Admission Guidelines

Admission & Recertification Guidelines for Hospice

  • Terminal diagnosis,
  • Life expectancy of six months or less;
  • Certified by 2 physicians
  • Patient must give consent (DPOA or family if patient is unable to do so) ;
  • To bill for continuous care provide 8 hours a day care starting at 12 am
  • Patient can choose any physician to be his attending
  • The patient could consult another physician for secondary diagnosis (not for primary Dx that is the one he was admitted with)
  • Respite care is for 5 days : should be use infrequently; Psychosocial crisis of the caregiver may result in use of respite care;

Core measures:

  • General physical decline
  • PPS palliative performance scale = Karnofsky Scale < 70% (lower for HIV, stroke & coma)
  • FAST score for dementia worse than 7a
  • Decline in functional status: at least 2 or more ADL’s: (ABCDEF) Ambulation, Bathing, Continence, Dressing, Elevate (transfer), Feeding,
  • Decline in Descriptive scale : (MMNPE) Mental status; Mobility; Nutritional; Pain; Endurance.
  • Stage 3 or 4 pressure ulcers
  • Increase ER visits / multiple hospitalizations /physician office visits
  • Declining enteral / parenteral support
  • Multiple co-morbities: other diseases or s/s afflicting the patient
  • Rapid disease progression
  • Documenting life threatening complications with emphasis on positive and negative clinical findings
  • Worsening clinical status
  • Worsening s/s despite the treatment
  • Recurrent infections
  • Weight loss: > 10% in 6 months; 5% in 3 months ; despite food/fluid intake or due to decreased appetite which is documented with measuring weight or mid-arm circumference or abdominal girth or skin turgor or visualized weight loss: ill-fitting clothes or loose dentures or visual description of family members; decrease muscle mass
  • Ascites : weigh the patient & abdominal girth
  • Pain : not controlled or poorly controlled
  • Patient / family / friends/ DPOA : all wants patient to be on hospice
  • Patient desire / will to die
  • Serum albumin < 2.5 gm/dl
  • Dyspnea at rest, increased respiratory rate, using abdominal or accessory muscles, forced vital capacity <30%, needs O2 at rest, declining artificial ventilation
  • Intractable : cough, nausea, vomiting, diarrhea poorly responsive to treatment
  • Severe edema
  • Fluid retention: peripheral, pleural, pericardial & lymphatic spaces
  • Increased weakness
  • Systolic blood pressure < 90, or severe postural hypotension
  • Document all co-morbidities
  • Document clinical regression
  • Document declining in functional, structural & ADLs
  • Changes in the level of consciousness
  • Worsening of other symptoms : document all
  • Dysphagia: leading to recurrent aspiration &/or inadequate oral intake shown as decrease food / fluid intake
  • Labs (not essential) pCO2 or p02 or Sa02 ; high Calcium / creatinine / LFT (liver function tests); tumor markers (CEA or PSA) ; abnormal serum sodium or potassium (low or very high), Leukocytosis, , Lymphocytopenia, high CRP, high LDH (Take an action on any tests being done).
  • Patients should be discharged as soon as the team determines that they are not eligible & improved & stabilized then give 2 days of advance notice provided they are safe (follow your safe discharge policies).
  • The patients originally qualify for hospice but stabilize & improve while under hospice care, yet have a reasonable expectation of continue decline with life expectancy of < 6 months remain eligible for hospice

Palliative performance scale (PPS)

Palliative performance scale (PPS) or Karnofsky scale : (memorise this: fifty is fifty = fifty sit & lie; forty is flat; thirty is unable to feed) 100=normal; 80= normal with some disease, reduced or normal intake; 70= reduced ambulation, full self-care, unable to work; some disease; 60=reduced ambulation, able to care for most needs but occasionally require assistance; 50= sit/lie remember 50/50, needs considerable assistance, extensive disease; 40= mainly in bed but able to feed self, disable, require assistance; reduced intake; 30= unable to feed himself, totally bed bound, severely disable, extensive disease; 20=totally bed bound, very sick, extensive disease; 10=totally bedbound,total care; 0=dead

FAST SCORE : functional assessment scale

FAST SCORE 1.No difficulties. 2. Subjective forgetfulness 3. Difficulties at work / organizational activities 4. Difficulties with complex tasks, instrumental ADL’s 5.Require help with ADL’s 6. Impaired ADL’s with incontinent. 7. A. speech limited to 6 words (qualifies for hospice) B. single word C. unable to ambulate D. unable to sit E. unable to smile F. unable to hold head up.

