Making physician hospice referrals simple  in Roanoke, VA and Lynchburg, VA.

For a PDF of hospice medical criteria, you may download this Hospice Eligibility Guide. 

CANCER

Patient meets ALL of the following:

• Clinical findings of malignancy with widespread, aggressive or progressive disease as evidenced by: increasing symptoms, worsening lab values and/or evidence of metastatic disease
• Palliative performance Scale (PPS) ≤ 70%
• Refuses further life-prolonging therapy or continues to decline in spite of definitive therapy

Supporting documentation includes:

• Hypercalcemia > 12 Cachexia or weight loss of 5% in past 3 months
• Recurrent disease after surgery/radiation/chemotherapy
• Signs and symptoms of advanced disease (nausea, requirement for transfusions, malignant ascites or pleural effusion, etc.)

 

DEMENTIA 

Stage 7C or beyond according to the FAST scale

AND One or more of the following conditions in the past 12 months:

• Aspiration pneumonia
• Pyelonephritis
• Septicemia
• Multiple pressure ulcers ( stage 3-4)
• Recurrent Fever
• Other significant condition that suggests a limited prognosis Inability to maintain sufficient fluid and calorie intake in the past 6 months (10% weight loss or albumin < 2.5 gm/dl)

 

HEART DISEASE

CHF with NYHA Class IV* symptoms and both:

• Significant symptoms at rest
• Inability to carry out even minimal physical activity without dyspnea or angina

AND Patient is optimally treated (i.e. diuretics, vasodilators, ACEI, or hydralazine and nitrates)

or Patient has angina pectoris at rest, resistant to standard nitrate therapy and is either not a candidate for/or has declined invasive procedures.

Supporting documentation includes:

• EF ≤ 20%
• Treatment resistant symptomatic dysrythmias
• h/o cardiac related syncope
• CVA 2/2 cardiac embolism
• h/o cardiac resuscitation
• concomitant HIV disease

LIVER DISEASE

End stage liver disease as demonstrated by PT> 5 sec or INR > 1.5

AND Serum albumin <2.5 gm/dl

AND One or more of the following conditions:

• refractory ascite
• h/o spontaneous bacterial peritonitis
• hepatorenal syndrome
• refractory hepatic encephalopathy
• h/o recurrent variceal bleeding

Supporting Documents include:

• Progressive malnutrition
• Muscle wasting with decreasing strength
• Ongoing alcoholism (> 80 gm ethanol/day)
• Hepatocellular CA HBsAg positive
• Hep C refractory to treatment

 

PULMONARY DISEASE

Severe chronic lung disease as documented by ALL of the following:

• Disabling dyspnea at rest
• Little of no response to bronchodilators
• Decreased functional capacity (i.e. bed to chair existence, fatigue and cough)

AND Progression of disease as evidenced by recent h/o increasing office, home or ED visits and/or hospitalizations for pulmonary infection and/or respiratory failure

AND Documentation within the past 3 months ≥1:

• Hypoxemia at rest on room air (p02 < 55 mmHg by ABG) or oxygen saturation < 88%
• Hypercapnia evidenced by pC02 > 50 mmHg

Supporting documentation includes:

• Cor pulmonal and right heart failure
• Unintentional progressive weight loss

 

NEUROLOGIC DISEASE

(chronic degenerative conditions such as ALS, Parkinsons, Muscular Dystrophy, Myasthenia Gravis or Multiple Sclerosis)

The patient must meet at least one of the following criteria:

Critically impaired breathing capacity, with ALL: dyspnea at rest, vital capacity < 30%, needs O2 at rest, patient refuses artificial ventilation

or Rapid disease progression from: independent ambulation to wheelchair, or bed-bound status, normal to barely intelligible or unintelligible speech, or normal to pureed diet, or independence in most ADLs to needing major assistance in all ADLs

AND

Critical nutritional impairment demonstrated by ALL of the following in the preceding 12 months:

• Oral intake of nutrients and fluids insufficient to sustain life
• Continuing weight loss
• Dehydration or hypovolemia
• Absence of artificial feeding methods

or Life-threatening complications in the past 12 months as demonstrated  by ≥1:

• Recurrent aspiration pneumonia
• Pyelonephritis
• Sepsis
• Recurrent fever
• Stage 3 or 4 pressure ulcer/s

 

STROKE or COMA

PPS <40%

AND Poor nutritional status with inability to maintain sufficient fluid and calorie intake with >1 of the following:

• >10% weight loss in past 6 months
• >7.5% weight loss in past 3 months
• Serum albumin <2.5
• Current history of pulmonary aspiration without effective response to speech therapy interventions to improve dysphagia and decrease aspiration events

Supporting documentation includes coma (any etiology) with 3 of the following on the 3rd day of coma:

• Abnormal brain stem response
• Absent verbal responses
• Absent withdrawal response to pain
• Post anoxic stroke
• Serum creatinine > 1.5

 

HIV/AIDS

CD4+ <25 or Viral load >100,000

AND at least 1 of the following: CNS lymphoma, untreated or refractory wasting (loss of >33% lean body mass), MAC bacteremia, PML, systemic lymphoma, visceral ICS, renal failure / no hemodialysis, cyptosporidium infection, refractory toxoplasmosis

AND PPS <50%