Determining Eligibility

(also known as Lou Gehrig’s Disease)

• An ALS patient should be referred to hospice when they exhibit “rapid progression” with critically impaired function in one of the following areas:

Pulmonary

Nutritional

Serious infection complications

Rapid Progression means that the preceding 12 months, the patient has progressed in some of these ways:

• From independent ambulation to bed bound status
• From relatively normal speech to unintelligible speech
• From a normal diet to pureed diet
• From independence to needing major assistance in all activities of daily living
• Significant dyspnea at rest
• Vital capacity (VC) <30% of normal
• FVC <40% predicted (seated/supine)
• Requiring supplemental oxygen at rest
• Declines invasive artificial ventilation
• Absence of artificial feeding methods
• Recurrent aspiration pneumonia (with or without artificial feedings)
• Recurrent fever after antibiotic therapy
• Stage 3-4 decubitus ulcer(s)
• Oral intake of nutrients and fluid insufficient to sustain life
• Continuing weight loss
• Respiratory rate >20
• Weakening cough
• Symptoms of sleep disordered breathing
• Unexplained headaches
• Unexplained confusion
• Unexplained anxiety
• Unexplained nausea

• Vital capacity of less than 30% of normal
• Significant dyspnea at rest
• Requiring supplemental oxygen
• Declining artificial ventilation
• Nutritional

1. An insufficient oral intake of nutrients and fluid to sustain life
2. Significant weight loss (clothes too big, arm circumference, % of meals eaten)
3. Signs of dehydration
4. Declining artificial feeding methods

• Serious infection complications

1. Recurrent aspiration pneumonias
2. Upper urinary tract infections
3. Sepsis
4. Stage III or IV decubitus ulcers
5. Recurrent fevers despite antibiotic therapy

• A pulmonary patient should be referred to hospice when they exhibit end-stage lung disease:
• Persistent breathlessness despite optimal medical therapy
• Inability to get out of the house despite pulmonary rehabilitation
• Increasing number of hospital admissions
• Limited improvement after hospital admission
• Weight loss
• Fatigue
• Loss of energy
• Expressions of fear, anxiety, panic attacks
• Patients express concern about dying
• LCD Criteria – need all three

1. Disabling dyspnea at rest, poor response to bronchodilators, bed to chair existence, persistent cough
2. Progression of disease: Prior increasing visits to ER or prior increased hospitalizations for pulmonary infections or respiratory failure
3. Hypoxemia at rest: patients must be on oxygen having a PO2 <55 or O2 saturation <88% documented is good

• The following documentation is helpful, but not required:

1. Cor pulmonale (Right Heart Failure)
2. Unintentional progressive weight loss of >10% over the preceding 6 months

• Resting tachycardia > 100 bpm
• Pulmonary Symptoms:
• Chest tightness
• Wheezing
• Cyanosis
• Cold extremities
• Tachypnea
• Orthopnea
• Weak pulse
• Shallow breaths
• Increased work of breathing
• Edema/location
• Jugular vein distention
• Mottling/location
• Reduced capillary refill
• Gagging/choking
• Irregular breaths
• Reduced speaking ability
• Arrythmia

• LCD is for CHF
• Not included in the LCD

1. Coronary Artery Disease
2. Valvular Heart Disease
3. Arrhythmias (V-fib)

• Pacemakers have a minimal effect on prognosis
• Internal defibrillators – try to get cardiologists to discontinue when patient is terminal
• LCD Criteria:

1. Optimal Medical Treatment
2. Diuretics, vasodilators, ACE inhibitors, Nitrates, Coreg
3. Patient having chest pain or dyspnea at rest and is either refusing or not a candidate for surgery
4. NYHA class IV

• New York Heart Association Class IV
• Unable to carry on any physical activity without symptoms (chest pain, shortness of breath)
• Symptoms are present even at rest
• If any physical activity is undertaken symptoms are increased

Ejection Fraction

• The ejection fraction is the percent of blood that is pumped out of the left ventricle on one beat.
• It is usually measured on a cardiac ultrasound

