What Criteria Qualifies A Patient for Hospice Care

Last Updated on June 19, 2024 by Frank Davis

Hospice can only be considered as an option if a prognosis by a physician is given that the patient has a life expectancy of six months or less if the disease runs its normal course. Listed below are guidelines that Hospice can use in order to determine if a patient is eligible for hospice services. These guidelines can be used to identify Medicare beneficiaries whose current health status and anticipated progression of disease may result in a life expectancy of six months or less.

The guidelines is as seen in the website of Centers for Medicare & Medicaid Services. Please use the table of contents below to navigate the page easier.

If you or a loved one is interested in knowing whether you or they qualify for hospice care, then feel free to contact us at (747) 755-5181.

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Non-disease specific baseline guidelines

(both of these should be met)

1. Physiologic impairment of functional status as demonstrated by:
   Karnofsky Performance Status (KPS) or Palliative Performance Score (PPS) <70%. Note that two of the disease specific guidelines (HIV Disease, Stroke and Coma) establish a lower qualifying KPS or PPS.
2. Dependence on assistance for two or more activities of daily living (ADLs)
   • Feeding
   • Ambulation
   • Continence
   • Transfer
   • Bathing
   • Dressing

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ALS – Amyotrophic Lateral Sclerosis

Patients will be considered to be in the terminal stage of ALS (life expectancy of six months or less) if they meet the following criteria. (Should fulfill 1, 2, or 3).

1. Patient should demonstrate critically impaired breathing capacity.
   • Critically impaired breathing capacity as demonstrated by all the following characteristics occurring within the 12 months preceding initial hospice certification:
     • Vital capacity (VC) less than 30% of normal (if available);
     • Dyspnea at rest;
     • Patient declines mechanical ventilation; external ventilation used for comfort measures only.
2. Patient should demonstrate both rapid progression of ALS and critical nutritional impairment.
   • Rapid progression of ALS as demonstrated by all the following characteristics occurring within the 12 months preceding initial hospice certification:
     • Progression from independent ambulation to wheelchair to bed bound status;
     • Progression from normal to barely intelligible or unintelligible speech;
     • Progression from normal to pureed diet;
     • Progression from independence in most or all activities of daily living (ADLs) to needing major assistance by caretaker in all ADLs.
   • Critical nutritional impairment as demonstrated by all the following characteristics occurring within the 12 months preceding initial hospice certification:
     • Oral intake of nutrients and fluids insufficient to sustain life;
     • Continuing weight loss;
     • Dehydration or hypovolemia;
     • Absence of artificial feeding methods, sufficient to sustain life, but not for relieving hunger.
3. Patient should demonstrate both rapid progression of ALS and life-threatening complications.
   • Rapid progression of ALS, see 2.a above.
   • Life-threatening complications as demonstrated by one of the following characteristics occurring within the 12 months preceding initial hospice certification:
     • Recurrent aspiration pneumonia (with or without tube feedings);
     • Upper urinary tract infection, e.g., pyelonephritis;
     • Sepsis;
     • Recurrent fever after antibiotic therapy;
     • Stage 3 or 4 decubitus ulcer(s).

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Cancer

1. Disease with distant metastases at presentation OR
2. Progression from an earlier stage of disease to metastatic disease with either:
   • a continued decline in spite of therapy
   • patient declines further disease directed therapy

Note: Certain cancers with poor prognoses (e.g. small cell lung cancer, brain cancer and pancreatic cancer) may be
hospice eligible without fulfilling the other criteria in this section.

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Dementia due to Alzheimer’s Disease and Related Disorders

Note: This section is specific for Alzheimer’s Disease and related disorders, and is not appropriate for other types of dementia, such as multi-infarct dementia.

Patients will be considered to be in the terminal stage of dementia (life expectancy of six months or less) if they meet the following criteria. Patients with dementia should show all the following characteristics:

1. Stage seven or beyond according to the Functional Assessment Staging Scale
2. Unable to ambulate without assistance;
3. Unable to dress without assistance;
4. Unable to bathe without assistance;
5. Urinary and fecal incontinence, intermittent or constant;
6. No consistently meaningful verbal communication: stereotypical phrases only or the ability to speak is limited to six or fewer intelligible words.

Patients should have had one of the following within the past 12 months:

1. Aspiration pneumonia;
2. Pyelonephritis or other upper urinary tract infection;
3. Septicemia;
4. Decubitus ulcers, multiple, stage 3-4;
5. Fever, recurrent after antibiotics;
6. Inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin <2.5 gm/dl.

