Quick Hospice Eligibility Check for Clinicians

Does the patient meet one or more of the general eligibility guidelines?(Required)

(Choose all that apply)

Uncontrolled or increased pain

Evidence of metastatic disease

Progressive weight loss

Recurrent infections

Decline in functional status

Deteriorating mental abilities

Multiple decubitus ulcers

Increased breathing difficulties

Increasing ER visits, hospitalizations, or MD visits

Decreasing Palliative Performance Scale (PPS) score – PPS Chart

Deterioration in lab values

None of these

Additional details for ALS(Required)

(Choose all that apply)

Critically impaired breathing

Rapid progression in ALS

Critical nutritional impairment

Recurrent aspiration pneumonia

Challenges in the ability to breathe

Challenges in the ability to swallow

Additional details for Alzheimer's(Required)

(Choose all that apply)

FAST Scale rating of seven or more?

Recurrent infections

UTI

Fever, recurrent after antibiotic

10% weight loss during previous six months

Aspiration pnuemonia

Additional details for cancer(Required)

(Choose all that apply)

Palliative Performance Scale (PPS) < 70%

Dependent on two or more ADLs

Pathology report reveals malignancy or metastasis

Progression from earlier stage of disease to metastatic disease

Additional details for cardiac disease(Required)

(Choose all that apply)

Patient optimally treated with diuretics and vasodilators

Angina pectoris at rest

Resistant to standard nitrated therapy

Unable to carry on physical activity without symptoms or symptoms increase

Additional details for dementia(Required)

(Choose all that apply)

FAST Scale rating of 7 or more?

Aspiration pneumonia

UTI

Fever, recurrent after antibiotic

10% weight loss during previous six months

Additional details for HIV disease(Required)

(Choose all that apply)

CD4+ Count 1000,000 coies/ml

CNS Lymphoma

Wasting (loss of 33% lean body mass)

Additional details for liver disease(Required)

(Choose all that apply)

Ascites

Lab results show elevated creatinine and BUN

Progressive malnutrition

Muscle wasting

Continued active alcoholism

Hepatitis B positivity

Additional details for Parkinson's(Required)

(Choose all that apply)

Dyspnea at rest

Supplemental Oxygen at rest

Patient declines artificial ventilation

Decline from Independent ambulation to wheelchair dependent

Decline from normal to barely intelligible speech

Additional details for pulmonary disease(Required)

(Choose all that apply)

Disabling dyspnea at rest

Poor response to bronchodillators

Frequent upper respiratory infection

Frequent hospitalization

Oxygen saturation of 88% or less on room air

Additional details for renal disease(Required)

(Choose all that apply)

Patient not seeking dialysis or renal transplant

Lab results with increased serum creatinine

Co‑morbidities such as sepsis and cachexia

Hospice Eligibility Quiz

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