Basis for Starting Hospice

The basic requirement for hospice eligibility is a prognosis (expected survival time) of six months or less. However, it is difficult if not impossible to estimate a prognosis for diseases such as heart disease and emphysema, so Medicare has outlined some very specific criteria to aid physicians in determining whether or not a person with these or other diseases qualifies for hospice care. Below are some examples of how a person with one of these chronic diseases can qualify.

Click on the following diseases to learn more:

Heart Disease

The person must have already been treated with the appropriate medicines for their heart condition, and must not be a candidate for corrective surgery. They must have such severe heart disease that they cannot carry on any physical activity without becoming extremely short of breath. Other heart problems, such as an uncomfortable, uncontrollable abnormal heart rhythm, spells of passing out, or needing cardiac resuscitation (CPR) may also strengthen the case for hospice eligibility.

Emphysema (COPD) and other lung diseases

The person’s disease must be so severe as to make it impossible to do anything without becoming extremely short of breath and very fatigued, even though they take inhalers such as albuterol. Their disease must be getting worse, as shown by lung function tests, more frequent hospitalizations or ER visits, or higher oxygen requirements. Other complications of lung disease, such as an enlarged heart with leg swelling, weight loss, or a rapid heart beat at rest also indicate that the disease is severe enough to require hospice care.

Dementia, both Alzheimer’s type and vascular dementia (from small strokes—usually affects persons with heart disease and high blood pressure)

A person must be unable to ambulate, dress or bathe without assistance. They must be incontinent of urine and stool at least some of the time. Their speech consists only of repetitive phrases or phrases of six or fewer intelligible words. They also must have a complication of dementia in the past year, such as aspiration pneumonia (from poor swallowing ability), urinary tract infection affecting the kidneys, systemic infection (sepsis), skin ulcers that go below skin deep, recurrent fevers, weight loss of more than 10% in six months, or very low protein levels in the blood due to poor nutrition.

Liver Disease (Cirrhosis)

The person’s liver failure results in a poor blood clotting response and very low blood protein levels. This may cause accumulation of a large amount of belly fluid needing drainage, infection of the belly fluid (peritonitis), kidney failure with very low urine output, confusion due to high ammonia levels in the blood, or bleeding of the veins in the stomach and esophagus. They may also have very advanced malnutrition, muscle wasting with weakness, active alcohol abuse, liver cancer, or hepatitis B or C not responding to treatment.

Kidney Disease

The person qualifying for hospice is not seeking a kidney transplant or dialysis. (NOTE: A person may receive dialysis while on hospice if their terminal diagnosis is something other than kidney disease, such as Congestive Heart Failure (CHF), but if their terminal diagnosis is Kidney Disease, they usually do not receive dialysis when on hospice). Serum creatinine levels must be very high (in the 6-8 range, depending on if the person has CHF or diabetes, or not). They may also have related conditions such as respiratory failure (breathing on a ventilator), cancer, lung or liver disease, or AIDS. They may also have almost no urine output, high potassium levels, fluid overload, or cardiac or liver complications.

Neurological Diseases (ALS, Multiple Sclerosis or Parkinson’s Disease)

Although the criteria for these diseases is not as clear as for the diseases described above, there are two criteria that usually qualify a person with a neurological disease for hospice care. These are a significant compromise in breathing or swallowing. When a person begins to be unable to clear their own respiratory secretions, and often coughs or develops pneumonia, their breathing has been severely compromised and their prognosis is very poor. Also, when a person can not swallow even thickened liquids or soft food without choking or coughing, it is time to get hospice care. Other factors support the need for hospice care, such as increasing shortness of breath at rest, wheelchair or bedbound status, barely intelligible speech, need for assistance with all activities of daily living, and insufficient nutrient and fluid intake resulting in weight loss.

AIDS

The person must have a CD4 count less than 25, or a viral load over 100,000, plus a complication such as lymphoma in the nervous system, muscle wasting syndrome, or one of many opportunistic infections. They also must be declining in their functional status to the extent that they can no longer do any work and can only sit or lie down.

Stroke

The person must be bed bound and need total care. They also must be losing weight at the rate of 10% in six months, be aspirating their food or secretions, or be unable to take in adequate calories and fluids to sustain their needs.