NYHA CRITERIA ( New York Heart association criteria )

1.no limitation. 2.Mild: Ok at rest, fatigue, palpitation, dyspnea with ordinary activity. 3. Moderate: limitated activities, less than ordinary activities causes: fatigue, palpitation, dyspnea. 4. Class IV : Severe: unable to carry out any physical activities without discomfort, symptomatic cardiac insufficiency at rest,

ADL ( Activities of daily living)

Activities of daily living decline in 2 or more ADL’s

I made mnemonic for (ABCDEF) Ambulation, Bathing, Continence, Dressing, Elevate (transfer),Feeding.

Scale is 1 to 4.

1 being completely dependent; 4 being independent.

DESCRIPTIVE SCALE

my nemonic is : MMNPE :

Mental status; Mobility; Nutritional; Pain; Endurance.

Scale 1 to 5. 5 being normal

Mental status: 1 comatose, 5 normal; Mobility: 1 unable to turn in bed, 5 up ad lib Nutritional : 1 no fluids, 5 eats/drink normally; Pain: 1 pain 9-10, 5 pain is 0-2 Endurance: 1 needs maximum assist; 5 no assistance

Protein calorie Malnutrition

PPS <40% mostly in bed, dependent on > 2 ADL; Descriptive score of 20 or less BMI < 22 BMI (kg/m2 = 703 x (weight in pounds) / (height in inches)2 patient / family / DPOA wants hospice care refusing curative care, parenteral / enteral nutrition not responding to any nutritional support weight loss >10% in 6 months; > 5% in 3 months Patient desire / will to die infections: aspiration, UTI, sepsis unable to maintain sufficient calories or fluids serum albumin < 2.5 gm/dl stage 3 or 4 pressure ulcers increase ER visits / multiple hospitalizations /physician office visits document all comorbities, no primary Dx emphasis on core indicators

Malignancy; cancer

Diagnosis confirmed through pathology / radiology pancreatic cancer, diffuse small cell cancer of lung, some CNS Tumors have poor prognosis Patient no longer receiving &/or declining curative or life prolonging therapies; Continued decline in spite of therapy progression of the disease with metastasis, palliative performance scale < 70%; ADL 18 or less, defendant on 2 or more ADL’s; Descriptive 25 or less hypercalcemia > 12 weight loss10% in 6 months; 5% in 3 months; S/S of advanced disease: intractable nausea / vomiting, ascites, effusion, multiple transfusion, malignant ascites individually evaluate the patients for palliative chemo / radiation therapies, if team agrees, go for it

ALS Amyotrophic lateral sclerosis: dysphagia & disabling dysphagia are worst prosnosticaters

rapidly declining during the preceding 12 months Disabling dyspnes : Vital capacity < 30% + two or more signs: significant dyspnea at rest with use of abdominal / accessory muscles, orthopnea, Paradoxical abdominal motion, Respiratory rate > 20 per minute, Requires O-2 at rest, weak cough, decline assisted ventilation Dysphagia : Critical nutritional impairment dehydration aspiration nausea, weight loss Poor speech / reduced vocal volume, barely discernible speech other comorbidities complications : infections, sepsis, decubiti, PPS < 50% decline in ADL 5 or less descriptive score < 18

Cardiac diseases

CHF with NYHA class IV significant S/S at rest dyspnea & angina with minimal physical activity, or at rest patient had been optimally treated with the Diuretics, ACEI, Vasodilators, Hydralazine, Nitrates not a candidate or declined curative / invasive /surgical therapies declining despite maximal medical management arrhythmias resistant to treatment EF ejection fractions < 20% h/o cardiac related / unexplained syncope, cerebrovascular accident due to cardiac embolism s/p cardiac resuscitation PPS < 60%; ADL 18 or less; Descriptive 20 or less

Diabetes

History of diabetes>20 yrs. Severe vascular disease ; CVA, MI, CHF, Angina Amputation or ulcer due to vascular complications Severe hypertension, Frequent infections PPS < 60%; ADL 12 or less; Descriptive 21 or less

