For Health Professionals

End-of-Life Indicators

It is often difficult to determine when a patient may have a life expectancy of six months or less. We provide the following guidelines to assist you in determining if your patient is appropriate for hospice care. They are to be viewed as guidelines and not mandated criteria. We always want to discuss potential referrals with you, so please feel free to call us at 845-634-4974.

General Guidelines (applicable to all diagnoses)

• Recurrent infections: pneumonia, sepsis, pyleonephritis
• Multiple hospital or ER visits, increasing MD visits
• Progressive weight loss >10% in prior six months not attributable to reversible cause
• Significantly decreased intake, artificial nutrition/hydration declined
• Non-healing pressure ulcers (Stage III or IV) with or without optimal care
• HGB<10; Albumin <2.5 when available
• Ascites or edema
• Systolic BP below 90 or progressive postural hypotension
• Unexplained or refractory fevers
• Changes in level of consciousness
• Increasing dependence of ADLs
• Palliative Performance Score <70 or Karnofsky Performance Status <70
• Symptoms poorly responsive to treatment: dyspnea, cough, nausea, vomiting, pain, diarrhea
• Labs (when available but not required): increasing pCO2 or decreasing pO2 or decreasing SaO2, increasing calcium, creatinine or liver function studies, increasing tumor markers (CEA, PSA), progressively decreasing/increasing serum sodium or increasing potassium
• Co-morbid conditions such as: dementia, COPD, CHF/ischemic heart disease, diabetes,neurological disease, advanced kidney disease, advanced liver disease, HIV/AIDS, autoimmune disease, malignancy

Cardiac Disease

• New York Heart Association Class IV CHF or Angina (symptoms present at rest; disabling symptoms with minimal exertion; unable to engage in any physical activity without discomfort)
• Medically optimized with diuretic/vasodilator therapies and supplemental oxygen
• Patient declined or is not a candidate for surgery
• Cardiac-specific supporting factors: prior cardiac arrest, unexplained syncope, ejection fraction <20%, treatment-resistant arrhythmia, severe valvular heart disease, brain embolism of cardiac origin, comorbid HIV

Click Here for the HeartWise: Heart Failure Zone Tool
 

Articles for Review

• Hospice Use Following Implantable Cardioverter-Defibrillator Implantation in Older Patients: More than one-third of older patients dying with ICDs receive hospice care. Five years after implantation, half of older ICD recipients have died or are being followed by hospice. Hospice providers should be prepared for ICD patients, whose clinical trajectories and broader palliative care needs require greater focus.
• Many With Heart Failure Aren’t Told About End-of-Life Care: A recent study conducted at the Mayo Clinic found nearly a third of health-care providers lacked confidence to end-of-life care with their heart failure patients.
• Decision Making in Advanced Heart Failure - A Scientific Statement From the American Heart Association: The importance of shared decision making in advanced heart failure cannot be overstated. A roadmap is offered for conversations with patients to support shared decision making in the context of uncertainties in prognosis, multiple and often competing outcomes, and barriers to communication. These guiding principles and simple tools help set future expectations, anticipate major decisions, and promote productive conversations.
• Palliative Care in the Treatment of Advanced Heart Failure: Palliative care and hospice have the potential to improve quality of life for heart failure patients, family members, and care providers. In addition, costs decrease significantly for payers, hospitals, patients, and families. Evidence suggests that these options are underused; or are used so late in the course of illness that the potential benefits are undermined and their efficacy decreased. Several strategies may be fruitful in making the implementation of palliation more common.
• Engaging Heart Failure Clinicians To Increase Palliative Care Referrals: Overcoming Barriers, Improving Techniques: This article reviews the needs of patients with heart failure and their families, the barriers to referral to palliative care for patients with heart failure, and provides suggestions for improving collaboration between palliative care and HF clinicians.
• Palliative Care Referral Among Patients Hospitalized with Advanced Heart Failure: Findings suggest that only a fraction of Heart Failure patients who are at high risk for morbidity and at a significant risk for mortality receive Palliative Care.