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Heart Disease

Patients will be considered to be in the terminal stage of heart disease (life expectancy of six months or less) if they meet the following criteria. (1 and 2 should be present. Factors from 3 will add supporting documentation.):

1. At the time of initial certification or recertification for hospice, the patient is or has been already optimally treated for heart disease or is not a candidate for a surgical procedure or has declined a procedure. (Optimally treated means that patients who are not on vasodilators have a medical reason for refusing these drugs, e.g., hypotension or renal disease.)
2. The patient is classified as New York Heart Association (NYHA) Class IV and may have significant symptoms of heart failure or angina at rest. (Class IV patients with heart disease have an inability to carry on any physical activity without discomfort. Symptoms of heart failure or of the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased.) Significant congestive heart failure may be documented by an ejection fraction of ≤20%, but is not required if not already available.
3. Documentation of the following factors will support but is not required to establish eligibility for hospice care:
   • Treatment resistant symptomatic supraventricular or ventricular arrhythmias;
   • History of cardiac arrest or resuscitation;
   • History of unexplained syncope;
   • Brain embolism of cardiac origin;
   • Concomitant HIV disease.

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HIV Disease

Patients will be considered to be in the terminal stage of their illness (life expectancy of six months or less) if they meet the following criteria. (1 and 2 should be present; factors from 3 will add supporting documentation):

1. CD4+ Count 100,000 copies/ml, plus one of the following:
   • CNS lymphoma;
   • Untreated, or persistent despite treatment, wasting (loss of at least 10% lean body mass);
   • Mycobacterium avium complex (MAC) bacteremia, untreated, unresponsive to treatment, or treatment refused;
   • Progressive multifocal leukoencephalopathy;
   • Systemic lymphoma, with advanced HIV disease and partial response to chemotherapy;
   • Visceral Kaposi’s sarcoma unresponsive to therapy;
   • Renal failure in the absence of dialysis;
   • Cryptosporidium infection;
   • Toxoplasmosis, unresponsive to therapy.
2. Decreased performance status, as measured by the Karnofsky Performance Status (KPS) scale, of ≤50%
3. Documentation of the following factors will support eligibility for hospice care:
   • Chronic persistent diarrhea for one year;
   • Persistent serum albumin <2.5 gm/dl;
   • Concomitant, active substance abuse;
   • Age >50 years;
   • Absence of, or resistance to effective antiretroviral, chemotherapeutic and prophylactic drug therapy related specifically to HIV disease;
   • Advanced AIDS dementia complex;
   • Toxoplasmosis;
   • Congestive heart failure, symptomatic at rest;
   • Advanced liver disease.

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Liver Disease

Patients will be considered to be in the terminal stage of liver disease (life expectancy of six months or less) if they meet the following criteria. (1 and 2 should be present; factors from 3 will lend supporting documentation.):

1. The patient should show both a and b:
   • Prothrombin time prolonged more than 5 seconds over control, or International Normalized Ratio (INR) >1.5;
   • Serum albumin <2.5 gm/dl
2. End stage liver disease is present and the patient shows at least one of the following:
   • Ascites, refractory to treatment or patient non-compliant;
   • Spontaneous bacterial peritonitis;
   • Hepatorenal syndrome (elevated creatinine and BUN with oliguria)
   • Hepatic encephalopathy, refractory to treatment, or patient non-compliant;
   • Recurrent variceal bleeding, despite intensive therapy.
3. Documentation of the following factors will support eligibility for hospice care:
   • Progressive malnutrition;
   • Muscle wasting with reduced strength and endurance;
   • Continued active alcoholism (>80 gm ethanol/day);
   • Hepatocellular carcinoma;
   • HBsAg (Hepatitis B) positivity;
   • Hepatitis C refractory to interferon treatment.

Patients awaiting liver transplant who otherwise fit the above criteria may be certified for the Medicare hospice benefit, but if a donor organ is procured, the patient should be discharged from hospice.

