hospice worksheet for determining prognosis, general guidelines, all diagnoses

Introduction

The patient should meet the following criteria:

• life-limiting condition
• patient &/or family informed that the condition is life-limiting
• patient &/or family has elected palliative care
• documentation of clinical progression of disease
  • serial physician assessment
  • laboratory studies
  • radiologic or other studies
  • multiple Emergency Department visits
  • inpatient hospitalizations
  • home health nursing assessment if patient is homebound &/or
• recent functional decline, determined by a or b
  • Karnofsky performance status < 50
  • dependence in 3/6 basic activities of daily living (bADL) &/or
• impaired nutritional status
  • unintentional weight loss > 10% over past 6 months
  • serum albumin < 2.5 mg/dL

Additional terms

• albumin in serum/plasma
• basic activities of daily living (bADL, Katz)
• Karnofsky performance index (palliative performance scale)
• weight loss