Referral Guidelines for Non-Cancer Diagnoses

Yes / No / The patient should meet the following general criteria:
Terminal condition either due to a specific diagnosis or a combination of disease.
Patient and/or family have elected a course of palliative care.
Patient/caregiver/physician agree exacerbation of terminal illness will not be treated aggressively.
Renal Disease—Acute Renal Failure
1, 2, and 3 must be present; factors from 4 will lend supporting documentation.
1. Patient not seeking dialysis or renal transplant.
2. Creatinine clearance <10 cc/min (15 cc/min. for diabetes)
3. Serum creatinine > 8.0 mg/dl (>6.0 mg/dl for diabetes)
4. Comorbid conditions:
Ventilator
Malignancy (other system)
Chronic lung disease
Advanced cardiac disease
Sepsis
Immunosuppression/AIDS
Albumin <3.5 gm/dl
Cachexia
Platelet count <25,000
GI bleeding
Disseminated intravascular coagulation
Chronic Renal Failure: Same as required acute factors with the following lending supporting documentation:
Uremia
Oliguria (<400 cc/day)
Intractable hyperkalemia (>7.0) not responsive to treatment
Uremic pericarditis
Hepatorenal syndrome
Intractable fluid overload, not responsive to treatment
Pulmonary Disease
All of the following must be present:
Disabling dyspnea at rest
Dyspnea responds poorly to bronchodilators
Dyspnea often exacerbated by other debilitating symptoms such as fatigue and cough
ER visits/hospitalizations for pulmonary infections and/or respiratory failure
Hypoxemia at rest on room aire (O2 sats £ 88% on oxygen or pO2<55 mm Hg) OR hypercapnia (pCO2³50 mmHg)
The following factors will support eligibility:
Cor pulmonale and right heart failure secondary to pulmonary disease
Unintentional, progressive weight loss >10% of body weight over preceding 6 months
Resting tachycardia >100/min.
Stroke/Coma
Stroke: Criteria 1 and 2 would support a terminal prognosis for individuals with a DX of stroke, or show documentation describing relevant comorbidity and/or rapid decline if 1 and 2 are not met:
1. Palliative Performance Scale (PPS) of <40
2. Inability to maintain hydration and caloric intake with one of the following:
Weight loss >10% during previous 6 months
Weight loss >7.5% in previous 3 months
Serum albumin <2.5 gm/dl
Current history of pulmonary aspiration without effective response to ST interventions to improve dysphagia and decrease aspiration events
Calorie counts document inadequate caloric/fluid intake
Coma: Any 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
Heart Disease
Both of the following must be present:
Optimal treatment with diuretics and vasodilators (or medical reason to refuse, e.g. hypotension or hyperkalemia) OR Angina pectoris, at rest, resistant to standard nitrate therapy and not candidate for invasive procedures
Significant symptoms of recurrent congestive heart failure at rest with NHYA Class IV
The following will support eligibility:
Treatment resistant symptomatic supraventricular or ventricular arrhythmias
History of unexplained syncope
History of cardiac arrest or resuscitation
Brain embolism of cardiac origin
Concomitant HIV disease
Ejection fraction of 20% or less, documented
Dementia
All of the following should be present:
³ Stage Seven FAST scale
Unable to walk without assistance
Unable to dress without assistance
Unable to bathe without assistance
Urinary and fecal incontinence, intermittent or constant
No meaningful verbal communication, £ six words
AND Patient must have had one of the following within the past 12 months:
Aspiration pneumonia
Pylenephritis or other upper urinary tract infection
Septicemia
Decubitus ulcers, multiple, stage 3-4
Fever, recurrent after antibiotics
Weight loss of >10% during past six months OR serum albumin < 2.5 gm/dl
HIV Disease
Factors 1 and 2 must be present:
1. CD4+ Count<25 cells/mcL or persistent viral load >100,000 copies/ml plus one of the following:
CNS lymphoma
Wasting (loss of 33% lean body mass), untreated or not responsive to treatment
MAC bacteremia, untreated, unresponsive to treatment, or treatment refused
Progressive multifocal leukoencephalopathy
Systemic lymphoma, with advanced HIV disease and partial response to chemotherapy
Cryptosporidium infection
Toxoplasmosis, unresponsive to therapy
2. Decreased performanc status with Karnofsky Scale of < 50%
Supporting factors:
Chronic persistent diarrhea for one year
Persistent serum albumin <2.5
Concomitant, active substance abuse
Age > 50 years
Absence of antiretroviral, chemotherapeutic, and prophylactic drug therapy related specifically to HIV disease
Advanced AIDS dementia complex
Toxoplasmosis
Congestive heart failure, symptomatic at rest
Adult Failure to Thrive
Both 1 and 2 must be present:
1. Severe nutritional impairment. BMI <22 kg/m2 with pt. declining or not responding to enteral/parental nutritional support. (BMI= 703 X (weight in pounds)/(height in inches squared)
2. Significant disability with Karnofsky or PPS £ 40%
Liver Disease
Numbers 1 and 2 must be present.
1. Patient should show both Prothrombin time prolonged > 5 sec. Over control or INR > 1.5 and Serum albumin <2.5 gm/dl
2. End-stage liver disease is present and patient shows at least one of the following:
Ascites, refractory to treatment or patient non-compliant
Spontaneous bacterial peritonitis
Hepatorenal syndrome (elevated creatinine and BUN with oliguria (<400 ml/day) and urine socium concentration <10 mEq/l)
Hepatic encephalopathy, refractory to treatment or patient non-compliant
Recurrent variceal bleeding despite intensive therapy
The following will support eligibility:
Progressive malnutrition
Muscle wasting with reduced strength and endurance
HbsAg positivity
Hepotocellular carcinoma
Continued active alcoholism (>80 gm ethanol/day)
Hepatitis C, refractory to interferon treatment
Amyotrophic Lateral Schlerosis (ALS)
Progression of disease differs markedly from patient to patient. Therefore, the history of the rate of progression for the patient is important to obtain to predict prognosis. Must meet 1, 2, OR 3.
1. Critically impaired breathing capacity. Must have shown all of the following within previous 12 months:
Vital capacity (VC) <30% of normal
Significant dyspnea at rest
Requires supplemental O2 at rest
Patient declines artificial ventilation
2. Patient must demonstrate rapid progression of ALS:
independent ambulation to wheelchair or bed
normal to barely intelligible speech
normal to pureed diet
loss of independence in all or most ADLs
AND critical nutritional impairment with all the following within last 12 months:
oral intake inadequate to sustain life
continued weight loss
dehydration or hypovolemia
absence of artificial feeding
3. Patient must demonstrate both repaid progression of ALS (see #2) and have life-theatening complications as demonstrated by one of the following within 12 months preceding:
Sepsis
Recurrent aspiration pneumonia
Upper urinary tract infection
Recurrent fever after antibiotic therapy
Explain any co-morbid conditions that would contribute to a terminal diagnosis:

See also: www.palmettogba.com/;almetto/LMRPs_PartA.nsf