Hospice Diagnostic Eligibility Guidelines


  • The patient has a life limiting condition with clinical progression of 6 months or less as determined by the patients attending physician and the hospice medical director
  • Weight loss >10% over 6 months, serum albumin <2.5gm/dl Dependence in Activities of Daily Living
  • The patient/designated decision maker and the attending physician, who orders hospice care, agrees with a plan of care for palliation and comfort care
  • Increasing emergency room visits, hospitalizations, or physician visit related to the hospice diagnosis

CANCER : Essential Criteria

  • Disease with distant metastases at presentation; or
  • Progression from an earlier stage of disease to metastatic disease with either:
  • A continued decline in spite of therapy or
  • Patient declines further disease directed therapy

Supporting Criteria
Hypercalcemia > 12, cachexia or weight loss of 5% in past 3 months, recurrent disease after surgery/radiation/chemotherapy, signs and sx of advanced disease (e.g. nausea, requirement for transfusions, malignant ascites or pleural effusion, etc.)

DEMENTIA : Essential Criteria

  • Stage 7 or beyond according to the Functional Assessment Staging Tool (FAST)
  • Unable to ambulate without assistance
  • Unable to complete ADLs without assistance
  • Urinary and fecal incontinence; intermittent or constant
  • No consistently meaningful verbal communication; stereotypical phrases only or the ability to speak is limited to six or fewer unintelligible words

Supporting Criteria
Aspiration pneumonia, urinary tract infection, septicemia, multiple decubitus ulcers (stage 3-4), recurrent Fever after antibiotics, serum albumin < 2.5 gm/dl

HEART DISEASE : Essential Criteria

  • Optimally treated with diuretics, vasodilators
  • Discomfort with physical activities
  • Presence of NYHA Class IV CHF or angina at rest

Supporting Criteria
Ejection fraction is less than 20%, arrhythmias resistant to treatment, history of cardia arrest or resuscitation, unexplained syncope, cardiogenic embolic stroke

LIVER DISEASE : Essential Criteria

  • Prothrombin time prolonged more than 5 seconds or INR .1.5
  • Serum albumin
  • Ascites, refractory to treatment, spontaneous bacterial peritonitis, hepatorenal syndrome, hepatic encephalopathy, refractory to treatment recurrent variceal bleeding

Supporting Criteria
Progressive malnutrition, muscle wasting with reduced strength and endurance, active alcoholism, hepatic carcinoma, hepatitis C refractory to treatment, hepatitis B positivity

PULMONARY DISEASE : Essential Criteria

  • Disabling dyspnea at rest
  • Poor or unresponsive bronchodilators
  • Progression of disease as evidenced by increasing ED visits, hospitalizations, pulmonary infections or respiratory failure
  • Oxygen saturation <88% room air, or PO250mmhg (ABG)

Supporting Criteria
Cor pulmonale, weight loss of greater than 10% of body weight over the preceding 6 months

RENAL FAILURE : Essential Criteria

  • The patient is not seeking dialysis or renal transplant
  • Serum creatinine > 8.0 mg/dl (> 6.0 mg/dl for diabetics)

Supporting Criteria
Uremia, Serum K>7.0 not responding to treatment, Oliguria 400cc/24 hours, Hepatorenal syndrome, Sepsis, Fluid overload, Nausea, uremia, puritis, sedation, confusion, restlessness, uremic pericarditis

STROKE OR COMA : Acute Phase –Hemorrhagic or ischemic

  • Coma or persistent vegetative state secondary to stroke, beyond 3 days
  • Post anoxic stroke-coma obtundation with myoclonus more than 3 days
  • Dysphagia severe enough to prevent the patient from receiving food and fluids to sustain life

Karnofsky score <50%

  • Post stroke dementia-unable to do ADLs without assistance
  • Poor nutritional states, whether artificial or not; weight loss greater than 10% over 6 months; serum albumin <2.5gm/dl

Supporting Criteria
Medical complications related to debility and progressive clinical decline, aspiration, pneumonia, pyelonephritis, sepsis, refractory stage 3-4 decubitus ulcers, fever recurrent after antibiotics. Documentation of various diagnostic imaging factors which support poor prognosis after stroke.


(chronic degenerative conditions such as ALS, Parkinson’s, Muscular Dystrophy, Myasthenia Gravis or Multiple Sclerosis)

Essential Criteria

  • Significant dyspnea at rest (requiring supplemental oxygen at rest)
  • Critical nutritional impairment, rapid disease progression over previous 12 months, wheelchair or bed bound, barely intelligible or unintelligible speech, pureed diet, major assist with ADLs, continued weight loss, insufficient intake, dehydration or hypovolemic
  • Life-threatening complications, aspiration pneumonia, urinary tract infection, sepsis, recurrent fever after antibiotic therapy

Functional Assessment Scale (FAST)

Stage 1 No difficulty, either subjectively or objectively
Stage 2 Complains of forgetting location of objects; subjective work difficulties
Stage 3 Decrease job functioning evident to coworkers; difficulty in traveling to new locations
Stage 4 Decreased ability to perform complex tasks (planning dinner for guests, handling finances)
Stage 5 Requires assistance in choosing proper clothing
Stage 6 Decreased ability to dress, bathe and toilet independently
6A Difficulty putting clothing on properly
6B Unable to bathe properly; may develop fear of bathing
6C Inability to handle mechanics of toileting ( forgets to flush, does not wipe properly)
6D Urinary incontinence
6E Fecal incontinence
Stage 7 Loss of speech, locomotion and consciousness
7A Ability to speak limited (1 to 5 words a day)
7B All intelligible vocabulary lost
7C Non-ambulatory
7D Unable to sit up independently
7E Unable to smile
7F Unable to hold head up

Palliative Performance Scale PPS

PPS Level Ambulation Activity & Evidence of Disease Self-Care Intake Conscious Level
70% Reduced Unable Normal Job/Work Significant disease Full Normal or reduced Stage 1
60% Reduced Unable hobby/house work Significant disease Occasional assistance necessary Normal or reduced Full or confusion
50% Mainly Sit/Lie Unable to do any work
Extensive disease
Considerable assistance required Normal or reduced Full or confusion
40% Mainly in bed Unable to do most activity
Extensive disease
Mainly assistance Normal or reduced Full or drowsy
+/- confusion
30% Totally bed bound Unable to do most activity
Extensive disease
Total Care Normal or reduced Full or drowsy
+/- confusion
20% Totally bed bound Unable to do most activity
Extensive disease
Total Care Minimal to sips Full or drowsy
+/- confusion
10% Totally bed bound Unable to do most activity
Extensive disease
Total Care Mouth care only Drowsy or coma +/- confusion
0% Death