Hospice admission guidelines

Hospice Admission Guidelines

September 18, 2014

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 : debility unspecified : are not acceptable now.

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 / favor   / 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

Watch admission guideline video

This is an old video uploaded 8 yrs ago. Except debility unspecified most of the  diagnostic criteria remain the same.

👉🏿GIP ADMISSION CHECK LIST

GENERAL INPATIENT CARE

🔲 Patient requires short term inpatient care for pain /other symptoms management which can not be controlled in any other setting.

🔲 Place of care: Hospital / skilled Nursing facility / Hospice in patient place.

🔲 Aggressive pain control is needed

🔲 Uncontrolled symptoms is needed

🔲 Uncontrolled agitation / delirium / anxiety around end stage

🔲 Uncontrolled nausea / vomiting

🔲 Severe uncontrolled SOB severe shortness of breath

🔲 Uncontrolled seizures

🔲 Fracture with severe pain control is needed

🔲 Uncontrolled S/S requiring skilled nursing care

🔲 It is different than current care being provided

🔲 Documented : Why patient can not be taken care in any other place

🔲 Discharge planning documented : where is patient going after resolution of S/S

🔲 Bring down the level of care once problem resolved

🔲 NOT COVERED due to : General decline, actively dying, caregiver not available/ breakdown, supervision needed, for prevention of symptoms.

🔲 Admit to GIP

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