End of Life Indicators

It is often difficult to determine when a patient may have a life expectancy of six months or less. We provide the following guidelines to assist you in determining if your patient is appropriate for hospice care. They are to be viewed as guidelines and not mandated criteria. We always want to discuss potential referrals with you, so please feel free to call us at 845-634-4974.

GENERAL GUIDELINES (applicable to all diagnoses)

  • Recurrent infections: pneumonia, sepsis, pyleonephritis
  • Multiple hospital or ER visits, increasing MD visits
  • Progressive weight loss >10% in prior six months not attributable to reversible cause
  • Significantly decreased intake, artificial nutrition/hydration declined
  • Non-healing pressure ulcers (Stage III or IV) with or without optimal care
  • HGB<10; Albumin <2.5 when available
  • Ascites or edema
  • Systolic BP below 90 or progressive postural hypotension
  • Uexplained or refractory fevers
  • Changes in level of consciousness
  • Increasing dependence of ADLs
  • Palliative Performance Score <70 (click for additional information on the PPS) or Karnofsky Performance Status <70 (click for additional information on KPS)
  • Symptoms poorly responsive to treatment: dyspnea, cough, nausea, vomiting, pain, diarrhea
  • Labs (when available but not required) : increasing pCO2 or decreasing pO2 or decreasing SaO2, increasing calcium, creatinine or liver function studies, increasing tumor markers (CEA, PSA), progressively decreasing/increasing serum sodium or increasing potassium
  • Co-morbid conditions such as: dementia, COPD, CHF/ischemic heart disease, diabetes,neurological disease, advanced kidney disease, advanced liver disease, HIV/AIDS, autoimmune disease, malignancy

CANCER

  • Confirmed diagnosis by pathology or radiology
  • Pt. no longer receiving/not a candidate for curative treatment
  • Evidence of end stage or metastatic disease
  • Recent lab/diagnostic studies supporting evidence of disease
  • Poorly responsive to chemotherapy/other disease treatment
  • Contributing co-morbidities

CARDIAC DISEASE

  • New York Heart Association Class IV: Symptoms of heart failure or anginal syndrome present at rest, unable to engage in any physical activity
  • Medically optimized with diuretics and vasodilators and supplemental oxygen
  • Ejection fraction <20%
  • Pt is not a candidate for or they have declined surgical procedures
  • Diagnosis-specific supporting factors: treatment resistant symptomatic supraventricular or ventricular arryhythmias, history of cardiac arrest or resuscitation, history of unexplained syncope, brain embolism of cardiac origin, severe valvular hear disease, comorbid HIV

RENAL FAILURE

  • Not seeking or discontinuing dialysis AND one of the next three criteria:
  • Creatinine Clearance <10cc/min, <15 cc/min. for diabetics OR for patients with comorbidity of CHF <15cc/min, <20cc/min. for diabetic and CHF
  • Serum creatinine > 8mg/dl (>6 mg/dl for diabetics)
  • Estimated glomerular filtration rate (GFR) <10 mL/min.
  • Uremia
  • Oliguria (<400c/24 hours)
  • Intractable hyperkalemia (>7.0 mEq/L) not responsive to treatment
  • Uremic pericarditis
  • Hepatorenal sundrome
  • Intractable fluid overload
  • Contributing comorbidities: advanced cardiac, liver or lung disease, malignancy or AIDS, albumin<3.5gm/dl, platelet count <25,000, DIC, GI bleeding, sepsis

PULMONARY DISEASE

  • Severe chronic lung disease as documented by disabling dyspnea at rest, unresponsive to broncodilators resulting in decreased fucntional capacity, ex: bed to chair, fatigue cough. FEV1 after bronchodilaor <30% (but not necessary to obtain) AND
  • Progression of end stage pulmonary disease by increasing visits to the ER, hospitalizations for pulmonary infections and/or respiratory failure or arrest. Serial decrease of FEV1 >40ml/year (not necessary to obtain) AND
  • Hypoxemia at rest on room air, as evidenced by pO2< or = 55mmHg, oxygen saturation < or= 88% OR pCO2 > or = 50mm Hg determined by ABG or oxygen saturation monitors from recent hospital records.
  • Resting tachycardia > 100/min
  • Right heart failure secondary to pulmonary disease (cor pulmonale), not secondary to left heart disease or valvulopathy

STROKE AND COMA

Stroke

  • Poor nutritional status/dysphagia severe enough to prevent patient from continuing fluids/food necessary to sustain life
  • Chair or bed bound
  • Current history of pulmonary aspiration
  • Karnofsky Scale or Palliative Performance Scale <40 (Click on higlighted Karnofsky Scale and/or Palliative Performance Scale for additional info.)

