Frequent falls Non- ambulatory Minimal verbal communication Two physicians certify eligibility FEV<30 PO2<55 O2 sat<88 Multiple comorbid conditions Increasing weakness Bedbound majority of the day Complications like aspiration pneumonia Decline in appetite Creatinine clearance < 10 mL/min Karnofsky Performance Status (KPS) <50% Dependence in ≥ 3 ADLs Frequent hospitalizations Functional decline Multiple pressure ulcers (stage 3-4) Uremic symptoms EF ≤ 20% INR>1.5 PT> 5 sec Incontinence of bowel & bladder Dyspnea at rest or minimal exertion FAST Stage 7c or beyond Advanced age (>95) CD4+ count <25 cell/mm3 or viral load >100k Recurrent infections Albumin < 3.1 OR BMI < 18 Life expectancy ≤ 6 months Requires continuous oxygen therapy Oliguria, urine output <400ml/24 hrs Frequent ED visits Patient/family chooses comfort care Progressive disease despite therapy Unintentional weight loss Frequent exacerbations Metastatic disease Refractory ascites Oxygen dependent Not pursuing dialysis Requires assistance with bathing PPS<50% Intractable angina NYHA Class IV ECOG score ≥3 Poor response to treatment Frequent falls Non- ambulatory Minimal verbal communication Two physicians certify eligibility FEV<30 PO2<55 O2 sat<88 Multiple comorbid conditions Increasing weakness Bedbound majority of the day Complications like aspiration pneumonia Decline in appetite Creatinine clearance < 10 mL/min Karnofsky Performance Status (KPS) <50% Dependence in ≥ 3 ADLs Frequent hospitalizations Functional decline Multiple pressure ulcers (stage 3-4) Uremic symptoms EF ≤ 20% INR>1.5 PT> 5 sec Incontinence of bowel & bladder Dyspnea at rest or minimal exertion FAST Stage 7c or beyond Advanced age (>95) CD4+ count <25 cell/mm3 or viral load >100k Recurrent infections Albumin < 3.1 OR BMI < 18 Life expectancy ≤ 6 months Requires continuous oxygen therapy Oliguria, urine output <400ml/24 hrs Frequent ED visits Patient/family chooses comfort care Progressive disease despite therapy Unintentional weight loss Frequent exacerbations Metastatic disease Refractory ascites Oxygen dependent Not pursuing dialysis Requires assistance with bathing PPS<50% Intractable angina NYHA Class IV ECOG score ≥3 Poor response to treatment
(Print)
Frequent falls
Non-ambulatory
Minimal verbal communication
Two physicians certify eligibility
FEV<30
PO2<55
O2 sat<88
Multiple comorbid conditions
Increasing weakness
Bedbound majority of the day
Complications like aspiration pneumonia
Decline in appetite
Creatinine clearance < 10 mL/min
Karnofsky Performance Status (KPS) <50%
Dependence in ≥ 3 ADLs
Frequent hospitalizations
Functional decline
Multiple pressure ulcers (stage 3-4)
Uremic symptoms
EF ≤ 20%
INR>1.5
PT> 5 sec
Incontinence of bowel & bladder
Dyspnea at rest or minimal exertion
FAST Stage 7c or beyond
Advanced age (>95)
CD4+ count <25 cell/mm3 or viral load >100k
Recurrent infections
Albumin < 3.1 OR BMI < 18
Life expectancy ≤ 6 months
Requires continuous oxygen therapy
Oliguria, urine output <400ml/24 hrs
Frequent ED visits
Patient/family chooses comfort care
Progressive disease despite therapy
Unintentional weight loss
Frequent exacerbations
Metastatic disease
Refractory ascites
Oxygen dependent
Not pursuing dialysis
Requires assistance with bathing
PPS<50%
Intractable angina
NYHA Class IV
ECOG score ≥3
Poor response to treatment
