Who Is a Candidate?

CARDIAC DISEASE

• Symptoms of CHF or angina receiving optimal treatment (i.e. vasodilators) who are not candidates for surgical procedures or who decline those procedures.
• NYHA Class IV- Inability to carry out any physical activity without discomfort. Symptoms of heart failure or angina may be present at rest and if any physical activity is undertaken, discomfort is increased.

PULMONARY DISEASE

• Disabling dyspnea at rest, poorly or unresponsive to bronchodilators resulting in decreased functional capacity(FEV1<30% of predicted)e.g. bed to chair existence, cough and fatigue with; Progression of end stage pulmonary disease, as evidenced by increasing visits to the ER or hospitalizations for infections and/or respiratory failure, or increasing physician visits prior to initial certification. (Serial decrease of FEV1>40 ml/year)
• Hypoxemia at rest on room air, as evidenced by pO2<55 mmHg or O2 sat<88% OR
• Hypercapnea, as evidenced by pCO2>50 mmHg(from hospital records within 3 months).

Supporting Documentation (not required):

• Ejection Fraction <20%
• Treatment resistant symptomatic arrhythmias
• History of cardiac arrest or resuscitation
• Embolic CVA of cardiac origin
• Concomitant HIV disease\
• Right heart failure secondary to pulmonary disease (Cor pulmonale); not VHD or LHF; Unintentional weight loss of >10% over preceding 6 months; Resting tachycardia >100 /min.

RENAL DISEASE

• Patient is not seeking dialysis or renal transplant, or is discontinuing dialysis AND\
• Creatinine clearance <10 cc/min (<15 cc/min in diabetics)<15 cc/min (<20 cc/min in diabetics) with co-morbidity of CHF; OR\
• Serum creatinine >8.0 mg/dl (>6.0 mg/dl in diabetics)

Supporting Documentation in CRF

• Uremia
• Oliguria (< 400 cc/24 hrs)
• Intractable hyperkalemia (> 7.0)
• Uremic pericarditis
• Hepatorenal Syndrome
• Intractable fluid overload

LIVER DISEASE

• Prolonged prothrombin time- INR >1.5 and serum albumin <2.5 gm/dl AND
• End-stage Liver disease with at least one of the following:
• Ascites- refractory or patient non-compliant;
• Spontaneous bacterial peritonitis;
• Hepatorenal syndrome- elevated BUN/Cr with oliguria and urine Na <10 meq/l;
• Hepatic encephalopathy- refractory or patient non-compliant;
• Recurrent variceal bleeding.

Supporting Documentation in ARF

• Mechanical Ventilation
• Malignancy
• Chronic Lung Disease
• Advanced Cardiac Disease
• Advanced Liver Disease
• Immunosuppression/AIDS
• Albumin < 3.5 gm/dl
• Cachexia - Sepsis
• Platelet count < 25,000
• Disseminated intravascular coagulation (DIC)
• Gastrointestinal bleeding
• Progressive malnutrition;
• Muscle wasting with reduced strength and endurance;
• Continued active alcoholism (>80 gm ETOH/day);
• Hepatocellular carcinoma;
• Hepatitis B (HBsAg) positivity;
• Hepatitis C refractory to interferon treatment.
  
  Note: Patients awaiting liver transplant who otherwise fit the above criteria may be certified for the Medicare hospice benefit, but if a donor organ is procured, the patient should be discharged from hospice.

STROKE

• Palliative Performance Scale (PPS) # 40%
• Inability to maintain hydration and caloric intake with one of the following:-Weight loss > 10% in the last 6 months or > 7.5% in the last 3 months;-Serum albumin < 2.5 gm/dl-Current history of aspiration not responsive to Speech Therapy interventions;-Sequential calorie counts documenting inadequate caloric/fluid intake;-Severe dysphagia which prevents patient from receiving adequate nutrition and fluids, in a patient who declines or does not receive artificial nutrition and hydration.

Supporting documentation

• Aspiration pneumonia
• Pyelonephritis or other upper urinary tract infection
• Sepsis
• Fever recurrent after antibiotics
• Refractory decubitus ulcers Stage III-IV
• Imaging parameters

COMA (any etiology with any 3 of the following on day 3 of coma)

• Abnormal brain stem response
• Absent verbal response
• Absent withdrawal response to pain
• Serum creatinine > 1.5 mg/dl.

DEMENTIA Note: Specific for Alzheimer's Disease and related disorders, and is not appropriate for other types of dementia such as multi-infarct dementia.

• Functional Assessment Staging(FAST)> 7
• Unable to ambulate without assistance (7c)
• Unable to dress without assistance (6a)
• Unable to bathe without assistance (6b)
• Urinary and fecal incontinence, intermittent or constant (6c,d & e)
• No consistent verbal communication, stereotypical phrases or limited to 6 or fewer words (7a)

DEBILITY/ADULT FAILURE TO THRIVE*

• Nutritional impairment and declining or is not responding to enteral/parenteral support with a body mass index(BMI) < 22 kg/m5.
• BMI (kg/m5) = 703 x (wt in pounds) ) (ht in inches)5
• Functional impairment as demonstrated by PPS # 40%
• Mainly in bed requiring assist with all ADLs

Supporting documentation:

• Aspiration pneumonia;
• Pyelonephritis or other upper urinary tract infection;
• Septicemia;
• Decubitus ulcers, multiple, Stage III-IV
• Fever, recurrent after antibiotics;
• Inability to maintain sufficient fluid and calorie intake with:10% weight loss in last 6 months or, serum albumin < 2.5 gm/dl
• *Instead of Debility, NOS (799.3), consider;
• Choose a diagnosis that is contributing to the terminal prognosis, then,
• Add comorbidities and secondary conditions.