Diagnostic Guidelines

Below are some of the more common hospice eligibility guidelines, also known as Local Coverage Determinations (LCD), that help physicians determine a prognosis of six months or less for some of the most common terminal conditions. Hospice eligibility can vary depending on many individual factors and co-morbidities. Please do not hesitate to call and speak to our Medical Director at (520) 398-2333 if you have any questions about whether one of your patients would qualify for hospice care.

Learn about the diagnostic guidelines for hospice care.

Cancer

At least ONE of the following should be present:

  • Disease with distant metastases at presentation
  • Progression of disease to metastatic disease with continued decline in spite of related therapies (palliative chemotherapy or radiation)
  • Patient refusing further disease-related therapy

Also, cancers with poor prognoses, such as small cell lung cancer, brain cancer, and pancreatic cancer, may be eligible without fulfilling other criteria in this section.

Dementia

Specific to Alzheimer's disease and related disorders; not for other types, such as multi-infarct dementia.

ALL of the following should be present:

  • Stage 7 or above on FAST scale
  • Unable to ambulate/dress/bathe without assistance
  • Incontinence, intermittent or constant
  • Unable to speak or communicate meaningfully

Heart Disease

Clinical Signs

  • Patient has been optimally treated for heart disease, or is not a candidate for surgical procedures, or refuses procedures
  • Signs and symptoms of CHF at rest
  • Optimal dose of diuretic and vasodilator therapy
  • Arrhythmias resistant to therapy
  • New York Heart Association Class IV
  • If data available, CHF with an ejection fraction of 20% or less

Liver Disease

ALL of the following should be present:

  • Prothrombin time prolonged more than five seconds or INR >1.5, and
  • Serum albumin <2.5 gm/dl

End-stage liver disease with at least ONE of the following:

  • Ascities, refractory to treatment or patient non-compliant
  • Spontaneous bacterial peritonitis
  • Hepatorenal syndrome: elevated Creatinine and BUN with oliguria <400ml/day and urine sodium concentration <10mEq/l
  • Hepatic encelphalopathy, refractory to treatment or patient non-complaint
  • Recurrent variceal bleeding

Factors needing documentation:

  • Progressive malnutrition
  • Muscle wasting
  • Active alcoholism
  • Hepatocellular carcinoma
  • Hepatitis B
  • Hepatitis C refractory to interferon treatment

Renal Failure

Signs and symptoms of chronic renal failure:

  • Oliguria <400cc/24 hours
  • Uremia
  • Hyperkalemia > 7.0, not responsive to treatment
  • Intractable fluid overload, not responsive to treatment
  • Uremic pericarditis
  • Hepatorenal syndrome
  • The patient is no longer pursing dialysis or renal transplant

ONE of the following:

  • Creatinine clearance <10cc/min (<15 for diabetics), or <15 (<20 for diabetics) with comorbidity of CHF
  • Serum creatinine >8.0 mg/dl (>6.0 for diabetics)
  • GFR <10ml/min

The following add support to prognosis:

  • GI bleeding
  • AIDS
  • Chronic lung disease
  • Sepsis
  • Advanced cardiac disease
  • Disseminated intravascular coagulation
  • Advanced liver disease
  • Malignancy in another organ
  • Albumin <3.5gm/dl
  • Vent
  • Platelet count <25,000

Pulmonary Disease

Clinical signs

Progression of disease documented by any of these symptoms:

  • Dyspnea at rest
  • Dyspnea on exertion
  • Oxygen dependent
  • Copius/purulent sputum
  • Cyanosis: fingertips, lips
  • Barrel chested
  • Poor response to bronchodilators

Functional status

  • Decline in Palliative Performance Scale
  • Increased hospitalizations for pulmonary infections
  • Unintentional weight loss in the past 6 months
  • Resting tachycardia (more than 100 per minute)