For Physicians – Hospice Eligibility Guidelines

Hospice Eligibility Guidelines and General Indications for Hospice

In order to be eligible to receive hospice services under the Medicare benefit, a beneficiary must:

  • Be eligible for Medicare Part A
  • Be terminally ill and have a life expectancy of six (6) months or less (if the disease runs its normal course)
  • Have the terminal illness confirmed by the attending physician and the hospice Medical Director
  • Meet criteria related to their terminal diagnosis
  • Be willing to sign an election statement that identifies services to be provided by hospice— services that are palliative not curative
  • Agree to give up traditional Medicare benefits related to the terminal diagnosis (after signing on to the hospice benefit)
  • Have an available relative or friend willing and able to care for the patient (this may be waived under certain circumstances)
  • Live within the service area of their chosen hospice.

Determination of terminal status is based on a physician’s clinical judgment, and is not an exact science.  Congress supported this position in Section 322 of the Benefits Improvement and Protection Act of 2000 (BIPA), which says that the hospice certification of terminal illness “shall be based on the physician’s or medical director’s clinical judgment regarding the normal course of the individual’s illness.”

This reference includes clinical variables without regard to diagnosis, as well as clinical variables applicable to a limited number of diagnoses provided by CMS. These guidelines are not regulations, but are meant to help determine hospice eligibility.

Decline in Clinical Status

The patient has documented evidence of decline in clinical status based on the guidelines listed below. Determination of decline presumes assessment of the patient’s status over time. These changes in clinical variables apply to patients whose decline is not considered to be reversible. They are listed in order of their likelihood to predict poor survival, the most predictive first and the least predictive last. No specific number of variables must be met, but fewer of those listed first (more predictive) and more of those listed last (least predictive) would be expected to predict longevity of six months or less

  1. Progression of disease as documented by worsening clinical status, symptoms, signs and laboratory results
    1. Clinical Status
      1. Recurrent or intractable infections such as pneumonia, sepsis or upper urinary tract
      2. Progressive inanition as documented by:
        1. Weight loss not due to reversible causes such as depression or use of diuretics
        2. Decreasing anthropomorphic measurements (mid-arm circumference, abdominal girth), not due to reversible causes such as depression or use of diuretics
        3. Decreasing serum albumin or cholesterol
      3. Dysphagia leading to recurrent aspiration and/or inadequate oral intake documented by decreasing food portion consumption
    2. Symptoms
      1. Dyspnea with increasing respiratory rate
      2. Cough, intractable
      3. Nausea/vomiting poorly responsive to treatment
      4. Diarrhea, intractable
      5. Pain requiring increasing doses of major analgesics more than briefly
    3. Signs
      1. Decline in systolic blood pressure to below 90 or progressive postural hypotension
      2. Ascites
      3. Venous, arterial or lymphatic obstruction due to local progression or metastatic disease
      4. Edema
      5. Pleural / pericardial effusion
      6. Weakness
      7. Change in level of consciousness
    4. Laboratory (When available. Lab testing is not required to establish hospice eligibility.)
      1. Increasing pCO2 or decreasing pO2 or decreasing SaO2
      2. Increasing calcium, creatinine or liver function studies
      3. Increasing tumor markers (e.g. CEA, PSA)
      4. Progressively decreasing or increasing serum sodium or increasing serum potassium
  2. Decline in Karnofsky Performance Status (KPS) or Palliative Performance Score (PPS) from <70% due to progression of disease
  3. Increasing emergency room visits, hospitalizations, or physician’s visits related to hospice primary diagnosis
  4. Progressive decline in Functional Assessment Staging (FAST) for dementia (from ≥7A on the FAST)
  5. Progression to dependence on assistance with additional activities of daily living
  6. Progressive stage 3-4 pressure ulcers in spite of optimal care

** See Appendices for Assessment Tools

Non-disease Specific Baseline Guidelines

The patient has both 1 and 2 below. Documentation of conditions such as those listed in #3 support eligibility.

  1. Physiologic impairment of functional status as demonstrated by: Karnofsky Performance Status (KPS) or Palliative Performance Score (PPS) <70%.
    (Note that two of the disease specific guidelines (HIV Disease, Stroke and Coma) establish a lower qualifying KPS or PPS.)
  2. AND

  3. Dependence on assistance for two or more activities of daily living (ADLs)
    1. Feeding
    2. Ambulation
    3. Continence
    4. Transfer
    5. Bathing
    6. Dressing
  4. Co-morbidities: Although not the primary hospice diagnosis, the presence of disease such as the following, the severity of which is likely to contribute to a life expectancy of six months or less, should be considered in determining hospice eligibility.Chronic obstructive pulmonary disease
    1. Congestive heart failure
    2. Ischemic heart disease
    3. Diabetes mellitus
    4. Neurologic disease (CVA, ALS, MS, Parkinson’s)
    5. Renal failure
    6. Liver Disease
    7. Neoplasia
    8. Acquired immune deficiency syndrome
    9. Dementia

