hospice care - som - state of michigan
TRANSCRIPT
HospiceCareA Physician's Guide
Includes Medical Guidelinesfor Determining Prognosis
▲ ▲▲5123 W. St. Joseph Hwy., Ste 204
Lansing, Michigan 48917
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HOSPICE CARE: A PHYSICIAN’S GUIDE
This reference guide was first published by the Minnesota Hospice Organization, andcontained information specific to hospice programs in Minnesota as well as dataspecific to hospice care, regardless of where delivered. Because of the extraordinarygenerosity of the Minnesota group, and with the able assistance of the NationalHospice & Palliative Care Organization, Michigan was able to obtain the rights tomodify the guide for Michigan use, and publish a Michigan version.
This reference guide is designed to help physicians and other referral sources usehospice in the treatment of terminally ill patients. Materials were prepared with thehelp and input of hospice medical directors and physicians throughout Michigan.
The Michigan Hospice & Palliative Care Organization revised the guide with the ableassistance of hospice physicians in Michigan, and this guide contains Michigan-specific information. The Michigan Hospice & Palliative Care Organization is amember-supported organization of hospice programs, businesses, and manyindividuals that advocate for the needs of the terminally ill and their families, educateprofessionals and the general public regarding hospice care, and promote increasedaccess to quality hospice care for all Michiganians.
Michigan Hospice & Palliative Organization5123 W. St. Joseph Hwy, Suite 204
Lansing, MI 48917517-886-6667
Referral line: 1-800-536-6300Fax: 517-886-6737
© 2006: All rights reserved. No portion may bereproduced without permission.
sixth edition, September, 2006
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Table of Contents
Physician's Role in Hospice Care ................................. 07
Preparing Patients for Hospice Care ........................... 09
Suggestions for Delivering Difficult News ......... 10
Common Questions from Patient and Families .. 12
Utilizing the Hospice Team........................................... 13
How to Refer to Hospice ........................................ 13
Ongoing Care ........................................................... 14
Extending Care Through the Hospice Team ....... 15
Hospice Interdisciplinary Team ............................ 16
Where Hospice Care is Provided ................................. 17
Hospice in the Home .............................................. 17
Hospice in the Inpatient Setting ............................ 18
Residential Hospice ................................................. 18
Hospice in Long Term Care Facilities .................. 19
Karen S. Ogle, M.D.Michigan State University: Professor, Family PracticeDirector, Palliative Care Education and Research Program .... 05
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$ How Hospice Care is Paid For ...................................... 21
Hospice Medicare Benefit ......................................... 21
Reimbursement for Physicians under Medicare ... 24
Hospice Medicaid Benefit ......................................... 26
Private Insurance Coverage ..................................... 26
Non-Medicare Certified Programs ......................... 26
For More Information .................................................... 27
Addendum: Medical Guidelines for DeterminingPrognosis in Selected Non-Cancer Diseases .............. 29
Introduction and Overview (NHPCO) .................... 30
Hospice Local Coverage Determination (LCD) ACTIVE Final 10-01-04 (UGS) ....................................... 36
Indications and limitations of Coverage and/or Medical Necessity ....................................................... 36Documentation Requirements ........................... 41Cancer Diagnosis .................................................. 48Non-Cancer Diagnosis ......................................... 48Amyotrophic Lateral Sclerosis ........................... 48Dementia due to Alzheimer’s............................. 51Heart Disease ........................................................ 52HIV Disease ........................................................... 53Liver Disease ......................................................... 54Pulmonary Disease .............................................. 55Renal Disease ........................................................ 56Stroke and Coma .................................................. 58
References .................................................................... 43
Appendices I thru VII ........................................... 44-67
Sources of Information and Basis for Decision ........ 68
Worksheets ............................................................... 70-78
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“In truth,what you cangive topatients is . . .the opportu-nity to livewith dignityat the end oflife.”
Forwardby Karen S. Ogle, M.D.
As physicians, we are trained to fight disease and death. We have
been taught to diagnose andcure, and prolonging life canoften seem like our only missionas health professionals.
