Hospice & Palliative Care Referral Guidelines Issued 2010 (901) 516-1600 www.methodisthealth.org
Give us time to help your patients. Unfortunately, few patients and families receive the full benefit of hospice and palliative services, as they are often referred quite late in the illness trajectory. A recent VA study showed that the average inpatient palliative care referral occurs 14 days prior to death. Similarly, the median length of stay in hospices has been falling across the country (from 29 days in 1995 to 20 days in 2007, a drop of 31%). The declining length of stay creates a perfect storm of barriers to quality care. Continuity of care, trust, and clinical efficacy are difficult to establish in less time with the patient and family. Having established such marvelous tools in the practice of medicine to attend to the needs of patients with advanced illness, it s a pity to see them underutilized. The literature is replete with studies that settle the issue; hospice and palliative care offer a better approach to the patient with advanced, lifelimiting illness than traditional medical care. Let s commit to giving our patients that care early enough in their illness trajectory to offer them (and their families) maximal benefit.
It s about you and your patients. The confidence your patients have in you is a sacred trust. When you choose Methodist Hospice and Palliative Services, you allow us to share in that trust. During the most difficult times of your patients lives, we re there to help you help them on their journey. Whether the need is for complex symptom management, guidance in decision-making or comprehensive supportive services, we intend to provide outstanding care. It s a responsibility that we take seriously, from each of our home health aides, to our chaplains and social workers; from our dedicated nurses, to each of our five board-certified Hospice and Palliative Medicine physicians. In addition to our hospice services, we offer consultation in palliative care at each of the metro Methodist hospitals (including Le Bonheur). We re also educating the next generation of palliative care clinicians, with training programs for nurses, pharmacists, and doctors (including the area s first fellowship program in Hospice and Palliative Medicine). When the time comes to focus on comfort, we want to be the partner you and your patients can trust. We pledge 24/7 availability, outstanding clinical performance, continued communication and inspired compassion. Thanks for allowing us to be part of your team.
Eligibility Criteria for Hospice Admission General Guidelines 1. The patient meets the following criteria: Life limiting condition Patient/family elects palliative care 2. Documentation of clinical progression of disease evidenced by: Physician assessment Radiologic or other studies Inpatient hospitalizations Laboratory studies Multiple ER visits Home health nurse assessment if homebound 3. Recent decline in functional status, as evidenced scoring 50% or less on Karnofsky/PPS scales 4. Dependence in 3 of 6 Activities of Daily Living: Bathing Dressing Feeding Transfers Elimination Ambulation (over)
General Guidelines (cont.) 5. Recent impairment of nutritional status evidenced by: Unintentional, progressive weight loss of 10% over past 6 months Serum albumin < 2.5 mg/dl (may be helpful prognostic indicator but should not be used by itself) Please call Methodist Hospice and Palliative Services at (901) 516-1600 to request a consult.
Palliative Care: Inpatient Consultation Service Consider an inpatient Palliative Care referral if your patient meets any of the following criteria: Advanced disease process with severe organ dysfunction and poor quality of life Persistent, moderate to severe pain (stated or nonverbal) or other symptom distress after 24 hours of appropriate therapy Sepsis with multi-system organ failure after 3 days Ventilator dependence over 3 days Stage IV malignancy Post cardiopulmonary arrest with CNS damage Intracranial hemorrhage on the ventilator 80 years old or greater AIDS with dementia, cachexia, neoplasm or failure of HAART ED visit or hospital admission for the same diagnosis greater than once per month Prolonged LOS in ICU without evidence of progress or documented poor prognosis Requested by patient or surrogate (over)
Palliative Care: Inpatient Consultation Service (cont.) What can Palliative Care do for your patient? Pain/symptom management Help patient/families determine goals of care when faced with complex healthcare decisions Complete POST form and/or advanced directive documents Symptom management and family communication during the actively dying phase Ventilator withdrawal (palliative extubation) Coordinate post-acute services referrals (e.g. hospice, home health) Facilitate ethics consultation when needed Please call Methodist Hospice and Palliative Services at (901) 516-1600 to request a consult.