Amyotrophic Lateral Sclerosis (ALS)

The patient has at least 1, 2 or 3 below:

  1. Critically impaired breathing capacity with all of the following findings:
    • Dyspnea at rest
    • Vital Capacity less than 30%
    • Artificial ventilation declined by the patient
  2. Rapid disease progression as evidenced by all of the following in the preceding twelve (12) months:
    • Progression from independent ambulation to wheelchair or bed-bound status
    • Progression from normal to barely intelligible or unintelligible speech
    • Progression from normal to pureed diet
    • Progression from independence in most or all activities of daily living (ADLs) to needing major assistance by caretaker in all ADLs

    AND

  3. Rapid disease progression with either A or B below.
    1. Critical nutritional impairment demonstrated by all of the following in the preceding twelve (12) months:
      • Oral intake of nutrients and fluids insufficient to sustain life
      • Continuing weight loss
      • Dehydration or hypovolemia
      • Absence of artificial feeding methods sufficient to sustain life, but not for relieving hunger
    2. Life-threatening complications demonstrated by one or more of the following in the preceding twelve (12) months:
      • Recurrent aspiration pneumonia (with or without tube feeding)
      • Upper urinary tract infection (e.g. pyelonephritis)
      • Sepsis
      • Recurrent fever after antibiotic therapy
      • Stage 3 or Stage 4 decubitus ulcer(s)

In the absence of one or more of the above findings, general decline in status and comorbidities may also support eligibility for hospice care.

Alzheimer’s Disease

The patient has both 1 and 2:

  1. Stage 7 or beyond according to the Functional Assessment Staging Scale* with all of the following:
    • Inability to ambulate without assistance
    • Dependent with ADL’s
    • Incontinent of bowel and/or bladder – intermittent or constant
    • Unable to speak/communicate intelligibly
  2. Has had at least one (1) of the following conditions within the past twelve (12) months:
    • Aspiration pneumonia
    • Pyelonephritis or urinary tract infection
    • Septicemia
    • Decubitus Ulcers, multiple, Stage 3-4
    • Fever, recurrent after antibiotics
    • Inability to maintain sufficient fluid and calorie intake demonstrated by either of the following:
      • Serum albumin less than 2.5
      • 10% weight loss during the previous six (6) months.

In the absence of one or more of the above findings, general decline in status and comorbidities may also support eligibility for hospice care.

* See Appendix for the Functional Staging Scale

Cancer

The patient either 1 or 2. Documentation of conditions in #3 support eligibility.

  1. Disease with distant metastases at presentation
  2. OR

  3. Progression from an earlier state of disease to metastatic disease with either:
    1. A confirmed decline in spite of therapy
    2. Patient declines further disease-directed therapy
  4. Supportive criteria includes
    • Albumin <3.5
    • Necessity of frequent pain/symptom management
  5. Impaired performance status with a PPS* < 70%
    • Hypercalcemia > 12
    • Cachexia or weight loss of 10% in the preceding 3 months
    • Recurrent disease after surgery/radiation/chemo­therapy
    • Unresponsive to hormonal therapy or hormonal therapy is refused
    • Signs and Symptoms of advanced disease (e.g., nausea, requiring transfusions, malignant ascites, or pleural effusion etc.)

Tissue diagnosis of malignancy or reasons why a tissue diagnosis is not available will be required. Certain cancers with poor prognoses (e.g. small cell lung cancer, brain,, and pancreatic cancer) may be hospice eligible without fulfilling other criteria in this section.

In the absence of one or more of the above findings, general decline in status and comorbidities may also support eligibility for hospice care.

* See Appendix for Palliative Performance Scale

Heart Disease

Congestive Heart Failure (CHF)/Coronary Artery Disease (CAD)

The patient has both 1 and 2. Documentation of conditions in #3 support eligibility.

  1. Already optimally treated for heart disease (treatment with vasodilators and other appropriate drugs, or inability or refusal to take such drugs; not a candidate for a surgical procedure or refusal of such a procedure)
  2. AND

  3. Classified as New York Heart Association (NYHA)* Class IV* with:
    • Symptoms of heart failure and/or angina at rest
    • Ejection Fraction of less than 20% for heart failure patients
  4. Documentation of the following factors will support eligibility, but are not required:
    • Treatment resistant symptomatic supraventricular or ventricular dysrhythmias
    • History of unexplained syncope
    • Brain embolism of cardiac origin
    • History of cardiac arrest or resuscitation
    • Concomitant HIV disease

**New York Heart Association (NYHA) Class IV patients with heart disease have an inability to carry on any physical activity without discomfort. Symptoms of heart failure or of the anginal syndrome may be present even at rest. Any physical activity increases discomfort.