But doctors also have a vital roleto play when curative treatmenthas become futile. It is neither topush forward with the use ofintrusive and useless technologynor to abandon patients with theresigned observation that“there’s nothing more we cando.” In the last stage of life, thephysician can help the dyingpatient and the patient’s familyto live those final days to thefullest.
Through hospice care, physicians can become part of a teamthat ensures effective management of their patients’ painand other physical symptoms as well as their broaderpsychosocial and spiritual needs. No patient need behelpless and alone when facing a terminal illness.
This is sometimes called death with dignity, but in truthwhat you can give to patients is something larger and moreprecious: the opportunity to live with dignity at the end oflife.
This book is intended as a guide for physicians who are
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ready to accept an expanded role that includes enhancinglife even when it can no longer be extended. It will helpyou to understand the place of hospice in the continuum ofmedical care and to add the tools of hospice and palliativemedicine to your clinical practice.
Physicians who understand what hospice care has to offercan ensure that their patients receive hospice services inthe most timely manner. You are the person in whom yourpatients have entrusted their care, and it is you who canhelp them find an affirmation of life in the face of death.
Karen S. Ogle, M.D.Professor, Family PracticeDirector, Palliative Care Education and Research ProgramCancer CenterMichigan State University
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Physician’s Role inHospice Care
Physician’s Role inHospice Care
The importance of the physician's relationshipwith a terminally ill patient and his or herfamily throughout the course of illness cannot
be overemphasized. In a focus group discussionconducted through the Allina Foundation’s ProjectDECIDE, one patient commented, “You are so tied tophysicians, you are relying on them for the lifeline. Ifthey suggest an option, you think, OK, I guess Ibetter look at this.” Another reiterated the trustrelationship: “I just went along with what the doctorsaid...I thought he knew what to do and would takecare of it” (Allina Foundation, 1994 ).
The physician is a key member of the hospice team. Frominitiating the discussion about hospice to signing the deathcertificate, the physician's involvement is crucial to the patient,family and other members of the hospice team. Yet manyphysicians, especially those who refer to hospice onlyoccasionally, may not be aware of the full range of servicesoffered by hospice or the tremendous growth experience at theend of life that can occur within patients and families.
In addition to the physician, the hospice team includes nurses,home health aides and homemakers, social workers,chaplains, and volunteers. Under the physician's direction, thehospice team specializes in pain and symptom management,and provides support for the family as well as the patient.
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Preparing Patientsfor Hospice Care
Rarely in the course of a patient's disease andtreatment is there one moment when thefocus clearly shifts from curative to
palliative. Just as disease treatment is a process, so ispreparing a patient for the time when treatment forcure is no longer an option. Preparing a patientbegins with an honest discussion of the disease andits outcomes.
According to Leslie J. Bricker,M.D., Medical Director,Hospices of Henry FordHealth System, Detroit,Michigan. “We need to dispelthe notion among health careproviders and patients that areferral to hospice implies“giving up”. Hospice is goal-oriented but the goals haveshifted from cure to symptomcontrol, quality of life, andreconciliation with family;from healing of the body tohealing of the spirit. Those ofus involved in the care ofhospice patients on a dailybasis realize that hospice careis truly “intensive care”
In a recent Louis Harris Poll,96 percent of Americans saidthey would want to be told ifthey have cancer and 85percent would want a “realis-tic estimate” of how long theyhad to live if their type of
preparing patients forhospice Care
“Patientswant physicianswho will share theirhumanity withthem. They wantsomeone who willlisten and showthey care, even inthe face of death . . .Making an impacton the quality oflife or bringingpeace to a dis-traught family isvery gratifying . . .”
John W. Finn, M.D., MedicalDirector, Hospice of Michigan.
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cancer usually led to death inless than a year.
LISTENING TO PATIENT NEEDS
Introducing a patient to hospiceinvolves more than tellingthem, "Now it's time forhospice." It is also an art thatinvolves listening to what apatient is saying.