Eligibility Criteria for Hospice Admission Cancer The cancer is unresponsive to conventional therapies, and/or curative treatment is no longer a realistic alternative Patient demonstrates multiple symptoms, requiring aggressive, on-going medical management: pain, nausea, vomiting, dyspnea, psychological distress, anxiety, constipation Patient is frail, demonstrates weight loss and/or multiple organ system failure The patient s condition has taken a recent decline The patient has decided to terminate curative treatment, and desires supportive care only Meets general guidelines for hospice admission Please call Methodist Hospice and Palliative Services at (901) 516-1600 to request a consult.
Eligibility Criteria for Hospice Admission Adult Failure to Thrive/Debility Medicare considers Debility, unspecified an appropriate diagnosis for hospice patients when a current weight is unobtainable to calculate a body mass index. When BMI is not met, Debility, unspecified may be used for patients who meet the general hospice criteria. The patient must meet criteria in # s 1 and 2 to use the Adult Failure to Thrive diagnosis and to be considered appropriate for admission to hospice. An admission weight must be obtained to use Adult Failure to Thrive on admission. Measurements/observations for criteria in # s 1 and 2 must be made within six months of the most recent certification or re-certification. Nutritional impairment as evidenced by a Body Mass Index (BMI) below 22 kg/m2 - Formula for calculating BMI: 703x (wt in LBS) / (ht in inches 2 ) Patient is either declining enteral/parenteral nutritional support, or has not responded to such nutritional support despite adequate caloric intake Significant disability as evidenced by a Karnofsky or PPS Value of < 40% If patient admitted under Debility, documentation must be present to explain why Adult Failure to Thrive cannot be used (i.e. unable to obtain weight, BMI >22, Karnofsky > 40 %) Please call Methodist Hospice and Palliative Services at (901) 516-1600 to request a consult.
Eligibility Criteria for Hospice Admission Heart Disease 1. The patient is optimally treated with diuretics and vasodilators, usually angiotensin-converting enzymes (ACE) inhibitors. (Optimally treated means that patients who are not on vasodilators have a medical reason for refusing these drugs, e.g. hypotension or renal disease) 2. The patient has significant or recurrent Congestive Heart Failure (CHF)s/sx at rest, and is classified as New York Heart Association (NYHA) Class IV. (Inability to carry on any physical activity without discomfort: Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased) 3. Documentation of the following factors will support eligibility for hospice care: Ejection Fraction < 20% if available Treatment resistant symptomatic supraventricular or ventricular arrhythmias History of cardiac arrest or resuscitation History of unexplained syncope Brain embolism of cardiac origin Concomitant HIV disease (over)
Heart Disease (cont.) Additional symptoms exhibited by the patient: Chest tightness Cyanosis Tachypnea Orthopnea Reduced Capillary refill Wheezing Weak pulse Shallow breaths JVD Gagging/choking Reduced speaking ability Irregular breaths Arrhythmia Increased work of breathing Edema Mottling Cold extremities Increased work of breathing Edema Please call Methodist Hospice and Palliative Services at (901) 516-1600 to request a consult.
Eligibility Criteria for Hospice Admission Stroke Acute phase of hemorrhagic or ischemic stroke 1. Coma or persistent vegetative state secondary to stroke, beyond three days duration OR 2. In post-anoxic stroke, coma, or severe obtundation, accompanied by severe myoclonus, persisting beyond three days past the anoxic event OR 3. Dysphagia, which prevents sufficient intake of food and fluids to sustain life, in a patient who does not receive artificial nutrition and hydration Chronic phase of hemorrhagic or ischemic stroke: #s 1 and 2 must be present 1. Patient has PPS score of 40% or lower 2. Patient has post-stroke dementia demonstrated by the following: Stage 7 or beyond according to FAST scale Unable to ambulate without assistance No meaningful verbal communication: stereotypical phrases only or the ability to speak is limited to 6 or fewer intelligible works (over)
Stroke (cont.) Unable to bathe without assistance Urinary and fecal incontinence 3. Patient has poor nutritional status with inability to maintain sufficient fluid and calorie intake with > 10% weight loss during the previous 6 months, or serum albumin < 2.5 mg/dl 4. Coma (should have 3 of the following on day 3 of coma) Abnormal brain stem response Absent withdrawal response to pain Absent verbal response Serum creatinine = 1.5 mg/dl 5. Documentation of the following factors will support eligibility for all stroke/coma patients: Aspiration pneumonia Upper urinary tract infection Sepsis Refractory (stage 3-4) decubitus ulcers Fever recurrent after antibiotics Age > 70 Please call Methodist Hospice and Palliative Services at (901) 516-1600 to request a consult.