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Pulmonary Disease

Patients will be considered to be in the terminal stage of pulmonary disease (life expectancy of six months or less) if they meet the following criteria. The criteria refer to patients with various forms of advanced pulmonary disease who eventually follow a final common pathway for end stage pulmonary disease. (1 and 2 should be present. Documentation of 3, 4, and 5, will lend supporting documentation.):

1. Severe chronic lung disease as documented by both a and b:
   • Disabling dyspnea at rest, poorly or unresponsive to bronchodilators, resulting in decreased functional capacity, e.g., bed to chair existence, fatigue, and cough: (Documentation of Forced Expiratory Volume in One Second (FEV1), after bronchodilator, less than 30% of predicted is objective evidence for disabling dyspnea, but is not necessary to obtain.)
   • Progression of end stage pulmonary disease, as evidenced by increasing visits to the emergency department or hospitalizations for pulmonary infections and/or respiratory failure or increasing physician home visits prior to initial certification. (Documentation of serial decrease of FEV1>40 ml/year is objective evidence for disease progression, but is not necessary to obtain.)
2. Hypoxemia at rest on room air, as evidenced by pO2 ≤55 mmHg; or oxygen saturation ≤88%, determined either by arterial blood gases or oxygen saturation monitors; (These values may be obtained from recent hospital records.) OR Hypercapnia, as evidenced by pCO2 ≥50 mmHg. (This value may be obtained from recent [within 3 months] hospital records.)
3. Right heart failure (RHF) secondary to pulmonary disease (Cor pulmonale) (e.g., not secondary to left heart disease or valvulopathy).
4. Unintentional progressive weight loss of greater than 10% of body weight over the preceding six months.
5. Resting tachycardia >100/min.

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Renal Disease

Patients will be considered to be in the terminal stage of renal disease (life expectancy of six months or less) if they meet the following criteria.

Acute renal failure:
(1 and either 2 or 3 should be present. Factors from 4 will lend supporting documentation.)

1. The patient is not seeking dialysis or renal transplant or is discontinuing dialysis;
2. Creatinine clearance GFR <15 ml/min
3. Serum creatinine >8.0 mg/dl (>6.0 mg/dl for diabetics);
4. Comorbid conditions:
   • Mechanical ventilation;
   • Malignancy (other organ system);
   • Chronic lung disease;
   • Advanced cardiac disease;
   • Advanced liver disease;
   • Sepsis;
   • Immunosuppression/AIDS;
   • Albumin
   • Cachexia;
   • Platelet count <25,000;
   • Disseminated intravascular coagulation;
   • Gastrointestinal bleeding.

Chronic renal failure:

(1 and either 2 or 3 should be present. Factors from 4 will lend supporting documentation.)

1. The patient is not seeking dialysis or renal transplant or is discontinuing dialysis;
2. Creatinine clearance GFR <15ml/min
3. Serum creatinine >8.0 mg/dl (>6.0 mg/dl for diabetics);
4. Signs and symptoms of renal failure:
   • Uremia;
   • Oliguria
   •  Intractable hyperkalemia (>7.0) not responsive to treatment;
   • Uremic pericarditis;
   • Hepatorenal syndrome;
   • Intractable fluid overload, not responsive to treatment.

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Stroke & Coma

Patients will be considered to be in the terminal stage of stroke or coma (life expectancy of six months or less) if they meet the following criteria.

Stroke:

1. Karnofsky Performance Status (KPS) or Palliative Performance Scale (PPS) of 40% or less;
2. Inability to maintain hydration and caloric intake with one of the following:
   • Weight loss >10% in the last 6 months or >7.5% in the last 3 months;
   • Serum albumin <2.5 gm/dl
   • 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 the patient from receiving food and fluids necessary to sustain life, in a patient who declines or does not receive artificial nutrition and hydration.

Documentation of diagnostic imaging factors which support poor prognosis after stroke include:

For non-traumatic hemorrhagic stroke:

1. Large-volume hemorrhage on CT:
   • Infratentorial: ≥20 ml.;
   • Supratentorial: ≥50 ml.
2. Ventricular extension of hemorrhage;
3. Surface area of involvement of hemorrhage ≥30% of cerebrum;
4. Midline shift ≥1.5 cm.;
5. Obstructive hydrocephalus in patient who declines, or is not a candidate for, ventriculoperitoneal shunt.

For thrombotic/embolic stroke:

1. Large anterior infarcts with both cortical and subcortical involvement;
2. Large bihemispheric infarcts;
3. Basilar artery occlusion;
4. Bilateral vertebral artery occlusion.

Coma (any etiology):
Comatose patients with any 3 of the following on day three of coma:

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

Documentation of the following factors will support eligibility for hospice care:

Documentation of medical complications, in the context of progressive clinical decline, within the previous 12 months, which support a terminal prognosis:

1. Aspiration pneumonia;
2. Upper urinary tract infection (pyelonephritis);
3. Sepsis;
4. Refractory stage 3-4 decubitus ulcers;
5. Fever recurrent after antibiotics.