“Patients may be ready forhospice before we realize,”says Tom George, M.D.,Medical Director for Hospice ofSouthwestern Michigan andMichigan legislator. “We mayhave presented a wide range oftreatment options - and all thewhile the patient has beenthinking, “I just want to gohome and be comfortable.”
FEAR OF THE UNKNOWN
For many people, fear of theunknown is at least as great asfear of death itself (Fletcher,1992). Presenting hospice as amedical option for treating aterminal illness can help withmany unknowns - “fear ofuncontrollable pain, nausea,vomiting, embarrassment andespecially abandonment” - thatoften accompany end stagedisease (Creagan, 1994).
Not all patients are ready toaccept the idea of hospice care
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Suggestions fordelivering difficult news
Following are some suggestionsfor delivering difficult news andinitiating a discussion of hospicecare.
• Choose a private areawhere there will be nointerruptions. An unhurriedpresence will show morecare and concern.
• Sit down with the patientand family. Try to avoidthe patient being alone toreceive difficult news.
• Use plain language tooffer an overview of thesituation, the diagnosis,and its implications. Makeno assumptions aboutwhat the patientunderstands.
• Be prepared to repeatinformation several timesif necessary. Allow time torecognize the patient’semotional reaction.
• Find out and addressspecific concerns of thepatient and family.
• Without overwhelming thepatient and family, provideoptions such as hospice,and to the extent possible,offer a general estimate oflength of survival(Creagan, 1994 andFaulkner, 1994).
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when it is introduced. Often thebarriers to acceptance are less apatient's unwillingness to accept thedisease prognosis and more a fear ofabandonment.
According to Dr. George, “At thiscritical time patients are clinging toevery word from their doctor. So bysaying, “I’ll still be your doctor whenyou’re in Hospice; I‘ll still bethinking of you”, we can allay thisfear of being abandoned.”
WORKING WITH THE FAMILY
The patient's family is crucial in thehospice discussion. A patient can beready to accept hospice when their family is not. Sometimesthey are the ones encouraging the patient to continuetreatment even when the burdens outweigh the benefits.
“Families are often concerned about how long their loved onehas to live,” says Fred Isaacs, M.D., Medical Director forHospice of Lansing. “I tell them there are no pat answers. Noone can predict these things. I have seen some patients live formonths who should have died rapidly based on the extent oftheir disease, and others die quickly and unexpectedly. Thekey thing we can do at hospice is to ensure that their final daysare comfortable.”
Often, the family simply needs to hear that hospice is a choicethe patient is making. As the physician, you can best ask thequestion for the family, "Given the medical information, whatdo you want?"
Dr. Tom George states, “When we survey hospice patients andtheir families one of the comments we hear over and over is,”Why couldn’t we have come in earlier? Why didn’t mydoctor tell us about hospice?”
“Hospice is aplace ofcomfort andrest on adifficultjourney”
Susan Urba, M.D.University of MichiganMedical Center
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Common Questions From Patients and Families:
Q: Does this mean there's nothing more we can do?
A: Hospice is not an end to treatment — It is a shift to intensivepalliative care that focuses on allowing the patient to live his or herlife to the fullest. In addition to managing pain, hospice providesextensive counseling and social service support to address theemotional and spiritual aspects of coping with a terminal illness.
Q: What about the pain?
A: A primary goal of hospice is effective pain management. Painrelated to the terminal illness is aggressively treated using a widevariety of medically sound therapies.
Q: What should we do next?
A: The next step is to contact a hospice. Here are a few importantpoints to tell your patient about hospice:
• As your physician, I will continue to see you and care for you.
• Our first priority is managing your symptoms.
• Services are available where you live.
• Your family will also receive the support of the hospice team.
• Hospice care is covered by Medicare, the Michigan MedicaidProgram, and many private insurances.
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“The key tosuccess at hospiceis the teamconcept. The teamconcept providesmuch greatersupport than anyone disciplinecould ever provide.It takes thephysician and allthe hospice staffto deliver qualityof life at thistime.”Fred Isaacs, M.D.Internal Medicine
Utilizing theHospice Team
The attending physician is the patient's primarymedical doctor, provides medical servicesthroughout the course of the illness, and is an
integral part of the hospice team.
