Exploring the Clinical Indicators of Hospice Eligibility: Is your patient eligible for hospice care, or do they need palliative care instead? Patients are eligible for hospice if they receive a terminal diagnosis from an MD, with a life expectancy determination of six months or less. Discover the crucial criteria in this guide for healthcare professionals.
There are also several condition-specific indicators of hospice eligibility for a list of terminal conditions, including ALS, muscular dystrophy, MS, stroke, cancer, Alzheimer’s, Parkinson’s, heart disease, renal disease, HIV/AIDS liver disease, protein-calorie malnutrition, COPD, and associated conditions.
See the full list of criteria for hospice eligibility for these and other medical diagnoses below. This article is intended for use as a diagnostic aid and can’t take the place of a full determination by a physician.
A quick reference guide, Clinical Indicators of Hospice Eligibility, is available for download [PDF].
Lou Gehrig Disease (ALS) / Muscular dystrophy
Myasthenia gravis / Multiple sclerosis
- Dyspnea at rest, O2 dependent, vital capacity 30%, dysphagia, no BiPAP/ventilator, bed/chair bound, assist with all ADL’s, O2 88% on RA.
- Recent progression to: Bed/chair bound, barely intelligible or unintelligible speech, assist with all ADL’s, pureed diet, documented weight loss, NO feeding tube, documented hypovolemia and dehydration
- Recent progression to: bed/chairbound, barely intelligible or unintelligible speech, assist with all ADL’s, pureed diet, sepsis, recurrent aspiration PNA, pyelonephritis, recurrent fevers, stage 3 or 4 pressure ulcers.
ALL ITEMS MUST BE PRESENT FOR ADMITTING DIAGNOSIS
Coverage for hospice care may still be appropriate for patients not meeting these determinants due to co-morbidity or rapid decline.
Cerebrovascular Accident (CVA) / Stroke
- * Decreased LOC
- * PPS score ≤ 40%
- Albumin ≤ 2.5
- No artificial hydration or nutrition without decline or weight loss
- Weight loss of 10% in past 6 months or 7.5% in the last 3 months
- Unable to intake adequate nutrition
- Recurrent infections
- Assist with all ADL’s
- Post stroke dementia
* ALL STARED ITEMS MUST BE PRESENT FOR ADMITTING DIAGNOSIS
Coverage for hospice care may still be appropriate for patients not meeting these determinants due to co-morbidity or rapid decline.
Cancer
- * Metastasis to multiple sites
- * Choosing palliative care and to stop chemotherapy/radiation
- Small cell lung, brain and pancreatic cancers do not require metastasis
- Weight loss
- Karnofsky ≤ 70%
* ALL STARED ITEMS MUST BE PRESENT FOR ADMITTING DIAGNOSIS
Coverage for hospice care may still be appropriate for patients not meeting these determinants due to co-morbidity or rapid decline.
Dementia / Alzheimer’s
- * FAST 7A or beyond
- * Unable to walk without physical assistance
- * Assist with bathing, dressing and ambulating
- * Less than 6 intelligible words, or no consistent meaningful conversation
- * At least 2 of the following complications within last 12 months: PNA, UTI, sepsis, pyelonephritis, stage 3 or 4 pressure ulcers, recurrent fevers
- * Urinary and fecal incontinence, either intermittently or constantly
- Difficulty swallowing
- Albumin ≤ 2.5
* ALL STARED ITEMS MUST BE PRESENT FOR ADMITTING DIAGNOSIS
Coverage for hospice care may still be appropriate for patients not meeting these determinants due to co-morbidity or rapid decline.
Parkinson’s Disease
- Tremors in extremities
- Dysphagia
- Garbled speech
- Ambulation decline
- Dyspnea at rest
- Increased assistance with ADL’s
* ALL STARED ITEMS MUST BE PRESENT FOR ADMITTING DIAGNOSIS
Coverage for hospice care may still be appropriate for patients not meeting these determinants due to co-morbidity or rapid decline.