Eligibility Criteria for Hospice Admission Pulmonary Disease #s 1 and 2 must be present. Factors 3-6 will add supporting documentation. 1. Patient shows both (a) and (b) a) Disabling dyspnea at rest, poorly or not responsive to bronchodilators, resulting in decreased functional capacity, e.g. bed to chair existence, fatigue and cough b) End stage pulmonary disease, as evidenced before hospice admission by increasing visits to the ED or hospitalizations for pulmonary infections and/or respiratory failure 2. Patient has hypoxemia at rest on room air (as evidenced by a p02 < 55 mmhg or 02 sat < 88%); or hypercapnia (as evidenced by pco2 > 50 mmhg). Document available values 3. Patient has right heart failure secondary to pulmonary disease (Cor Pulmonale) 4. Patient has unintentional progressive weight loss > 10% of body weight over the preceding 6 months 5. Patient has resting tachycardia > 100/min (over)
Pulmonary Disease (cont.) 6. Additional signs and symptoms exhibited by the patient: Chest tightness Wheezing Cyanosis Cold extremities Tachypnea Orthopnea Weak pulse Shallow breaths Increased work of breathing Edema/location JVD Mottling/location Reduced Cap. Refill Gagging/choking Irregular breaths Reduced speaking ability Arrythmia Please call Methodist Hospice and Palliative Services at (901) 516-1600 to request a consult.
Eligibility Criteria for Hospice Admission Liver Disease 1. Severely impaired liver function as demonstrated through prothrombin time prolonged more than 5 seconds over control or INR > 1.5 (in patients not on anticoagulants) 2. Serum Albumin < 2.5 mg/dl 3. Patient has at least one of the following to support end stage liver disease: Ascites, refractory to treatment or patient non-compliant Spontaneous bacterial peritonitis Hepatorenal syndrome (elevated creatinine and BUN with oliguria and urine sodium < 10 meq/l Hepatic encephalopathy, refractory to treatment, or patient non-compliant Recurrent variceal bleeding, despite intensive therapy 4. Documentation of the following will support eligibility for hospice: Progressive malnutrition Muscle wasting with reduced strength and endurance Continued active alcoholism (>80 gm ethanol/day) Hepatocellular carcinoma HbsAg (Hepatitis B) positivity Hepatitis C refractory to interferon treatment (over)
Liver Disease (cont.) Patient who is waiting for liver transplant, but otherwise fits the above criteria, may be certified for the Medicare Hospice benefit, but must be discharged from hospice if a donor organ is procured. Please call Methodist Hospice and Palliative Services at (901) 516-1600 to request a consult.
Eligibility Criteria for Hospice Admission Renal Disease Acute Renal Failure 1. Patient is not seeking dialysis or renal transplant or dialysis discontinued 2. Creatinine clearance < 10 cc/min (< 15cc/min for diabetics) AND 3. Serum creatinine > 8.0 mg/dl (>6.0 mg/dl for diabetics) 4. Other clinical factors such as: Mechanical ventilation Malignancy (other organ system) Chronic lung disease Advanced cardiac disease Advanced liver disease Sepsis Immunosuppression/AIDS Albumin < 3.5 gm/dl Cachexia Platelet count < 25,000 Disseminated Intravascular Coagulation GI Bleeding (over)
Renal Disease (cont.) Chronic Renal Failure 1. Patient is not seeking dialysis or renal transplant or dialysis discontinued AND 2. Creatinine clearance < 10 cc/min(<15 cc/min for diatetics) AND 3. Serum creatinine > 8.0 mg/dl (>6.0 mg/dl for diabetics) 4. Signs and symptoms of renal failure: Uremia Oliguria (< 400cc/day) Intractable hyperkalemia (> 7.0) not responsive to treatment Uremic pericarditis Hepatorenal syndrome Intractable fluid overload, not responsive to treatment Please call Methodist Hospice and Palliative Services at (901) 516-1600 to request a consult.