HOW TO REFER TO HOSPICE
An initial referral to hospice always begins with anhonest discussion with the patient about care andtreatment options.
Once this has occurred, a hospiceprogram will ask for the followinginformation regarding the patient:
• admitting diagnosis andprognosis
• current medical findings
• orders for medications andtreatments
• patient and familyunderstanding of disease andprognosis
• relevant patient and familyinformation
• history and physical
• order for hospice care
utilizing the hospice team
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ONGOING CARE
Once the patient is enrolledin a hospice program, theattending physician will bea primary resource on thepatient's medical conditionand needs. The hospicenurse will be in regularcontact regarding symptommanagement, changes inthe patient's condition, andneed for clinic or home visitfollow-up.
The physician is responsiblefor
• signing the initialcertification of terminalillness
• reviewing the hospiceplan of care for thepatient
• ongoing clinic visitswith the patient
• prescribing medicationfor comfort care
• reviewing with hospicestaff the patient's condition and prognosis
• making telephone contact and house calls to the patient asnecessary
• signing the death certificate
• home visits when necessary
“The goal ofmedicalintervention atthis point is torelieve distressingsymptoms and topromote apeaceful death.Thus, medicalefforts are turnedfrom the diseaseand its attendantcomplications,and turnedtoward patientcomfort.”
John W. Finn, M.D.
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EXTENDING CARE THROUGH THEHOSPICE TEAM
Because the care needs of a dyingpatient encompass more thanmedical treatment of a disease, thehospice team can be a valuableresource in dealing with complexissues and extending the physician'scare.
"Most physicians would say hospicecare is worth the investment," saidMichael Levy, M.D., Ph.D., directorof the supportive oncology programat the Fox Chase Cancer Center inPhiladelphia. "[In many cases] thedoctor doesn't get calls [or] go to theER in the middle of the nightbecause hospice takes the calls andthe hospice nurse goes out to thehome."
"The hospice team is skilled atpatient and family education," Dr.Levy continues, "so medicines aretaken properly and side effects canbe anticipated and treated."
The team approach to hospice carecan ultimately alleviate much of thestress traditionally associated withcare of the dying patients.According to Ira Byock, M.D., Director of Palliative Medicineat Dartmouth-Hitchcock Medical Center, "Care of the dyingstops being a stressor and starts being a source of professionalsatisfaction" (Skelly, 1994).
MYTH:Physicians losecontrol of theplan of carewhen theirpatients enterhospice.
FACT:“Hospice is themissingresource as apatient becomesterminally ill. Itis thephysician’s tool,and under thephysician’sdirection, theteam can anddoes providethe necessarycare, forphysical,emotional, andspiritual needs .. . for the patientand the family.”
Tom M. George,M.D.
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Hospice Interdisciplinary Team
Each team member has a role to play to address the physical,emotional, and spiritual needs of patients and family.
Home Health AideHospice Home Health Aidesassist with personal care andlight housekeeping services.
VolunteerTrained Volunteers provide avariety of services, including
companionship and respite care.
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Attending PhysicianPatients designate an attendingphysician to manage their care.
Spiritual CareThe Hospice Spiritual Care
Coordinator assists inidentifying spiritual concerns
and the connection with acommunity of faith.
Hospice Medical directorThe Medical Director oversees thetreatment by the hospice team and
coordinates with the AttendingPhysician.
Bereavement CoordinatorBereavement Care supports theperson and family throughout the
dying process and offers follow-upgrief education and support .
Patient &Family
Hospice NurseHospice Nurses coordinate the
individualized care plan andprovide specialized palliative
care services.
Social WorkerHospice Social Workers offeremotional support, counseling
and community resourcesupport services.
Other therapistsPhysical, occupational andspeech therapists provide
palliative care according to theindividualized care plan.
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Where hospice care
is provided
Nineout oftenAmericanssaid theywouldprefer tobe caredfor anddie athome.