In the absence of one or more of the above findings, general decline in status and comorbidities may also support eligibility for hospice care.

HIV Disease

The patient must have both 1 and 2. Documentation of conditions in #3 support eligibility.

  1. CD4+ Count <25 cells/mcl OR Persistent (2 or more assays at least one month apart) viral load > 100,000 copies/ml
  2. AND

    At least one (1) of the following conditions:

    • CNS lymphoma
    • Untreated, or persistent despite treatment, wasting (loss of at least 10% lean body mass)
    • Mycobacterium Avium Complex (MAC) bacteremia, untreated, unresponsive to treatment, or treatment refused
    • Progressive multifocal leukoencephalopathy
    • Systemic lymphoma, with advanced HIV disease and partial response to chemotherapy
    • Visceral Kaposi’s Sarcoma, unresponsive to therapy
    • Renal failure in absence of dialysis
    • Cryptosporidium infection
    • Toxoplasmosis, unresponsive to therapy

    AND

  3. Decreased performance status as measured by Karnofsky Performance Status Scale (KPS)** of ≤ 50%
  4. The following factors support eligibility:
    • Chronic persistent diarrhea for one year
    • Persistent serum albumin < 2.5
    • Concomitant active substance abuse
    • Age ˃ 50 years
    • Absence of, or resistance to effective antiretroviral, chemotherapeutic and prophylactic drug therapy related specifically to HIV disease
    • Congestive heart failure, with symptoms at rest
    • Toxoplasmosis
    • Advanced AIDS dementia complex
    • Advanced liver disease

In the absence of one or more of the above findings, general decline in status and comorbidities may also support eligibility for hospice care.

**  See Appendix for Karnofsky Performance Status Scale (KPS) Scale

Liver Disease

The patient has both 1 and 2. Documentation of conditions in #3 support eligibility.

  1. The patient should show both:
    1. Prothrombin time (PT) prolonged more than 5 seconds over control, or International Normalized Ratio (INR) >1.5
    2. AND

    3. Serum albumin <2.5 gm/dl
    4. AND

  2. End stage liver disease is present , and the patient shows at least one of the following::
    • History of spontaneous bacterial peritonitis
    • Ascites, unresponsive to treatment or non-compliant patient
    • Hepatic encephalopathy, refractory to treatment, or patient non-compliant
    • Hepatorenal syndrome (elevated creatinine + BUN with oliguria [<400ml/day] and urine sodium concentration ˂ 10 mEq/l
    • History of recurrent variceal bleeding despite intensive therapy or patient declines sclerosing therapy
  3. Documentation of the following factors support eligibility:
    • Progressive malnutrition
    • Muscle wasting with reduced strength and endurance
    • Continued active alcoholism (>80 gm ethanol/day)
    • Hepatocellular carcinoma
    • HBsAg (Hepatitis B) positive
    • Hepatitis C refractory to interferon treatment

Patients awaiting liver transplant who otherwise fit the above criteria may qualify for hospice, but if a donor organ is procured, the patient should be discharged from hospice.

In the absence of one or more of the above findings, general decline in status and comorbidities may also support eligibility for hospice care.

Pulmonary Disease

The patient has both 1 and 2. Documentation of conditions in #3, #4, and #5 support eligibility.

  1. Severe chronic lung disease as documented in both A and B:
    1. Disabling dyspnea at rest, poorly or unresponsive to bronchodilators, resulting in a decreased functional capacity, e.g. bed to chair existence, fatigue and cough (Documentation of Forced Expiratory Volume in One Second [FEV1], after bronchodilator, less than 30% of predicted is objective evidence for disabling dyspnea, but is not necessary to obtain.)
    2. AND

    3. Progression of end stage pulmonary disease as evidenced by increasing visits to the emergency department or hospitalizations for pulmonary infections and/or respiratory failure or increasing physician home visits (Documentation of serial decrease of FEV1˃40 ml/year is objective evidence of disease progression, but is not necessary to obtain.)
  2. Documentation within the past 3 months of A or B or both:
    1. Hypoxemia at rest on room air (pO2 ≤ 55mgHg by ABG or oxygen saturation ≤ 88% determined either by arterial blood gases or oxygen saturation monitors
    2. Hypercapnia evidenced by pCO2 ≥ 50mmHg
  3. Right heart failure secondary to pulmonary disease (Cor pulmonale) (e.g., not secondary to left heart disease or valvulopathy)
  4. Unintentional progressive weight loss > 10% over the preceding six months
  5. Resting tachycardia > 100bpm

In the absence of one or more of the above findings, general decline in status and comorbidities may also support eligibility for hospice care.

