The McLean Interdisciplinary Hospice Team Provides Palliative Care Consultations to Physicians, Patients, Families and Other Healthcare Providers.
For compassionate expertise and care, please call 860-658-3954.
Medicare coverage of hospice care in any setting depends upon a physician’s certification that an individual’s prognosis is a life expectancy of six month or less if the terminal illness runs its normal course. Medicare does not require the patient to be homebound. These guidelines are intended to be used to assess if the clinical status and anticipated progression of disease is more likely than not to result in a life expectancy of six months or less.
- Clinical findings of malignancy with widespread, aggressive or progressive disease as evidenced by increasing symptoms, worsening lab values and/or evidence of metastatic disease
- PPS 70% or less
- A continued decline in spite of therapy or patient declines further disease-directed therapy
- Note: Certain cancers with poor prognoses (e.g.; small cell lung cancer, brain cancer, pancreatic cancer) may be hospice eligible without fulfilling this criteria
- Being optimally treated with diuretics and vasodilators – chest pain at rest and resistant to nitrate therapy
- Significant symptoms of recurrent CHF at rest and is classified as a
- Unable to carry on any physical activity without symptoms
- Symptoms are present at rest
- If any physical activity is undertaken, symptoms are increased
- Additional Supportive Documentation: treatment resistant symptomatic supraventricular or ventricular arrhythmias; history of cardiac arrest or resuscitation; brain embolism of cardiac origin; concomitant HIV disease; ejection fraction of 20% or less
FAST SCALE 7C or beyond
- Inability to ambulate without personal assistance
- Inability to dress or bathe without assistance
- Unable to sit without support
- Bowel and bladder incontinence, intermittent or constant
- Ability to speak is limited to no more than six intelligible words in the course of an average day
One of the following within the past 12 months:
- Aspiration pneumonia
- Pyelonephritis or upper UTI
- Decubitus ulcers, multiple, stage 3-4
- Fever, recurrent after antibiotics
Inability to maintain sufficient fluid and calorie intake
demonstrated by either of the following:
- 10% weight loss during previous six months
- Serum albumin <2.5 g/dL
- Lab values: PT>5 seconds: INR>1.5; albumin<2.5 g/dl
- Progressive malnutrition (muscle wasting, BMI<22)
- Bacterial peritonitis
- Jaundice: hepatic encephalopathy
- Hepatorenal syndrome
- Recurrent variceal bleeding
- Hepatocellular carcinoma
- Hepatorenal syndrome (elevated creatinine, BUN, oliguria and urine sodium concentration < 10 mEQ/L)
Neurological (Stroke and Coma)
- PPS 40% or less
- Unintentional weight loss (despite tube feeding) of 10% in six months or 7.5% in last three months
- Sequential calorie counts documenting inadequate caloric fluid intake
- Dysphagia without tube feeding
- Serum albumin 2.5 gm/dL or less
- Pulmonary aspiration not responsive to speech pathology intervention
- Coma – following day three of the coma: abnormal brain stem response; absent verbal response or withdrawal response to pain, serum creatinine < 1.5 mg/dL
- Additional Supportive Doc: rapid decline or comorbidities
- Not seeking dialysis, needs transplant or is discontinuing dialysis
- Creatinine clearance < 10cc/min or 15 cc/min for diabetics
- Serum creatinine > 8 mg/dL or > 6 mg/dL for diabetics
- Glomerular filtration rate <10 mL/min
- Unintentional weight loss > 10% of body weight
- Disabling dyspnea at rest
- Little or no response to bronchodilators
- Hypoxia at rest (PO2 below 55 mm Hg or 02 saturation below 88% on room air; FEV1 of less than 30% of age predicted)
- Decreased functional capacity (e.g.; bed to chair existence, fatigue, and cough)
- Increased ER visits or hospitalizations for pulmonary infections and/or respiratory failure
- Additional Supportive Doc: cor pulmonale and right heart failure; unintentional progressive weight loss> 10% of body weight over six months; resting tachycardia > 100/min
Adult Failure to Thrive
- Decline in functional status with PPS equal to or less than 40% (mostly in bed and requires mainly assistance with ADLs)
- Body Mass Index (BMI) below 22
- The patient is refusing enteral or parenteral nutritional support or has not responded to such nutritional support, despite adequate caloric intake
Decline in Clinical Status
- Clinical Status:
- Recurrent or intractable serious infections, such as pneumonia, sepsis or pyelonephritis;
- Progressive inanition documented: Weight loss of at least 10% of total body weight in the prior six months, not due to reversible causes, or other signs if weight not documented (skin folds, loose clothes)
- Dysphagia leading to recurrent aspiration and/or inadequate oral intake/decreasing food portions
- Two or more of the following six ADLs are dependent upon human assistance: Ambulation, Continence, Transfer, Dressing, Feeding, Bathing.
- Progressive decline in function – Decline in Karnofsky Performance Status (KPS) or Palliative Performance Scale (PPS) scores due to disease progression.
- Progressive stage 3-4 pressure ulcers in spite of optimal care.
- History of serial treatment failure, increasing ED visits, hospitalizations or MD visits prior to electing hospice.
- Symptoms may include: Pain requiring increasing doses of major analgesics more than briefly; dyspnea with increasing respiratory rate; intractable cough; nausea/vomiting poorly responsive to treatment; intractable diarrhea.
- Signs may include: Decline in systolic blood pressure to below 90 or progressive postural hypotension; ascites; venous, arterial or lymphatic obstruction due to local progression or metastatic disease; edema; pleural/pericardial effusion; weakness; change in level of consciousness.
- Comorbidities: Severity and progression of which is likely to contribute to a life expectancy of six months or less such as dementia, COPD, HF, ischemic heart disease, DM, neurologic disease, renal failure or liver disease.