Where HospiceCare is Provided
Hospice care is available to patients in a varietyof settings. While home is the most commonand the preferred place for many patients, it is not
always possible or even desirable for all hospice patients.Individual patient needs determine the location for deliveryof hospice care. Patients can receive the services of thehospice team at home, in the hospital, or in a long-term careor other residential facility.
HOSPICE CARE IN THE HOME
Hospice patients in the home receiveregular visits from the interdisciplinaryteam. In addition, hospice nurses willtriage phone calls 24 hours a day frompatients and families, communicating withthe physician as necessary. Pain, nausea,vomiting and bowel management arespecial areas of expertise. Hospice nursescan handle many of these issues, usingstanding orders from the physician.Patients at home can continue to makeclinic visits or may receive visits from thephysician in the home.
Most hospice patients at home are cared forby family caregivers, but more and morehospice programs are able to offer care tothose patients who choose to live alone. Insuch cases, the hospice team assists inmaking special arrangements. Check withthe hospice to see if this option is available.
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HOSPICE CARE IN THE INPATIENT SETTING
An acute care setting is sometimes necessary for themanagement of symptoms related to the terminal disease.General inpatient care is available in acute care facilities whichcontract with the hospice program. These facilities have madearrangements for such thingsas direct admission of thehospice patient to the unit andwaiving of routine tests whichmay not be appropriate. Inaddition, the inpatient staffhas been oriented to thespecial needs of the dyingpatient and grieving family.
The hospice nurse remainscase manager for the patientthroughout the inpatient stayand communicates with thephysician about the patient'scare. Other hospice teammembers make visits to thepatient to ensure continuity ofcare.
Respite care in an inpatient setting is also available for briefperiods of time when family members are in need of a restfrom caregiving duties. Respite care is covered under theHospice Medicare Benefit.
RESIDENTIAL HOSPICE
Home-like, residential facilities exclusively for hospice patientsand their families are available in some areas. The hospiceteam remains in charge of patient care and visits frequently.Payment for residential room and board is usually madeprivately. The Medicare Hospice Benefit provides coverage forall services related to the terminal illness except room andboard.
MYTH: Hospice is aplace to go to die.
FACT: Hospice isprovided wherever thepatient lives. "Home"may be anywhere thepatient chooses to live,which includes one'shome, foster home,assisted living area,board and care or longterm care facility.
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HOSPICE IN LONG TERM CARE FACILITIES
Palliative care and hospice services are available forindividuals living in long term care facilities. Collaborativeagreements between hospice programs and long term carefacilities make it possible for residents, family and staff tobenefit from a unique multi-disciplinary approach to caredelivery. The patient and family focus of care provides forinnovative delivery of care interventions. Interventions suchas pain and symptom management lead to patient acceptanceof the dying process, greater patient and family satisfaction ofcare and improved quality of life.
“Some patients cannot get the care they need at home and endup in a nursing home,” says Dr. Fred Isaacs. “ I think that oneof the greatest services we provide is support of these nursinghome patients. They are in strange surroundings and they aredying. The hospice team works with the nursing home staff toprovide extra support and time and care to make their finaldays comfortable. The hospice team also supports the nursinghome staff as they lose patients they have learned to love.”
Surviving family members and long term care staff receivesupport through hospice bereavement services for a period oftime after the individual’s death. This support leads tohealthier expressions of grief and loss, and stress management.
WORKING WITH PHYSICIANS
Hospice program members of the Michigan Hospice andPalliative Care Organization work with Hospice MedicalDirectors and referring physicians trained in manyspecialities, and from many Medical Schools. Both MD’s andDO’s are well represented within the hospice communitythroughout the state, and are prepared to work with allphysician specialities in developing the right plan of care forterminally ill patients.
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How Hospice Care is
paid for
How Hospice Careis Paid For
Hospice programs work closely with patients andfamilies to identify reimbursement options.Care is provided regardless of the patient’s
ability to pay.
