Common Indicators Of End Stage Disease In Hospice Patients

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
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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


  • 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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