Identifying Common Indicators Of End Stage Disease In Hospice Patients

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In this article, we will identify common indicators of end stage disease in hospice patients. The patient may exhibit ONE or more of the following:

Heart Disease – CHF

  • Symptomatic despite maximal
  • Medical management with diuretics and vasodilators
  • NYHA Class IV
  • Ejection fraction < 20%
  • History of cardiac arrest
  • *Pacemaker/AICD

Pulmonary Disease – COPD

  • Disabling Dyspnea at rest, bed to chair existence
  • Recurrent pulmonary infections
  • Unintentional weight loss
  • Resting tachycardia >100/min
  • FEV1 <30%
  • pO2 <55mm Hg
  • O2 sat <88% (on room air)
  • pCO2, 50mm Hg

Stroke and Coma

  • Level of consciousness down, comatose
  • Post-stroke dementia
  • Palliative Performance Scale, 40% or less
  • Predominately bed bound
  • Unable to do self care w/o assistance
  • Dysphagia
  • Co-morbidities: Aspir. pneumonia, URI, sepsis

Alzheimer’s & Dementia

  • Fast score of > 7
  • Urinary and fecal incontinence
  • Speech limited to <6 words/day
  • Unable to sit up or hold head up
  • Dysphagia
  • Not responding to nutritional support
  • Weight loss
  • Co-morbidities: Aspir. pneumonia, UTI, sepsis, decubiti

Debility Unspecified

  • Multiple co-morbidities with no primary diagnosis
  • Emphasis on Core Indicators

Amyotrophic Lateral Sclerosis

  • Unable to walk, needs assistance with ADL’s
  • Barely intelligible speech
  • Difficulty swallowing
  • Oral intake insufficient to sustain life
  • Significant dyspnea, on O2 at rest
  • Co-morbidities: pneumonia, URI, sepsis
  • Feeding tube
  • *Assisted ventilation

Failure to Thrive

  • Declines enteral/parenteral support
  • Not responding to nutritional support
  • Palliative Performance Scale 40% or less
  • Body Mass Index < 22 kg/m2

Core Indicators

  • Physical Decline
  • Weight Loss
  • Serum Albumin <2.5 gm/dl
  • Not Responding to Nutritional support
  • Palliative Performance Scale
    (PPS), 40% or less
  • Multiple Co-morbidities
  • Frequent Hospitalizations
  • Loss of Will to Live

Liver Disease

  • Hepatic encephalopathy refractory to treatment
  • Recurrent variceal bleeding
  • Ascites despite maximum therapy
  • Peritonitis
  • Hepatorenal syndrome
  • Serum albumin <2.5g/dl
  • PTT >5sec above control
  • *Liver transplant

Renal Disease

  • Signs of uremia (confusion, nausea, pruitis, restlessness, pericarditis)
  • Intractable fluid overload
  • Oliguria <400cc/24hrs
  •  Creat. Clear. <10cc/min
  •  Hyperkalemia >7mEq/L
  • *Dialysis, Renal transplant

HIV/AIDS

  • Wasting syndrome
  • CD4 <25/mcl
  • CD4 >50/mcl
  • Viral load >100,000/mil despite therapy
  • Viral load <100,000 mil plus complications
  • AIDS dementia
  • Current substance abuse
  • Co-morbidities
  • Non-adherence to antiviral, chemotherapeutic and prophylactic drug therapy

*Adapted Medical Guidelines for Determining Prognosis in Selected Non-cancer Diseases, 2nd ed. National Hospice Organization, 1996 and Palmetto GBA Local Coverage Decisions

 

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