1. Normal: 50-75%
2. Low: <35%
3. Life expectancy under 6 months: <20%

• The following documentation is helpful, but not required:
• History of cardiac arrest or resuscitation
• History of unexplained syncope
• Brain embolism of cardiac origin
• Concomitant HIV
• Ejection Fraction of 20% or less
• Check the medication list – optimal?
• Get a good history about surgeries, angioplasties, stents, ER and hospital visits
• Get a good history about current symptoms and with what activities
• Ask if they know their ejection fraction
• Oxygen dependent?
• End Stage Heart Disease Symptoms:
• Chest tightness
• Cyanosis
• Tachypnea
• Orthopnea
• Reduced capillary refill
• Wheezing
• Weak Pulse
• Shallow breaths
• Jugular vein distention
• Gagging/choking
• Reduced speaking ability
• Irregular breaths
• Arrhythmia
• Increased work of breathing
• Edema
• Mottling
• Cold Extremities
• Increased work of breathing
• Edema
• Secondary and/or comorbid conditions are directly related to a primary condition:
• Delirium
• Pneumonia
• Stasis ulcers and pressure ulcers
• Endstage Renal Disease (ESRD): related impairments of water, mineral and electrolyte balance-coexisting with cardiopulmonary impairments associates with the primary cardio condition (Aortic Stenosis, COPD, Heart Failure)

• LCD Requirement – Three criteria:
• Prothrombin Time prolonged more than 5 seconds over control (blood clotting)
• Serum albumin <2.5 gm/dl (protein)
• One of the following:
• Ascites, refractory (treatment or non-compliance)
• Spontaneous Bacterial Peritonitis (SBP)
• Hepatorenal Syndrome (elevated creatinine and BUN with oliguria (<400ml/day) and urine sodium concentration <10mEq/l

1. Hepatic Encephalopathy, refractory (ammonia increased) to treatment, or patient non-compliant

• Variceal bleeds –recurrent despite therapy
• The following documentation is helpful, but not required:
• Progressive malnutrition
• Muscle wasting
• Continued alcoholism (>80 g ethanol/day)
• Hepatocellular carcinoma
• Hepatitis B positivity
• Hepatitis C refractory to therapy (interferon)
• Liver Transplantation
• Patients awaiting liver transplant who otherwise fit the criteria for hospice may be admitted to hospice, but if a donor organ is procured, the patient must be discharged from hospice.
• Transplant is not part of the hospice plan of care therefore typically hospice does not pay for transplant costs
• Liver Disease Symptoms:
• Abdominal pain and tenderness
• Ascites (excess fluid between the membranes lining the abdomen and abdominal organs)
• Confusion
• Dry mouth / excessive thirst
• Fatigue
• Fever
• Jaundice
• Ecchymosis-purpura
• Loss of appetite
• Nausea
• Weight gain due to ascites
• Altered mood/behavior
• Restlessness
• Incoherent speech
• Flapping tremor of hands
• Sweet smelling breath
• Itchy skin
• Enlarged liver
• Anorexia
• Diarrhea
• Hyperventilation
• Breathing difficulties
• Functional decline:

1. Loss of functional independence
2. Weight loss/reduced oral intake
3. Unable to work
4. Mainly sit/lie
5. Confusion, cognitive impairment

• Abnormal liver enzymes:

1. Alkaline phosphates
2. SGOT
3. Bilirubin

ACUTE RENAL DISEASE

• LCD Criteria

1. The patient is not seeking dialysis or renal transplant
2. Creatinine Clearance <10 cc/mm or <15 cc/min for diabetics; based on measurement or calculation; or <15cc/min (<20cc/min of diabetics) with comorbidity of congestive heart failure
3. Serum creatinine > 8.0 (> 6.0 for diabetics)
4. Note: This means a patient cannot have a hospice diagnosis of renal disease and be on dialysis.
5. Why?

