renal Disease

  • Patient with:
    • Sufficient clinical information including specific structural/functional impairments and activity limitations and environmental factors support the life expectancy of 6 or fewer months if the illness runs its normal course.
    • Use of the International Classification of Functioning, Disability and Health (ICF) to help identify and document the unique service needs of individuals with cardiopulmonary conditions is suggested but not required. The ICF contains domains (e.g., structures of cardiovascular and respiratory systems, functions of the cardiovascular and respiratory system, communication, mobility and self care) that allow for a comprehensive description of an individual’s health status and service needs.
  • Specific secondary and co-morbid conditions also support eligibility for hospice care
    • Co-morbid Conditions Impacting Prognosis (e.g., Vascular Dementia, PVD, Coronary Heart Disease)
    • Secondary Conditions Impacting Prognosis (e.g., Hyperkalemia, fluid overload and secondary hyperparathyroidism)

HIV
Patient meets both 1 and 2. Factor 3 will add supporting documentation.

  1. CD4+ Count100,000 copies/ml, plus 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

  2. Decreased performance status, as measured by the Karnofsky Performance Scale (PPS) scale, of < or = to 50
  3. Documentation of the following factors will support eligibility for hospice care:
    • Chronic persistent diarrhea for one year
    • Persistent serum albumin <2.5
    • Concomitant, active substance abuse
    • Age> 50 years
    • Absence of antiretroviral, chemotherapeutic and prophylactic drug therapy related specifically to HIV disease
    • Advanced AIDS dementia complex
    • Toxoplasmosis
    • Congestive heart failure, symptomatic at rest

If the patient does not meet the criteria outlined above, yet is deemed appropriate for hospice care, sufficient documentation of the patient's condition that justifies terminal status would be necessary.

Liver Disease
Patient meets both 1 and 2.

  1. Severely impaired liver function with both:
    • Prothrombin time prolonged more than 5 seconds over control, or International Normalized Ratio (INR)> 1.5
    • Serum albumin
  2. End stage liver disease with at least one of the following:
    • Ascites, refractory to treatment or patient non-complaint
    • Spontaneous bacterial peritonitis
    • Hepatorenal syndrome [elevated creatinine and BUN with oliguria (<400ml/day) and urine sodium concentration
    • Hepatic encephalopathy, refractory to treatment, or patient non-complaint
    • Recurrent variceal bleeding, despite intensive therapy

Documentation of the following factors supports eligibility for hospice care:

  • Progressive malnutrition
  • Muscle wasting with reduced strength and endurance
  • Continued active alcoholism (> 80 gm ethanol/day)
  • Hepatocellular carcinoma
  • HBsAg (Hepatitis 8) positivity
  • Hepatitis C refractory to interferon treatment

Patients awaiting a 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 must be discharged from hospice.

Neurological Disease

  • Patient with:
    • Sufficient clinical information including specific structural/functional impairments and relevant activity limitations and other documentation to support the life 'expectancy of 6 or fewer months if the illness runs its normal course.
    • Use of the International Classification of Functioning, Disability and Health (ICF) to help identify and document the unique service needs of individuals with cardiopulmonary conditions is suggested but not required. The ICF contains domains (e.g. structures of cardiovascular and respiratory systems, functions of the cardiovascular and respiratory system, communication, mobility and self care) that allow for a comprehensive description of an individual's health status and service needs.
  • Specific secondary and co-morbid conditions also support eligibility for hospice care
    • Co-morbid Conditions Impacting Prognosis (e.g., COPD)
    • Secondary Conditions Impacting Prognosis (e.g., dysphagia, pneumonia and pressure ulcers)

Stroke or Coma
Patient meets both 1 and 2.

  1. Palliative Performance Scale (PPS) value less than or equal to < or = to 40%
  2. Poor nutritional status with inability to maintain sufficient fluid and calorie intake with more than one of the following:
    • or = to 10% weight loss in the past 6 months
    • or = to 7.5% weight loss in past 3 months
    • Serum albumin
    • Current history of pulmonary aspiration without effective response to speech therapy interventions to improve dysphagia and decrease aspiration events

Supporting documentation includes:

  • Coma (any etiology) with 3 of the following on the third day of coma
  • Abnormal brain stem response
  • Absent verbal responses
  • Absent withdrawal response to pain
  • Serum creatinine > 1.5 gm/di

Specific secondary and co-morbid conditions also support eligibility for hospice care

  • Co-morbid Conditions Impacting Prognosis (ex. Cerebrovascular, CHF, COPD, Diabetes, PVD, Coronary Heart, Renal)
  • Secondary Conditions Impacting Prognosis (ex pressure ulcers, joint contractures, UTI, depression)

*Information listed is subject to change.


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