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Early identification of hospice eligible patients increases the likelihood that they and their families will benefit from hospice care. Physicians must certify that patients meet guidelines determined by CMS to be eligible for admission to a hospice provider.
General Eligibility Guidelines
For a patient to be eligible for hospice, the physician should consider the following guidelines:
Patients are considered to be hospice eligible for amyotrophic lateral sclerosis (ALS, or Lou Gehrig’s disease) when a physician makes a clinical determination that life expectancy is six months or less if the disease runs its normal course and they meet the following guidelines:
In end-stage ALS, two factors are critical in determining prognosis: ability to breathe and ability to swallow. ALS may be complicated by secondary and co-morbid conditions. Secondary conditions, such as dysphagia, pneumonia and pressure ulcers, are a direct result of the impairment of respiratory functions, swallowing, muscle power and muscle tone that are common in ALS. Co-morbid conditions, which often accompany the rapid progression of ALS, include chronic obstructive pulmonary disease (COPD), pyelonephritis or upper urinary tract infection, septicemia and fever after recurrent antibiotics. While feeding tubes may be a normal part of treatment in ALS, G-tubes and ventilator support prolonged life expectancy. Hospice eligible patients are those who have chosen to forego supportive ventilation, artificial hydration and nutrition.
Alzheimer’s disease and other progressive dementias are life limiting conditions for which curative therapy is not available. Patients with dementia or Alzheimer’s are eligible for hospice care when they show the following characteristics:
Patient should be at least stage 7 on the FAST scale
Secondary diagnoses associated with advanced dementia include:
Co-morbid conditions that might significantly impair the dementia patient’s health and functionality:
Patients are eligible for hospice care when a physician makes a clinical determination that life expectancy is six months or less if the disease runs its expected course.
Characteristics of end-stage congestive heart disease:
Characteristics of end-stage coronary artery disease:
To be eligible for hospice a patient should meet the following guidelines:
1. Disease with metastases at presentation OR;
2. Progression of disease to metastatic disease with either:
3. Patient is diagnosed with a cancer that is known to have a poor prognosis such as small cell lung cancer, brain cancer, or pancreatic cancer.
Palliative Performance Scale for Functional Status
In general, a cancer patient who scores 70% or lower on the Palliative Performance Scale may be eligible for hospice. These patients typically:
ECOG Score for Functional Status
The biggest predictor of hospice eligibility in oncology, is the patient’s functional status using the Eastern Cooperative Oncology Group (ECOG) scale. If your patients have decreased functional status and are spending an increasing amount of time sitting or lying down, a rough estimate of the prognosis is three months or less.
Using the ECOG scale, a median survival of three months roughly correlates with a score of >3. An ECOG score of 2 is generally supportive of being eligible for hospice services.