Common Indicators for End-Stage Diseases

ALS

  • Dyspnea at rest
  • Vital capacity less than 30%
  • Declines artificial ventilation
  • Critical nutritional impairment
  • Rapid disease progression or complications in the preceding 12 months

CANCER

  • Clinical finding of malignancy with widespread, aggressive metastatic disease
  • Patient no longer seeking curative treatment

DEMENTIA

  • Inability to ambulate or dress without assistance
  • Urinary and fecal incontinence, intermittent or constant
  • No consistent communication
  • One of the following within the last 12 months:
  • Aspiration pneumonia
  • Pyelonephritis or other UTI
  • Septicemia
  • Decubitus ulcers, multiple stage 3-4
  • Inability to maintain sufficient fluid and calorie intake
  • Fever, recurrent after antibiotics

HEART DISEASE

  • Poor response to optimal treatment with diuretics, vasodilators or ace inhibitors
  • Presence of NYHA Class IV CHF or refractory angina
  • Ejection fraction less than 20% (helpful but not required)
  • Not a candidate for, or has declined, revascularization procedures

LIVER DISEASE

  • PT prolonged more than five seconds over control or INR greater than 1.5
  • Serum albumin less than 2.5 gm/dl
  • May have one of the following:
  • Ascites
  • Hepatic encephalopathy
  • History or recurrent variceal bleeding
  • Spontaneous bacterial peritonitis
  • Hepatorenal Syndrome

NON-SPECIFIC TERMINAL ILLNESS

  • Recent rapid clinical decline and disease progression
  • Decline in functional status
  • Weight loss
  • Dependence on assistance for two or more ADL’s
  • Recurrent aspiration
  • Increase in ER visits, hospitalizations or physician contact
  • Progression of cognitive impairment
  • Progressive pressure ulcers in spite of optimal care
  • Dysphagia with recurrent aspiration

PULMONARY DISEASE

  • Decreased functional capacity
  • Disabling dyspnea at rest, or with minimal exertion
  • Poor response to bronchodilators
  • Progression of disease as evidenced by increasing visits to physician, ER or hospital for pulmonary infection.
  • Hypoxemia on room air less than 88%

RENAL FAILURE

  • Patient is not seeking, nor a candidate for dialysis
  • Creatinine clearance less than 10 cc/min (<15 cc/min for diabetics)
  • Serum creatinine greater 8.0 mg/dl (>6.0 mg/dl for diabetics)

STROKE

  • Palliative Performance Scale of < 40%
  • Poor nutritional status with weight loss over 10% in the past six months or 7.5% in the past three months
  • Serum albumin of less than 2.5
  • Recurrent aspiration pneumonia
  • Dysphagia/no artificial feeding tube
  • Coma with three of the following on the third day of coma:
  • Abnormal brain stem response
  • Absent verbal response
  • Absent withdrawal response to pain
  • Serum creatinine greater than 1.5

AIDS

  • Viral load > 100,000
  • CD 4 count < 25 cells/mcl
  • Palliative Performance Scale < 50%
  • Other syndromes, cytomegalovirus, PML, MAC, dementia, toxoplasmosis, Karposi’s sarcoma

Patients are also eligible if they meet some of the above criteria but have significant co morbidities or rapid decline suggesting a six-month or less prognosis. Even if the patient does not meet any of these conditions, they may still be eligible for hospice if based on documented data and in the judgment of the physician the life expectancy is six months or less.