AIDS / HIV

CD 4 < 25/ ml Viral load > 100,000 /ml Wasting syndrome ( loss of > 33% lean body mass or 10% weight loss chronic persistence diarrhea for > 1 year not receiving TPN Reccurent opportunistic infections patient not receiving active treatment AIDS dementia complex Age> 50 years Renal failure not on hemodialysis PPS of < 60%; ADL of 18 or less; Descriptive score of 20 or less

Liver disease

End stage liver disease Abnormal liver enzymes, abnormal coagulation : INR > 1.5; PT > 5 seconds over control serum albumin < 2.5 gm/dl One of these: refractory Ascites, recurrent variceal bleeding, spontaneous bacterial peritonitis, hepatorenal syndrome, oligouria, refractory hepatic encephalopathy, PPS < 60%; ADL 18 or less; Descriptive 20 or less progressive malnutrition, muscle wasting, > 80 gm. ethanol / day, hepatocellular cancer, HBsAg positive, Hepatitis C refractory to treatment

Neurological disorders

Unable to walk, talk & eat Unable to walk without assistance; needs assistance with ADLs, barely intelligible speech Dysphagia nutritional status down general decline disease progression emphasis on core indicators declines assisted ventilation complications: pneumonia, UTI, sepsis, and decubiti

Alzheimer’s disease (Dementia)

Alzheimer’s or related Fast scale 7a or beyond Unable to walk without assistance Urinary and bowel incontinent Insufficient fluid or food intake with weight loss, albumin < 2.5 gm/dl In the last 12 months aspiration; recurrent infections / fever; decubiti stage 3-4; sepsis; UTIs;

CVA (cerebrovascular accident); Stroke

Chair or bed-bound Large CVA: large anterior or bihemispheric infarct basilar artery or bilateral vertebral arterial occlusion Dysphagia Decreased appetite,food/fluid intake, > 10% wt. loss in 6 months or > 5 % in 3 months, Serum albumin < 2.5 gm./dl Age >70 Aspiration: failed speech / other measures Post-stroke dementia poor functional status; PPS < 40%, ADL 18 or less; Descriptive 20 or less Complications: pneumonia, UTI, sepsis, and decubiti Non-traumatic hemorrhage > 20 ml infratentorial; > 50 ml suprtentorial; or intraventicular extension Midline shift > 1.5 cm Stroke involving > 30% of cerebrum Decline surgical intervention / curative therapies (not a candidate)

COMA

Comatose for more than 3 days, no drugs on screening Abnormal brain stem response, absent verbal response, Absent withdrawal response to pain, Serum creatinine > 1.5 gm. /dl progressively declined in the last year PPS < 60%; ADL 18 or less; Descriptive 20 or less

Respiratory / Pulmonary diseases; COPD

Disabling dyspnea at rest or with minimal activities, little or no response to bronchodilators, Decrease functional capacity O2 dependent; hypoxemia at rest on room air O-2 sat < 88% pO-2 < 55 mm HG FEV1 < 30% with bronchodilators Multiple pulmonary medications Recurrent pulmonary infections unintentional progressive Weight loss >10% in the last 6 month Resting tachycardia >100/min bed to chair, fatigue, cough Increasing ER, Office, hospital visits for lung infections or respiratory failure Karnofsky < 60%; ADL 18 or less; Descriptive 20 or less Cor pulmonale, right heart failure,

Renal diseases

Discontinuing or refusing dialysis & / or transplant Signs of uremia (confusion, nausea, puritius, and restlessness) Chronic or acute illness that precipitated renal failure Creatinine > 8 mg/dl (> 6 mg/dl in diabetes) Creatinine clearance < 10 cc / min (< 15 cc/ min in diabetes) Oliguria < 400 cc/ 24 hrs Hyperkalemia > 7.0 meq / L Others: Uremia; Uremic pericarditis; Hyperkalemia > 7.0; fluid overload Karnofsky < 60%; ADL 18 or less; Descriptive 20 or less Other co-morbid conditions

Discharge or keep the patient on service:

Safe discharge : should be discharged as soon as the team determines that they are not eligible & improved & stabilized then give 2 days of advance notice provided they are safe Keep: Patients originally qualify for hospice but stabilize & improve while under hospice care, yet have a reasonable expectation of continue decline with life expectancy of < 6 months remain eligible for hospice

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