Patients will be considered to have a life expectancy of six months or less if there is documented evidence of decline in clinical status based on the guidelines listed below. Since determination of decline presumes assessment of the patient’s status over time, it is essential that both baseline and follow-up determinations be reported where appropriate. Baseline data may be established on admission to hospice or by using existing information from records. Other clinical variables not on this list may support a six-month or less life expectancy. These should be documented in the clinical record.
These changes in clinical variables apply to patients whose decline is not considered to be reversible. They are examples of findings that generally connote a poor prognosis. However, some are clearly more predictive of a poor prognosis than others; significant ongoing weight loss is a strong predictor, while decreased functional status is less so.
A. Progression of disease as documented by worsening clinical status, symptoms, signs and laboratory results.
1. Clinical Status:
- Recurrent or intractable serious infections such as pneumonia, sepsis or pyelonephritis;
- Progressive inanition as documented by:
- Weight loss of at least 10% body weight in the prior six 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 without documented weight;
- Decreasing serum albumin or cholesterol.
- Dysphagia leading to recurrent aspiration and/or inadequate oral intake documented by decreasing food portion consumption.
2. Symptoms:
- Dyspnea with increasing respiratory rate;
- Cough, intractable;
- Nausea/vomiting poorly responsive to treatment;
- Diarrhea, intractable;
- Pain requiring increasing doses of major analgesics more than briefly.
3. Signs:
- Decline in systolic blood pressure to below 90 or progressive postural hypotension;
- Ascites;
- Venous, arterial or lymphatic obstruction due to local progression or metastatic disease;
- Edema;
- Pleural/pericardial effusion;
- Weakness;
- Change in level of consciousness.
4. Laboratory (When available. Lab testing is not required to establish hospice eligibility.):
- Increasing pCO2 or decreasing pO2 or decreasing SaO2;
- Increasing calcium, creatinine or liver function studies;
- Increasing tumor markers (e.g. CEA, PSA);
- Progressively decreasing or increasing serum sodium or increasing serum potassium.
B. Decline in Karnofsky Performance Status (KPS ) or Palliative Performance Score (PPS) due to progression of disease.
C. Progressive decline in Functional Assessment Staging (FAST) for dementia (from 7A on the FAST).
D. Progression to dependence on assistance with additional activities of daily living (see Part II, Section 2).
E. Progressive stage 3-4 pressure ulcers in spite of optimal care.
F. History of increasing ER visits, hospitalizations, or physician visits related to the hospice primary diagnosis prior to election of the hospice benefit.
