Provider Guidelines for Referrals

Overview

Decline in Clinical Status Guidelines
Clinical Status
Symptoms
Signs
Laboratory

Non-Disease Specific Guidelines

Disease Specific Guidelines
Cancer
Amyotrophic Lateral Sclerosis
Dementia
Heart Disease
HIV Disease
Liver Disease
Pulmonary Disease
Renal Disease
Stroke
Coma

Refer a Patient

Overview

Hospice is a holistic approach to health care for terminally ill patients and their families that addresses their physical, emotional, and spiritual needs.

The goal of hospice is not to cure illness or hasten death, but to alleviate pain, control symptoms and provide spiritual, social and emotional support.

Hospice of Southern Maine primarily serves patients in their home or an extended care facility that has become their home. In addition, patients may be admitted to our Gosnell Memorial Hospice House (or another inpatient facility) when short-term care is needed for symptom management.

Qualifying Criteria for Admission to Hospice of Southern Maine:

• Anticipated life expectancy of 6 months or less

• Documented decline in clinical status

• Curative options no longer desired or beneficial

Criteria for Admission to Gosnell Memorial Hospice House (in addition to above):

• Uncontrolled pain

• Intractable nausea & vomiting

• Advanced open wounds with complex dressings

• Uncontrolled respiratory disease

• Severe agitation, anxiety or delirium

• Other uncontrolled symptoms

• Imminent death that requires skilled nursing

Decline in Clinical Status Guidelines

Progression of disease as documented by worsening clinical status, symptoms, signs and laboratory results.

Clinical Status

• Recurrent or intractable serious infections (e.g. pneumonia, sepsis or pyelonephritis)

• Weight loss of at least 10% body weight in the prior six months, not due to reversible causes (may be demonstrated by decrease in mid-arm circumference, or abdominal girth; decrease in skin turgor; or other observation of weight loss)

• Decreasing serum albumin or cholesterol

• Dysphagia leading to recurrent aspiration and/or inadequate oral intake documented by decreasing food portion consumption

• Decline in Karnofsky Performance Scale (KPS) or Palliative Performance Score (PPS)

• Progressive decline in Functional Assessment Staging (FAST) for dementia (from 7A on FAST)

• Progressive dependence on assistance with two out of six ADLs

• Progressive Stage 3-4 pressure ulcers in spite of optimal care

• History of increasing ER visits, hospitalizations, or physician visits related to terminal diagnosis

Symptoms

• Dyspnea with increasing respiratory rate Cough, intractable

• Nausea/vomiting poorly responsive to treatment

• Diarrhea, intractable

• Pain requiring frequent increasing doses of major analgesics

Non-Disease Specific Guidelines

View and download our Hospice Referral Checklist.

In addition to meeting disease specific criteria, patients must have impaired functional status as demonstrated by KPS or PPS <70% (lower for HIV, Stroke, Coma) and dependence on assistance with two out of six ADLs.

Furthermore, the presence of certain co-morbidities, such as the following, is likely to contribute to life expectancy of six months or less:

• COPD

• CHF

• Ischemic Heart Disease

• Diabetes Mellitus

• Neurologic disease (CVA, ALS, MS, Parkinson’s)

• Renal Failure

• Liver Disease

• Neoplasia

• Dementia

• Acquired Immune Deficiency Syndrome/HIV

• Refractory severe autoimmune disease (e.g. Lupus or Rheumatoid Arthritis)

Disease Specific Guidelines

These are to be used in conjunction with the “Non-Disease-Specific Guidelines.”

Cancer (all types)

Disease with metastases at presentation or progression from an earlier stage of disease to metastatic disease with either continued decline in spite of therapy or the patient declines further disease directed therapy.

Amyotrophic Lateral Sclerosis

Two critical factors in determining prognosis are ability to breathe and, to a lesser extent, ability to swallow. Neurologist examination within three months of assessment for hospice is advised, both to confirm the diagnosis and to assist with prognosis.

Patients are considered eligible for hospice if they do not elect tracheotomy and invasive ventilation, and display evidence of critically impaired respiratory function (with or without use of NIPPV) and/or severe nutritional insufficiency (with or without use of a gastrostomy tube).