Renal Failure (Acute)

The patient has 1 and either 2 or 3. Documentation of conditions in #4 support eligibility.

  1. The patient is not seeking dialysis or renal transplant or is discontinuing dialysis
  2. AND

  3. Creatinine clearance** <10 cc/min (<15 cc/min for diabetics) based on measurement or calculation; or <15 cc/min (<20 cc/min for diabetics) with comorbidity of congestive heart failure
  4. OR

  5. Serum creatinine >8.0 mg/dl (>6.0 mg/dl for diabetics)
  6. Supporting conditions:
    • Mechanical ventilation
    • Malignancy (other than organ system)
    • Chronic lung disease
    • Advanced cardiac disease
    • Advanced liver disease
    • Sepsis
    • Immunosupression/AIDS
    • Albumin <3.5 gm/dl
    • Cachexia
    • Platelet count <25,000
    • Disseminated intravascular coagulation,
    • GI bleeding

**Creatinine Clearance Calculation
(140 – age, in yrs.) x (weight, in kg.) – 72 x (serum creatinine in mg/dl)
Multiply answer by 1 for men and by 0.85 for women

In the absence of one or more of the above findings, general decline in status and comorbidities may also support eligibility for hospice care.

Renal Failure (Chronic)

The patient has 1 and either 2 or 3. Documentation of conditions in #4 support eligibility.

  1. The patient is not seeking dialysis or renal transplant or is discontinuing dialysis
  2. AND

  3. Creatinine clearance** <10 cc/min (<15 cc/min for diabetics) based on measurement or calculation or <15 cc/min (<20 cc/min for diabetics) with comorbidity of congestive heart failure
  4. OR

  5. Serum creatinine >8.0 mg/dl (>6.0 mg/dl for diabetics)
  6. Signs and symptoms of renal failure
    • Uremia
    • Oliguria (<400cc/24 hours)
    • Intractable hyperkalemia (˃7.0) not responsive to treatment
    • Uremic pericarditis
    • Hepatorenal syndrome
    • Intractable fluid overload (not responsive to treatment)

*Creatinine Clearance Calculation
(140 – age, in yrs.) x (weight, in kg.) – 72 x (serum creatinine in mg/dl)
Multiply answer by 1 for men and by 0.85 for women.

In the absence of one or more of the above findings, general decline in status and comorbidities may also support eligibility for hospice care.

Stroke and Coma

Stroke: Patients will be considered to be in the terminal stages of stroke if they meet the following criteria:

  • Karnofsky Performance Status (KPS) or Palliative Performance Scale (PPS) of 40% or less
  • Inability to maintain hydration and caloric intake with one of the following:
    1. Weight loss > 10% in the last 6 months or >7.5% in the last 3 months
    2. Serum albumin <2.5 gm/dl
    3. Current history of pulmonary aspiration not responsive to speech language pathology intervention;
    4. Sequential calorie counts documenting inadequate caloric/fluid intake
    5. Dysphagia severe enough to prevent patient from continuing fluids/foods necessary to sustain life and patient declines or does not receive artificial nutrition and hydration

Coma: Patients will be considered to be in the terminal stages of coma if they meet any 3 the following criteria:

  1. Abnormal brain stem response
  2. Absent verbal response
  3. Absent withdrawal response to pain
  4. Serum creatinine >15 mg/dl.

Documentation of the following factors will support the eligi­bility for hospice care:

  • Documentation of medical complications, in the context of progressive clinical decline, within the previous 12 months, which support a terminal prognosis
  • Aspirational pneumonia
  • Pyelonephritis
  • Refractory stage 3-4 decubitus ulcers
  • Fever recurrent after antibiotics

Documentation of diagnostic imaging factors which support poor prognosis after stroke include:

  1. For non-traumatic hemorrhagic stroke:
    1. Large-volume hemorrhage on CT
      1. Infratentorial: ≥20ml;
      2. Supratentorial: ≥50 ml;
    2. Ventricular extension of hemorrhage
    3. Surface area of involvement of hemorrhage ≥30% of cerebrum
    4. Midline shift greater than or equal to 1.5cm
    5. Obstructive hydrocephalus in patient who declines, or is not a candidate for, ventriculoperitoneal (VP) shunt
  2. For thrombotic/embolic stroke:
    1. Large anterior infarcts with both cortical and subcortical involvement
    2. Large bihemispheric infarcts
    3. Basilar artery occlusion
    4. Bilateral vertebral artery occlusion

In the absence of one or more of the above findings, general decline in status and comorbidities may also support eligibility for hospice care.