For Physicians-When to make a Referral

General Hospice Eligibility Triggers: A patient who might be eligible for and benefit from hospice care may demonstrate some of these symptoms:

The patient must have a life-limiting condition or terminal illness with a prognosis of six months or less, either due to a specific diagnosis or a combination of factors. At the end of six months, the patient will be reassessed to determine if hospice is still appropriate considering the progress of the disease. While determining life expectancy is not an exact science, the recent legislation states that “a physician’s certification of a patient is based on clinical judgment regarding the normal course of illness.”

The patient must be aware of their condition and both the patient and family must agree to hospice care, accepting palliative care over curative treatment.

A patient who might be eligible for and benefit from hospice care may demonstrate some of these symptoms:

• Multiple hospital visit/stays in the past six months

• Difficulty breathing, even at rest or with increased oxygen levels

• Pain that is poorly controlled

• Loss of interest in activities

• Unplanned weight loss

• Excessive sleeping throughout the day

• Weakness during activities of daily living

• Frequent changes in medications

• Excessive swelling of the legs and ankles, even when feet are propped up

• Loss of speech

• Infections

• Not sleeping through the night due to pain, shortness of breath or other symptoms

• Not “bouncing back” after an illness

• Not responding to current treatments or therapy

• Loss of appetite

• Confusion

• Wounds that are not healing

Symptoms Worksheet for Potential Hospice Eligibility (NOTE: not all inclusive; to be used as a guide) FAX to 770.940.0700 From: _________________________________ Organization: ___________________________________ Phone: _________________________________ Fax: __________________________________________ For all indicators except HIV/AIDS: □ Karnofsky Performance Status Scale ≤70% □ Palliative Performance Scale ≤70% For all indicators except ALS and HIV/AIDS: □ BMI<22; unintentional weight loss or gain Heart Disease: □ NYHA Class IV – inability to carry on activity □ Ejection fraction of ≤20%v □ Shortness of breath or angina at rest/minimal activity □ Symptoms persist with optimal doses of medications □ Increased frequency of ER visits or hospitalizations □ History of MI or cardiac arrest; unexplained syncope □ Current inotropic therapy dose unable to be reduced Pulmonary Disease: □ Increased frequency of respiratory infections □ Oxygen saturation <88% on room air □ PCO2 ≥ mm HG/decreased functional capacity □ Disabling dyspnea at rest/minimal activity □ Frequency of ER visits/hospitalizations or MD visits □ Resting tachycardia >100bpm Alzheimer's Disease: □ FAST scale of ≥7C Co-morbid conditions associated with dementia in recent 12 months: □ Aspiration pneumonia □ Septicemia □ Pyelonephritis □ Fever, recurrent after antibiotics □ Serum albumin Renal Disease □ Creatinine clearance <10cc/min or <15cc/min for diabetics □ Serum creatinine >8.0 mg/dl or 6.0 mg/dl for diabetics with co-morbidity or CHF □ Glomerular filtration rate (GFR)<10 ml/min □ Not seeking dialysis, transplant or stopping dialysis □ If on dialysis, prognosis of 6 months or less Clinical symptoms of renal failure: □ Confusion; nausea/vomiting/ restlessness □ Generalize pruritus □ Uremia – urine output < 400cc/24 hr □ Oliguria/intractable hyperkalemia >7.0 Liver Disease □ Both Prothrombin time >5 sec over control or INR > 1.5 and serum albumin< 2.5 gm/dl End-stage liver disease: □ Ascites unresponsive to treatment □ Muscle wasting with reduced ADLs □ Jaundice; hepatic encephalopathy □ Recurrent variceal bleeding Stroke or Coma □ Dysphagia without tube feeding □ Pulmonary aspiration not responsive to speech pathology intervention □ Serum albumin≤ 2.5 gm/dl Complications related to decline in past 12 months: □ Aspiration pneumonia □ Absent verbal response □ Absent withdrawal response to pain □ Serum creatinine> 1.5 mg/dl Comatose patients – day 3 of coma: □Abnormal brain stem response □ Absent verbal response □ Absent withdrawal response to pain □ Serum creatinine> 1.5 mg/dl ALS □ Tracheostomy and invasive ventilation and display evidence of critically impaired respiratory function □ Severe nutritional insufficiency □ Loss of 5% of body weight with or without G tube □ Critically impaired ventilatory capacity: □ Vital capacity (FVC) less than 40% of predicted □ Significant dyspnea at rest □ Use of accessory respiratory musculature □ Requiring oxygen at rest/minimal activity □ Reduced speech/vocal volume HIV/AIDS □ CD4+ is below 25 cells/mcL measured when a patient is relatively free from acute illness but should be followed clinically and observed for disease progression and decline in recent functional status □ Patients with a persistent HIV RNA (viral load) of >100,000 copies/ml may have a prognosis less than 6 months □ Have elected to forgo anti-retroviral medication □ Karnofsky <50%; Palliative Performance Scale <50% □ HIV/AIDS with opportunistic diseases □ Serum albumin <2.5 gm/dl □ Age><2.5 gm/dl □ Age 50 years □ Advanced AIDS dementia complex Cancer □ Dependence for 2 or more ADLs □ Disease with metastases at presentation or progression from an earlier stage of the disease to metastatic disease with either: □ A continued decline in spite of therapy □ Patient declines further disease directed therapy

Evaluate for Avycare

( □ In-Patient / □ Home Patient )

Patient’s Name: ___________________________________________ DOB: ____________________

Physician Signature: _______________________________________Date:_____________________

Physician Name (Please Print):________________________________________________________

Avycare, we are committed to making this journey as peaceful and meaningful as possible, regardless of it's length. Avycare is your Partner in End-of-Life Care.

              Call Avycare at 770.940.0700 with any questions.