Critically impaired respiratory function is as defined by FVC <40% predicted (seated or supine) and two or more of the following symptoms and/or signs (or three or more if unable to perform the FVC):

• Dyspnea at rest

• Orthopnea

• Use of accessory respiratory musculature

• Paradoxical abdominal motion

• Respiratory rate >20

• Reduced speech/vocal volume

• Weakened cough

• Symptoms of sleep disordered breathing

• Frequent awakening

• Daytime somnolence/excessive daytime sleepiness

• Unexplained headaches, confusion, anxiety or nausea

Severe nutritional insufficiency is defined as dysphagia with progressive weight loss of at least 5% of body weight with or without election for gastrostomy tube insertion.

These criteria reflect the reality that not all patients with ALS can or will undertake regular pulmonary function tests.

Dementia
(Specific to Alzheimer’s Disease and Related Disorders)

Dementia Referral Checklist

All of the following should be present:

• Stage 7 or beyond on the FAST scale

• Inability to ambulate/dress/bathe without assistance

• Urinary and fecal incontinence, intermittent or constant

• No consistently meaningful verbal communication (ability to speak is limited to six or fewer intelligible words)

Patients should have had one of the following within the past 12 months:

• Aspiration pneumonia

• Pyelonephritis

• Septicemia

• Decubitus ulcers, multiple, stage 3 or stage 4

• Fever, recurrent after antibiotics

• 10% weight loss past six months or serum albumin <2.5gm/dl

Heart Disease

Heart Disease Referral Checklist

All of the following should be present:

• Patient has been optimally treated for heart disease or is not a candidate for, or declined, surgical procedures

• CHF or angina that meets the criteria for the New York Heart Association Class IV

• If data available, CHF with an ejection fraction of 20%

The following support terminal diagnosis:

• Treatment-resistant symptomatic supraventricular or ventricular arrhythmias

• History of cardiac arrest or resuscitation

• History of unexplained syncope

• Brain embolism of cardiac origin

• Concomitant HIV disease

HIV Disease

CD4 count <25 cells/mcl or persistent viral load >100,000 copies/ml, plus one of the following:

• KPS 50%

• CNS lymphoma

• Untreated, or persistent despite treatment, wasting (weight loss 10% of lean body mass)

• Mycobacterium avium complex (MAC) bacteremia, untreated, unresponsive to treatment, or treatment refused

• Progressive multifocal leukoencephalopathy

• Systemic lymphoma, with advanced HIV disease and partial response to chemotherapy

• Visceral Kaposi’s sarcoma unresponsive to therapy

• Renal failure in the absence of dialysis

• Cryptosporidium infection

• Toxoplasmosis, unresponsive to therapy

The following support terminal diagnosis:

• Chronic persistent diarrhea for one year

• Persistent serum albumin <2.5 gm/dl

• Concomitant, active substance abuse;

• Age >50 years

• Absence of or resistance to effective antiretroviral, chemotherapeutic and prophylactic drug therapy related specifically to HIV disease

• Advanced AIDS dementia complex

• Toxoplasmosis

• CHF, symptomatic at rest

• Advanced liver disease

Liver Disease

Prothrombin time prolonged more than 5 seconds over control, or INR >1.5, AND serum albumin <2.5 gm/dl.

Liver Disease Referral Checklist

End stage liver disease is present with at least one of the following:

• Ascites, refractory to treatment or patient non- compliant

• Spontaneous bacterial peritonitis

• Hepatorenal syndrome: elevated creatinine BUN with oliguria (<400ml/day) and urine sodium concentration <10mEq/l

• Hepatic encephalopathy, refractory to treatment, or patient non-compliant

• Recurrent variceal bleeding, despite intensive therapy

The following support terminal diagnosis:

• Progressive malnutrition

• Muscle wasting with reduced strength and endurance

• Continued active alcoholism (>80 gm ethanol/day)

• Hepatocellular carcinoma

• Hepatitis B

• Hepatitis C refractory to interferon treatment

Pulmonary Disease

Pulmonary Disease Referral Checklist

All the following should be present:

• Disabling dyspnea at rest, poorly or unresponsive to bronchodilators, resulting in decreased functional capacity (e.g. bed to chair existence, fatigue and cough)

• Increasing ER visits, hospitalizations or MD visits for pulmonary infections and/or respiratory failure

• Hypoxemia at rest on room air, as evidenced by pO2 55 mmHG or O2 saturation 88% or hypercapnia, as evidenced by pCO2 50 mmHg

The following support terminal diagnosis:

• Right Heart Failure (RHF) secondary to pulmonary disease (Cor Pulmonale)

• Progressive weight loss of >10% of body weight past six months

• Resting tachycardia >100/min

Renal Disease

Renal Disease Referral Checklist

Patient is not seeking dialysis or renal transplant, or is discontinuing dialysis and has creatinine clearance <10cc/min (<15 cc/min for diabetics) or <15cc/min (<20cc/min for diabetics) with co-morbidity of CHF, serum creatinine >8.0mg/dl (>6.0mg/dl for diabetics), or GFR <10ml/min.

The following support terminal diagnosis:

• Mechanical ventilation

• Malignancy (other organ system)

• Chronic lung disease

• Advanced cardiac disease

• Advanced liver disease

• Immunosuppression/AIDS

• Albumin <3.5 gm/dl

• Platelet count <25,000

• Disseminated intravascular coagulation

• Gastrointestinal bleeding

• Uremia

• Oliguria (<400cc/24 hrs)

• Intractable hyperkalemia (>7.0) not responsive to treatment

• Uremic pericarditis

• Hepatorenal syndrome

• Intractable fluid overload not responsive to treatment

Stroke

Stroke Referral Checklist

KPS or PPS <40% and inability to maintain hydration and caloric intake with one of the following:

• Weight loss >10% in the last 6 months or >7.5% in the last 3 months

• Serum albumin <2.5 gm/dl

• Current history of pulmonary aspiration not responsive to speech language pathology intervention

• Sequential calorie counts documenting inadequate caloric/fluid intake

• Dysphagia severe enough to prevent patient from continuing fluids/foods necessary to sustain life and patient does not receive artificial nutrition and hydration

Coma

Coma Referral Checklist

Comatose patients with at lease three of the following on day three of coma:

• Abnormal brain stem response

• Absent verbal response

• Absent withdrawal response to pain

• Serum creatinine >1.5 mg/dl

The following support terminal diagnosis:

• Documentation of the following medical complications, in the context of progressive clinical decline within the past 12 months:

  - Aspiration pneumonia
  - Pyelonephritis
  - Refractory stage 3-4 decubitis ulcers
  - Fever recurrent after antibiotics

• Documentation of the following diagnosis imaging, supporting poor prognosis:

Non-traumatic hemorrhagic stroke:

- Large volume hemorrhage on CT (infratentorial 20ml, supratentorial 50 ml)
- Ventricular extension of hemorrhage
- Surface area of involvement of hemorrhage 30% of cerebrum
- Midline shift 1.5 cm
- Obstructive hydrocephalus in patient who declines, or is not a candidate for, ventriculoperitoneal shunt

Thrombotic/embolic stroke:

- Large anterior infarcts with both cortical and subcortical involvement
- Large bihemispheric infarcts
- Basilar artery occlusion
- Bilateral vertebral artery occlusion

Refer a Patient

To refer one of your patients to Hospice of Southern Maine, please:

• Click Request Care - Health Professionals

• Fax the form to our Access Department at (207) 289-3685

If you have any problems, just call (207) 289-3640.

We are happy to help!

Following is a checklist of paperwork required to complete the referral process:

✓ Demographic sheet (include name, address, insurance information, SS#, etc.)

✓ Clinical documentation to provide a picture of what is happening clinically with patient and to support hospice eligibility (typically a recent office note or hospital discharge summary)

✓ Current discharge medication list

✓ Physician order for hospice (certificate of terminal illness)

✓ DNR order (if applicable)

✓ Advance Directive (if applicable)

✓ P.O.L.S.T. form (if applicable)

✓ Legal Guardian/Power of Attorney documentation (if applicable)

If you have any questions, please call our Access Department at (207) 289-3649.