Eligibility Criteria for Hospice Admission Dementia/Alzheimer s The following factors may support eligibility for Hospice: Stage 7a or below on the FAST scale (see other side) Unable to ambulate without assistance Unable to dress without assistance Unable to bathe without assistance Urinary and fecal incontinence, intermittent or constant No meaningful verbal communication: stereotypical phrases only, or the ability to speak is limited to 6 or fewer intelligible words Difficulty swallowing/eating Patient must have had one of the following within the past 12 months: Aspiration Pneumonia Septicemia Fever, recurrent after antibiotics Pyelonephritis or upper urinary tract infection Decubitus ulcers, multiple, stage 3-4 Inability to maintain sufficient fluid/calorie intake (with or without tube feedings) with 10% weight loss during previous 6 months or serum albumin < 2.5 gm/dl (over)
Dementia/Alzheimer s (cont.) Functional Assessment Staging Tool (FAST) (Score is highest consecutive level of disability) 1. No difficulties, either subjectively or objectively 2. Complains of forgetting location of objects; subjective word finding difficulties only 3. Decreased job functioning evident to co-workers; difficulty in traveling to new locations 4. Decreased ability to perform complex tasks (e.g., planning dinner for guests; handling finances; marketing) 5. Requires assistance in choosing proper clothing for the season or occasion 6a. Difficulty putting clothing on properly without assistance 6b. Unable to bathe properly; may develop fear of bathing. Will usually require assistance adjusting bath water temperature 6c. Inability to handle mechanics of toileting (i.e. forgets to flush; doesn t wipe properly) 6d. Urinary incontinence, occasional or more frequent 6e. Fecal incontinence, occasional or more frequent 7a. Ability to speak limited to about 1/2 dozen words in an average day 7b. Intelligible vocabulary limited to a single word in an average day 7c. Non-ambulatory (unable to walk without assistance) 7d. Unable to sit up independently 7e. Unable to smile 7f. Unable to hold head up Please call Methodist Hospice and Palliative Services at (901) 516-1600 to request a consult.
Eligibility Criteria for Hospice Admission Amyotrophic Lateral Sclerosis 1. The patient must demonstrate critical impaired breathing capacity: Vital capacity < 30% of normal Significant dyspnea at rest Requiring supplemental O2 at rest Patient has refused artificial ventilation OR 2. Patient demonstrates both rapid progression of ALS and nutritional impairment Patient is wheelchair or bedbound Speech is barely intelligible or unintelligible Requires pureed diet Major assistance needed for all ADL s Oral intake of food and fluids insufficient to sustain life Continued weight loss Dehydration or hypovolemia Absence of artificial feeding methods OR (over)
Amyotrophic Lateral Sclerosis (cont.) 3. Patient has had life threatening complications occur within the 12 months preceding certification: Recurrent aspiration pneumonia Upper urinary tract infection, e.g. pyelonephritis Sepsis Recurrent fever after antibiotic therapy Please call Methodist Hospice and Palliative Services at (901) 516-1600 to request a consult.
Eligibility Criteria for Hospice Admission AIDS Patients with CD4 count <25 cells/mcl or persistent viral load > 100,000 copies/ml plus at least one of the following: CNS Lymphoma Wasting (Loss of 30% lean body mass) Dilated cardiomyopathy Progressive Multifocal Leukoencephalopathy Mycobacterium avium complex bacteremia, untreated, unresponsive to treatment or treatment refused Visceral Kaposi s Sarcoma unresponsive to therapy Renal failure in the absence of dialysis Systemic lymphoma, with advanced HIV disease, and partial response to chemotherapy Cryptosporidium infection Toxoplasmosis, unresponsive to therapy Decreased performance status, as measured by the Karnofsky Performance scale of < 50 % (over)
AIDS (continued) The following factors may support eligibility for Hospice: Chronic persistent diarrhea for 1 year Concomitant, active substance abuse Advanced AIDS dementia complex CHF, symptoms at rest Cytomegalovirus Absence of antiretroviral, chemotherapeutic and prophylactic drug therapy related specifically to HIV Persistent serum albumin < 2.5 Age > 50 Toxoplasmosis Tuberculosis Pneumocysitis Carnii Pneumonia Please call Methodist Hospice and Palliative Services at (901) 516-1600 to request a consult.