Coma

  • Any three of the following symptoms on day three of the coma: abnormal brain stem response, absent verbal response, absent withdrawal response to pain, serum creatinine 1.5 mg/dl
  • Documentation of the following factors lend support to eligibility: (a) Medical complications, in the context of progressive clinical decline, within the previous 12 mos., which support a terminal diagnosis: aspiration pneumonia, pyleonephritis, refractory stage 3-4 pressure ulcers, fever after recurrent anitbiotics (b) diagnostic imaging factors that support a poor prognosis after stroke include: for non traumatic stroke: large volume hemorrhage on CT, infratentorial: > or =20 ml, or supratentorial > or = 50 ml. (c) ventricular extension or hemorrhage: Surface area of hemorrhage > or = 30% of cerebrum, midline shift > or = 1.5cm., or obstructive hydocephalus in patient who declines , or is not a candidate for ventriculoperitoneal shunt. (d) thrombotic/embolic stroke: large anterior infarcts with both cortical and subcortical inolvement, large bihemispheric infarcts, basilar artery occlusion, bilateral vertebral artery occlusion

ALZHEIMER'S DISEASE/DEMENTIA

  • Beyond Stage 7 of the Functional Assessment Staging Test (Click for info. on FAST)
  • No consistently meaningful verbal communication or word salad
  • Cannot eat, walk or sit up without assistance
  • History of progressive weight loss
  • Presence of medical complications within the past year: aspiration pneumonia, UTI, pressure ulcers, septicemia, recurrent fevers after antibiotics

LIVER DISEASE

  • INR>1.5; PT>5 seconds over control
  • Ascites, recurrent or refractory to treatment
  • Spontaneous bacterial peritonitis
  • Hepatorenal Syndrome (elevated creatinine and BUN with oliguria (<440 ml/day) and urine sodium concentration < 10mEq/l)
  • Hepatic Encephalopathy
  • Serum Albumin <2.5gm/dl
  • Recurrent variceal bleeding
  • Supporting documentation: Progressive malnutrition, muscle wasting, active alcoholism, positive Hep B/Hep C refractory to treatment, hepatocellular carcinoma

ALS

Two factors are critical in determining prognosis: Ability to breathe and swallow

  • Critically impaired breathing capcity and invasive ventilation declined as indicated by FVC < 40% and at least TWO (if no FVC then at least three of the following), with or without: dyspnea at reast or oxygen dependence at rest, orthopnea, accessory muscle use, paradoxical abdominal motion, respirtory rate >20, speech greatly reduced in qunatity, volume, intelligibility, weak cough, sleep disordered breathing (frequent awakening, excessive daytime fatigue), otherwise unexplained headache, confusion, anxiety or nausea

AND/OR

    Severe dysphagia and nutritional insufficiency inclduing weight loss >5% with or without artificial nutrition

HIV Disease

  • CD4 + count below 25 cells/mcL or viral load (HIV RNA) > 100,000
  • Decreasing performance status, as measured by KPS/PPS of 50% ( as evidenced by mainly sit/lie, extensive disease, considerable assistance required and normal or reduced intake)
  • One of the following: AIDS-defining illness (ex: lymphoma, cryptosporidosis, PML.MAC, toxoplasmosis), renal failure. AIDS wasting syndrome (weight loss> 10%)

Diagnosis supporting factors:

  • CNS Lymphoma
  • Progressive multifocal leukoencephalopathy
  • Age > 50
  • Chronic persistent diarrhea x 1 year, CHF, advanced AIDS dementia complex, advanced liver disease, active substance abuse, non-compliance with, refusal of, or resistance to antiretroviral/prophylactic regimen