• Acute Renal Disease Documentation:
• The following documentation is helpful, but not required:
• Mechanical ventilation
• Malignancy, AIDS
• Chronic Lung Disease
• Advanced Cardiac or Lung Disease
• Advanced Liver Disease
• Sepsis, GI bleed
• Immunosuppression/AIDS
• Albumin < 3.5, Platelets < 25,000
• Cachexia
• Disseminated intravascular coagulation
• Vascular disease manifested as coronary heart disease
• Peripheral vascular diseases
• Vascular dementia

CHRONIC RENAL DISEASE

• LCD Criteria

1. The patient is not seeking dialysis or renal transplant
2. Creatinine clearance < 10 cc/min (< 15 cc/min for diabetics) based on measurement or calculation; or <15cc/min (<20cc/min for diabetics) with co-morbidity of congestive heart failure
3. Serum creatinine > 8.0 (> 6.0 for diabetics)

• Chronic Renal Disease Documentation:
• The following documentation is helpful, but no required:
• Uremia
• Reduced urine production (< 400 cc/day) This can be replaced with Oleguria.
• Intractable hyperkalemia (>7.0) not responsive to treatment
• Elevated potassium (> 7.0) – not responsive to therapy
• Uremic pericarditis
• Hepatorenal syndrome
• Intractable fluid overload, not responsive to therapy

4. Secondary conditions directly related to ESRD:

• Hyperparathyroidism
• Calciphylaxis
• Nephrogenic systemic fibrosis
• Electrolyte abnormalities and anorexia
• Renal Disease Symptoms
• Hypertension
• Urea accumulation
• Azotemia
• Uremia
• Hyperkalemia
• Anemia
• Fatigue
• Fluid overload
• Edema
• Pulmonary edema
• Reduced urine or lack there of
• Nausea
• Vomiting
• Confusion
• Seizures
• Coma
• Excessive hiccups
• Itchy skin
• Excessive thirst
• Easy bruising
• Breath odor

LCD Criteria

• Functional Status
• PPS or Karnofsky < 40%

1. Nutritional Status

• Inability to maintain hydration or caloric intake
• Weight loss > 10% in past six months
• Weight loss > 7.5 % in past three months
• Serum albumin < 2.5 gm/dl
• Poor calorie counts
• Aspiration without response to speech therapy
• 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 patient does not receive artificial nutrition and hydration.

• LCD Criteria
• Need 3 of the following on day 3 of coma:

1. Abnormal brain stem response (on EEG)
2. Absent verbal response
3. Absent withdrawal response to pain
4. Serum creatinine > 1.5 mg/dl

• Following documentation will support eligibility for hospice care:
• Medical complications, in the context of progressive clinical decline, within the previous 12 months, which support a terminal prognosis:
• Aspiration pneumonia
• Upper urinary tract infection (phyelonephritis)
• Sepsis
• Refractory stage 3-4 decubitus ulcers
• Fever recurrent after antibiotics
• Documentation of diagnostic imaging factors which support poor prognosis after stroke include:
• For non-traumatic hemorrhagic stroke:
• Large-volume hemorrhage on CT:
• Infratentorial: >20ml
• Supratentiorial: >50ml
• Ventricular extension of hemorrhage
• Surface area of involvement of hemorrhage >30%
• Midline shift >1/5cm
• Obstructive hydrocephalus in patient who declines, or is not a candidate for ventriculoperitoneal shunt
• For thrombotic/embolic stroke:
• Large anterior infarcts with both cortical and subcortical involvement
• Large bihemispheric infracts
• Basilar artery occlusion
• Bilateral vertebral artery occlusion

• LCD Criteria

1. Karnofsky or PPS score of less than 50%
2. Need a CD4 count < 25 cells/mcL or a persistent viral load of < 100,000 copies/ml
3. And one of the following:

• CNS or systemic lymphoma
• Untreated , or not responsive to treatment, wasting (loss of 33% lean body mass)
• Mycobacteriuem avium complex (MAC) untreated, unresponsive or refused Rx
• Progressive Multifocal Leukoencephalopathy (PML)
• Systemic lymphoma, with advanced HIV disease and partial response to chemotherapy
• Visceral Kaposi’s Sarcoma – unresponsive
• Renal Failure (and no dialysis)
• Cryptosporidium infection
• Toxoplasmosis, unresponsive

HIV Documentation:

• Chronic persistent diarrhea for one year
• Persistent serum albumin < 2.5
• Active Substance Abuse
• Age >50 years
• Advanced AIDS dementia complex
• Toxoplasmosis
• CHF – symptomatic at rest
• Absence of HIV drug therapy
• Pneumocystis jiroveci pneumonia
• Cytomegalovirus
• Tuberculosis
• Salmonellosis
• Candidiasis
• Cryptococcal meningitis
• Kaposi’s sarcoma
• Lymphomas
• Advanced AIDS dementia complex
• Symptoms of Early Stage of ADC
• Difficulty concentrating
• Difficulty remembering phone numbers or appointments
• Slowed thinking
• Longer time needed to complete complicated tasks
• Reliance on list keeping to help track daily activities
• Mental status test and other mental capabilities may be normal
• Poor hand coordination an change in writing
• Depression
• Symptoms of middle stage ADC
• Symptoms of motor dysfunction, like muscle weakness
• Poor performance on regular tasks
• More concentration and attention required
• Slowed responses and frequently dropping objects
• General feelings of indifference or apathy
• Slowness in normal activities , like eating and writing
• Walking, balance and coordination requires a great deal of effort
• Symptoms of late ADC
• Loss of bladder or bowel control
• Spastic gait, making walking more difficult
• Loss of initiative or interest
• Withdrawing from life
• Psychosis of mania
• Confinement to bed
• Seizures
• Sleep disturbances
• Toxoplasmosis
• Congestive heart failure, symptomatic at rest

• Cancer diagnoses tend to be the easiest ones of all as far as hospice eligibility because of prognostication and the disease projection is more predictable.
• Must have:
• Cancer diagnosis is confirmed through pathology or radiology
• Patient is no longer receiving curative treatment
• There is evidence of end-stage disease and/or metastasis
• Lab/diagnostic studies have been done recently to support disease progression
• Karnosfsky Performance Score of 70%
• Common cancer syndromes:
• Malignant hypercalcemia
• Malignant pericardial effusion
• Carcinomatous meningitis
• Multiple brain metastasis
• Malignant ascites
• Malignant plural effusion
• Malignant bowel obstruction
• Some Cancers are worse than others:

1. Brain cancer, pancreatic cancer, small cell lung cancer are all cancers with a very poor prognosis.
2. You don’t need to document mets when a patient has a brain tumor
3. You don’t need to document mets with pancreatic cancer if a patient is losing weight and declining.

• Some Cancers are not so bad:

1. Patients with prostate cancer and thyroid cancer sometimes do very well – even with metastatic disease.
2. Bladder cancer is often an easily treated cancer and doesn’t often metastasize
3. Patients with metastatic testicular cancer are frequently cured.

• The Hormonal Cancers

1. Breast and Prostate
2. Often more aggressive and malignant in young patients
3. More benign in older patients
4. Head and Neck Cancers
5. Often look terrible due to treatment (disfiguring surgery, chemo, etc.), but can live surprisingly many years because it doesn’t often metastasize and because of feeding tubes which help maintain nutrition
6. Cancer Documentation:
7. Metastatic disease
8. Planned therapies
9. Planned diagnostic tests
10. More information if it is one of the “good” cancers or head/neck cancer
11. How long have they had it
12. How long has your doctor said you’ve had it
13. Weight loss
14. A patient is referred to hospice by the nursing home. The patient has a growth as evidenced by a recent MRI. The patient has chosen to not seek diagnostic testing to confirm/deny if it is malignant. The patient has had increased weakness and about 5 pound weight loss in the past 2 months. The physician has stated over the phone when getting an order to evaluate to assess for hospice, that he is almost certain the patient has cancer.
15. Would you admit this patient?
16. The hospice diagnosis on the CTI determines the eligibility criteria, that is, which LCD is to be considered
17. The hospice diagnosis can and should be changed as often as needed
18. If a patient meets the LCD criteria, they are presumed to be eligible for hospice.
19. If a patient does NOT meet the LCD criteria and is still thought to be “probably less than six months”, further documentation is needed to paint the picture of hospice eligibility.
20. Eligibility for admission and recertification is basically the same
21. The entire team, including the medical director, should be involved in the admitting hospice decision.