For Medical Providers

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

  1. PPS 40% or less and
  2. 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