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
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)
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
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
Improved. Add. Comment. Read articles. Learn by communicating. Teach.