Disease specific guidelines

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

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