Aceso Hospice provides these guidelines as a convenient tool. They do not take the place of a physician’s professional judgment.

Patients are eligible for hospice care when a physician makes a clinical determination that life expectancy is approximately six months or less if the terminal disease runs its normal course.

End-Stage CHF and other Heart Diseases NYHA Class IV as manifested by any of the following symptoms:
{Ejection fraction <20% (not required, but an important consideration)}
•Dyspnea and/or other symptoms at rest or with minimal exertion
•Inability to carry out physical activity without dyspnea and/or other symptoms or other symptoms worsen
•The patient is already being optimally treated for congestive heart failure with diuretics and vasodilators, such as ACE inhibitors, or they are maximally medically managed and have no available surgical options.
•Patient is not a candidate for (or declines) invasive procedures, such as percutaneous angioplasty or coronary artery bypass surgery.
•Impaired heart rhythms, contraction force of ventricular muscles and impaired blood supply to the heart
•Changes in appetite, unintentional weight loss
•Impaired sleep functions
•Decline in general physical endurance
End-Stage Cancer Patients General qualifiers include:
•Cancer that has metastasized
•Declined condition despite therapy
•Electing to forgo further curative treatment (In *Palliative care a patient may still receive curative treatment)
If >50% of a patient’s time is spent sitting or lying down, and if that time is increasing, you can roughly estimate the prognosis at three months or less.

Alzheimer’s / Dementia
Patients with dementia or Alzheimer’s may be eligible for hospice care when they show all the following characteristics (also listed under the Palliative Performance Scale < 50%, FAST scale greater than 7 and Karnofsky scale generally less than 50%)
•Unable to dress or bathe without assistance
•Unable to bathe properly
•Incontinence of bowel and bladder
•Unable to ambulate without assistance
•Unable to speak or communicate meaningfully (approximately 6 words or less of intelligible and different words)
Additional symptoms seen with late-stage Dementia I Alzheimer’s
•Aspiration pneumonia or Upper Respiratory Infection
•Pyelonephritis or upper urinary tract infection
•Decubitus ulcers stages 3 to 4
Amyotrophic Lateral Sclerosis (ALS)
In end-stage ALS, two factors are critical in determining prognosis: ability to breathe and ability to swallow.
*Patients may be hospice-eligible if they meet the following guidelines:
•BOTH rapid progression of ALS and critically impaired ventilatory capacity or
•BOTH rapid progression of ALS and critical nutritional impairment with a decision not to receive artificial feeding or
•BOTH rapid progression of ALS and life­ threatening complications such as:
•Recurrent aspiration pneumonia
•Decubitus ulcers, multiple, stage 3-4, particularly if infected
•Upper urinary tract infection, e.g., pyelonephritis
•Fever recurrent after antibiotics

COPD and Lung Diseases
Major characteristics
•02 sat. s 88 percent on room air
•Dyspnea at rest and/or with minimal exertion with or without oxygen therapy
•Dyspnea unresponsive or poorly responsive to bronchodilator therapy
•Progression of chronic pulmonary disease as evidenced by one or more of the following:
– Frequent use of medical services, including hospitalizations, ED visits and/or physician outpatient visits, due to symptoms of pulmonary disease
– Frequent episodes of bronchitis or pneumonia
– Unintentional weight loss of > 10 percent body weight over the preceding six months
– Progressive inability to independently perform various activities of daily living (ADLs) or an increasing dependency with ADLs, resulting in a progressively lower performance status
– Resting tachycardia > 100/minute

End-Stage Liver Disease
Hospice care is considered appropriate if, despite adequate medical management, they suffer from persistent symptoms of hepatic failure resulting in multiple hospitalizations’ ED visits or increased use of other healthcare services yet resulting in continued decline such as:
•Loss of functional independence
•Weight loss and/or reduced oral intake
•Unable to work
•Mainly sit or lie
•Confusion, cognitive impairment
•Ascites, refractory to sodium restriction and diuretics, especially with associated spontaneous bacterial peritonitis
•Hepatic encephalopathy refractory to protein restriction and lactulose or neomycin
•Recurrent variceal bleed despite therapeutic interventions
•Hepatorenal syndrome Suggested Lab Indicators are:
•Protime five seconds more than control or INR > 1.5
•Serum albumin < 2.5 g/dL

Neurological Diseases
•Severely compromised breathing, marked by inability to clear respiratory secretions persistent cough, or recurring aspiration pneumonia despite antibiotic therapy
•Increased shortness of breath, even at rest or on oxygen
•Inability to swallow liquids or soft food without choking or coughing, progression to a mainly pureed diet
•Spends most of the time in bed
•Barely intelligible speech up to 6 words
•Continued weight loss
•Inability to manage most activities of daily living
•Abnormal/absent brain response, verbal response or withdrawal response to pain

Hospice Guidelines for End-Stage HIV & AIDS
Patients are considered in the terminal stage of their illness if they meet the following (1 and 2 must be present; factors from 3 will add supporting documentation):
1. The CD4+ count < 25 cells / mm3 or persistent viral load > 100,000 copies / ml, plus one of these:
•Systemic lymphoma with advanced HIV disease and partial response to chemotherapy
•CNS lymphoma
•Untreated or not responsive to treatment”‘ wasting (loss of 33% lean body mass)
•Mycobacterium avium complex (MAC) bacteremia, untreated, unresponsive to treatment or treatment refused
•Progressive multifocal leukoencephalopathy
•Visceral Kaposi’s sarcoma unresponsive to therapy
•Renal failure in the absence of dialysis
•Cryptosporidium infection
•Toxoplasmosis unresponsive to therapy
•Cytomegalovirus (CMV) infection
•Advanced AIDS dementia complex
• Toxoplasmosis
•Congestive heart failure, symptomatic at rest
•Chronic persistent diarrhea for one year
•Persistent serum albumin <2.5
•Concomitant, active substance abuse

End-Stage Renal Disease (ESRD)
*Aceso Hospice can admit a patient receiving dialysis can continue dialysis based upon a Primary diagnosis other than ESRD (speak to one of our staff for further information on this but i.e. cancer, CHF or lung disease). Any hospice admission based on ESRD as the PRIMARY is then stipulated that further dialysis is NOT covered by (Medicare / MediCal) insurance.

End stage indicators include:
•Creatine clearance of <10cc/min (<15 cc/ min for diabetics)
•Serum creatine >8.0 mg/dl (>6.0 mg/dl for diabetics)
•Intractable hyperkalemia: persistent serum potassium >7.0
•Patient refusing dialysis or stopping dialysis
•Confusion, obtundation
•Intractable nausea and vomiting
•Generalized pruritus
•Restlessness, “restless legs”
•Uremic pericarditis
•Hepatorenal syndrome
•Intractable fluid overload
Patients with Sepsis
•Respiratory failure
•Circulatory shock
•Renal injury
.•Metabolic changes
•Liver injury
•Increased lactate