FAST TRACK HOSPICE REFERRAL
Do you have a patient or know someone who might benefit from hospice services? If so, please download this PDF Northland Hospice Referral, complete, and return this form; a representative will follow up promptly.
Ask yourself: “Would I be surprised if this patient died within the next 6 months?” If the answer is “No”, then he/she is appropriate for hospice.
Specific criteria to assist in determining hospice appropriateness for Non-Cancer diagnoses
AIDS
- CD4 less than 25 or HIV RNA over 100,000 and
- Life-threatening complication (e.g., CNS lymphoma, PML, muscle wasting, cryptosporidium (infection), refractory visceral Kaposi’s sarcoma, refractory MAC, resistant toxo, ESRD and no planned dialysis, resistant systemic lymphoma)
- Palliative Performance Scale Score ≤50%
ALS
- SOB at rest and refuses mechanical ventilation
- Rapid progression in last year (e.g., from ambulatory to wheelchair bound, from normal to barely intelligible speech, from normal to pureed diet) and either: 1) significant nutritional impairment (progressive weight loss, dehydration, and refuses artificial feeding) or 2) potentially life-threatening Complications (e.g., recurrent aspir pneumonia, sepsis, pyelo)
Alzheimer’s Disease
- FAST 7 and
- Significant comorbidity potentially limiting lifespan
Cardiac Disease
- Angina at rest despite max medical therapy OR
- NYHA Class IV CHF
Coma
Comatose patient with any 3 of the following on D3 of coma:
- No verbal response
- No withdrawal to pain
- Abnormal brainstem response
- Creatinine over 1.5
Kidney Disease
- CrCl under 10cc/min (15cc/min in diabetics) and
- Creatinine over 8.0 (6.0 in diabetics) and
- Not seeking dialysis or transplant
Liver Disease
PT more than 5 sec over control (INR over 1.5) and albumin less than 2.5 plus one of the following:
- Spontaneous bacterial peritonitis
- Hepatorenal syndrome
- Refractory ascites
- Refractory hepatic encephalopathy
- Recurrent variceal bleeding
Lung Disease
- Disabling SOB at rest and
- Evidence of progressive disease (e.g., increasing ER visits/hospitalizations) and
- PO2 under 56 (SaO2 under 89%) or pCO2 over 49
Stroke
- PPS 40% or less and
- Inadequate PO intake with one of the following:
- 10% weight loss in last 6 months (or 7.5% in 3 months)
- Albumin 2.5 or less
- Recurrent aspiration
- 24 hour cal count documenting inadequate intake
- If does not meet both #1 and #2, then should have significant comorbidity and/or rapid decline
- Age >70