Heart Disease / Coronary Artery Disease (CAD) Chronic Heart Failure (CHF)
- * NYHA Class IV (for pts w/CHF or angina)
- * Arrhythmias resistant to treatment
- * No BiPAP unless will DC in near future
- EF 20% or less
- Physical symptoms at rest
- Inability to tolerate vasodilators
- BNP ≥ 1000
- Symptomatic despite max medical tx
- Hx of syncope or cardiac arrest
- Cardiogenic embolic CVA
* ALL STARED ITEMS MUST BE PRESENT FOR ADMITTING DIAGNOSIS
Coverage for hospice care may still be appropriate for patients not meeting these determinants due to co-morbidity or rapid decline.
Protein Calorie Malnutrition
- * Albumin ≤ 2.5
- * Extreme, unintentional weight loss
- * Weakness/Falls
- * Assist with all ADLs
- * Bed/chair existence
- * NO feeding tube without continued decline and weight loss
- * Recent documented infections
- BMI of 22 or less
- Recent ER visit/hospitalizations
* ALL STARED ITEMS MUST BE PRESENT FOR ADMITTING DIAGNOSIS
Coverage for hospice care may still be appropriate for patients not meeting these determinants due to co-morbidity or rapid decline.
Renal Disease
- * Plan for discontinuing dialysis
- * At least 2 of the following: serum creatinine ≥ 8.0 or ≥6.0 for Diabetics, uremia (confusion, nausea, pruritus, restlessness), oliguria (< 400cc/day), uremic pericarditis, hepatorenal syndrome, intractable fluid overload, or creatinine clearance of ≤ 10cc/min or 15cc/min for diabetics, hyperkalemia (Potassium ≥ 7.0)
- GFR ≤ 10mL/min
* ALL STARED ITEMS MUST BE PRESENT FOR ADMITTING DIAGNOSIS
Coverage for hospice care may still be appropriate for patients not meeting these determinants due to co-morbidity or rapid decline.
Human Immunodeficiency Virus (HIV)
Acquired Immunodeficiency Syndrome (Aids)
- * Wasting syndrome
- * CNS lymphoma/Kaposi’s sarcoma
- * Viral load ≥ 100,000
- PPS ≤ 50%
- Co-morbidities/severe infections
- Albumin ≤ 2.5
- CD4 + ≤ 25
* ALL STARED ITEMS MUST BE PRESENT FOR ADMITTING DIAGNOSIS
Coverage for hospice care may still be appropriate for patients not meeting these determinants due to co-morbidity or rapid decline.
Liver Disease
- * PT ≤ 5 or INR ≥1.5
- * Albumin ≤ 2.5
- * At least 2 of the following: ascites, peritonitis, hepatorenal syndrome, (elevated BUN & Creatinine with oliguria 400mL/day & urine sodium concentration ≤ 10 mEq/L), recurrent variceal bleeding, hepatic encephalopathy with somnolence
- Malnutrition, continued active alcoholism, Hep B positive, hepatocellular carcinoma, Hep C refractory to interferon treatment
* ALL STARED ITEMS MUST BE PRESENT FOR ADMITTING DIAGNOSIS
Coverage for hospice care may still be appropriate for patients not meeting these determinants due to co-morbidity or rapid decline.
Pulmonary Disease
Chronic Obstructive Pulmonary Disease (COPD)
- * O2 dependent
- * Poor response to bronchodilators
- * O2 ≤ 88% on room air
- * Recurrent pulmonary infections
- * Resting tachycardia
- * Hypercapnia/hypoxemia
- * Dyspnea at rest
- * Bed-to-chair existence
- * Increased ER visits/hospitalizations
- * No BiPAP unless will DC in near future
- Weight loss of 10% in past 6 months
- Cor Pulmonale/Right Heart Failure
* ALL STARED ITEMS MUST BE PRESENT FOR ADMITTING DIAGNOSIS
Coverage for hospice care may still be appropriate for patients not meeting these determinants due to co-morbidity or rapid decline.
For more information or to make a referral:
For the full criteria guidance on the factors influencing hospice eligibility, please contact us or see the complete LCD guide on the CMS website. You can also make a hospice referral using the contact information below.
The Sage Family of Companies provides hospice services in:
