hospice worksheet for determining prognosis, dementia

Introduction

Both 1 & 2 must be present for hospice appropriateness.

• Is the patient severely demented
  • level 7 of functional assessment staging
  • the patient should show all of the following
    • inability to ambulate independently
    • unable to dress without assistance
    • unable to bath properly
    • incontinent of urine & stool
    • unable to speak or communicate meaningfully

• medical complication related to dementia in the past year
  • aspiration pneumonia
  • upper urinary tract infection (pyelonephritis)
  • septicemia
  • pressure ulcers, multiple, stage 3 & 4
  • fever recurrent after antibiotics
  • inability of unwillingness or take food or fluids sufficient to sustain life & not a candidate for enteral (tube) or parenteral feeding
  • for patients currently receiving enteral nutrition, impaired nutritional status must be documented by:
    • unintentional, progressive weight loss > 10% over prior 6 months, or
    • serum albumin < 2.5 mg/dL

Additional terms

• albumin in serum/plasma
• fever of unknown origin (FUO)
• functional assessment staging (FAST)
• pneumonia (PNA)
• pressure ulcer (decubitus ulcer, bedsore)
• pyelonephritis
• sepsis
• weight loss