Disease Specific Criteria
- Patient has severely impaired breathing capacity with dyspnea at rest and requires supplemental oxygen at rest
- Disease progression is rapid as evidenced by new wheelchair or bed-bound status, progression to unintelligible speech, need for pureed diet, severe nutritional impairment or development of life threatening complications such as sepsis or aspiration pneumonia
- Malignancy is widespread, aggressive, or progressive disease as evidenced by increasing symptoms, worsening lab values and/or evidence of metastatic disease.
- Impaired Palliative Performance Scale (PPS) <70%
- Refuses curative therapies or continues to decline despite definitive therapy
CVA/Stroke or Coma
- Poor functional status with Palliative Performance Scale of 40% or less and poor nutritional status with inability to maintain sufficient fluid and calorie intake
- Has had aspiration pneumonia, pyelonephritis or upper urinary tract infection, septicemic, or multiple decubitus ulcers stage 3-4 in the past 12 months
Heart disease/ CHF
- Poor response or patient’s choice not to pursue optimal treatments with diuretics, vasodilators or ACE inhibitors
- Has angina pectoris at rest resistant to standard nitrate therapy and is not a candidate for invasive procedures and/or has declined revascularization procedures.
- Is unable to carry out minimal activity without dyspnea or angina
- Has CD4+ count of <25 cells/mm3 or persist ant viral load of >10,000 copies/mL from 2 or more assays at least 1 month apart
- Has CNS lymphoma, refractory wasting, Mycobacterium avium, complex, progressive multifocal leukoencephalopathy, Kaposi’s sarcoma, renal failure, treatment resistant dysrythmias, cardiac related syncope, CVA secondary to cardiac embolism, or cardiac arrest.
- Palliative Performance Scale <50%
- Severe chronic lung disease with dyspnea at rest, poorly or unresponsive to bronchodilators, decreased functional capacity, fatigue, and cough
- Progression of end stage pulmonary disease, as evidenced by increasing visits to the emergency department or hospitalizations for pulmonary infections and/or respiratory failure
- Hypoxemia, as evidenced by oxygen saturation of 88% or less on room air, or O2 <= 55 mm Hg
- Cor pulmonale or right heart failure secondary to pulmonary disease
- Unintentional progressive weight loss of greater than 10% of body weight over the preceding six months
- Resting tachycardia >100/min
- Has prothrombin time prolonged more than 5 seconds over control, or International Normalized Ratio (INR)>1.5
- Ascites, refractory to treatment or patient is non-compliant
- Spontaneous bacterial peritonitis
- Hepatorenal syndrome (elevated creatinine and BUN with oliguria (<400ml/day) and urine sodium concentration
- Hepatic encephalopathy, refractory to treatment, or patient non-compliant
- Recurrent variceal bleeding, despite intensive therapy
- The patient is not seeking dialysis or renal transplant, creatinine clearance 8.0 mg/dl (>6.0 mg/dl for diabetes), and serum creatinine > 8.0 mg/dl (>6.0 mg/dl for diabetes)
- Patient has history of mechanical ventilation, malignancy (other organ system), chronic lung disease, advanced cardiac disease, advanced liver disease, sepsis, immunosuppression/AIDS, uremia, hepatorenal syndrome or intractable fluid overload.
Non-Specific Terminal illness
- Patient has rapid decline over the past 3-6 months as evidenced by progression of disease symptoms and test results, decline in Palliative Performance Scale, weight loss due to non-reversible causes, or increased dependence of ADLs.
- Dysphagia leading to inadequate nutritional intake
- Decline in systolic blood pressure to below 90 or progressive postural hypotension
- Increasing emergency room visits or hospitalizations
- Decline in Functional Assessment Staging (FAST) for Dementia
- Multiple progressive stage 3-4 pressure ulcers in spite of optimal carefully