The Medicare Hospice BenefitHospice care provided by Medicare certified hospiceprograms is covered by the Medicare Hospice Benefit(Part A). Physician services can continue to be billedthrough Medicare Part B.
Medicare beneficiaries who choose hospice care receivenon-curative medical and support services for theirterminal illness. Home care may be provided along withnecessary inpatient care and a variety of services nototherwise covered by Medicare.
ELIGIBILITY FOR CARE
Medicare coverage for hospice care is available if
• the patient is eligible for Medicare Part A;
• the patient's physician and the hospice MedicalDirector certify that the patient is terminally ill with alife expectancy of six months or less;
• the patient signs a statement choosing hospice careinstead of standard Medicare benefits for the terminalillness; and
• the patient receives care from a Medicare-certifiedhospice program. (Nearly all hospices in Michigan areMedicare-certified.)
$
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LENGTH OF BENEFIT
When a Medicare beneficiary elects to receive hospice care, heor she is entitled to receive that care as long as he or she meetsthe eligibility criteria. Hospice benefit periods consist of two90-day benefit periods, followed by an unlimited number of60-day benefit periods. The benefit periods may be usedconsecutively or at intervals. The patient must be certified asterminally ill at the beginning of each period.
The Hospice Medicare Benefit periods as stated above becameeffective with the signing of the Balanced Budget Act of 1997by President Clinton on August 5, 1997. The change eliminatesany lifetime limit to hospice care for Medicare beneficiaries. Inaddition, a patient who experiences a remission in theterminality of their disease and disenrolls in hospice care, canbe eligible for hospice care again in the future without regardto previous use of hospice services.
Medicaid requires that recertification of the terminal illnessoccur at the beginning of each Medicare-defined benefitperiod. Medicaid patients are also required to have a terminalprognosis of six months or less.
SERVICES NOT COVERED
All services required for the management of the terminal illnessmust be provided by or through the hospice. When a Medicarebeneficiary chooses hospice care, Medicare will not pay for• active treatment of the terminal illness that is not for
symptom management and pain control• care provided by another hospice that was not arranged
by the patient's hospice• care from another provider that duplicates care the
hospice is required to furnish
AVAILABILITY OF OTHER MEDICARE BENEFITS
When a Medicare beneficiary chooses hospice care, he or shegives up the right to standard Medicare benefits for themanagement of the terminal illness. A patient can use allappropriate Medicare Part A and B benefits for the treatmentof health problems unrelated to the terminal illness (U.S.Department of Health & Human Services Health CareFinancing Administration, 1995).
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Benefits covered by Medicareunder the Hospice Benefit
The Hospice Medicare Benefit covers the following services:
Physician services
Nursing care
Medical equipment
Medical supplies
Outpatient drugs for symptom management andpain relief
Short-term inpatient care, including respite care
Home health aide and homemaker services
Physical and occupational therapy
Speech/language pathology services
Medical social services
Dietary and other counseling
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Medicare pays for the entire cost of these services. However,hospices have the option of charging their patients a 5%coinsurance amount for drugs (up to a $5 maximum per drug)and 5% coinsurance on inpatient respite care (up to an amountequal to the annual Part A inpatient deductible) (Health CareFinancing Administration, 1995).
✓✓✓✓✓
✓
✓✓✓✓✓
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Reimbursement for Physicians under Medicare
The attending physician is the physician designated by thepatient to have the most significant role in his or her care. Theattending physician continues to bill Medicare Part B forprofessional services — home, inpatient, or nursing homevisits — in the usual manner, independent of the Hospicebenefit. Medications, laboratory tests, and other non-physicianservices required for themanagement of the terminal illnessare paid for by the hospice programthrough the hospice benefit.
Attending physicians can bill for careplan oversight for hospice patients.Payment is available for onephysician per month for oversightsupervision involving 30 or moreminutes of the physician's time permonth.
Care plan oversight includes thefollowing physician activities:
• development/revision of careplans
• review of subsequent reports of patient status and relatedlaboratory studies
• coordination and communication (including the telephonecalls) with other health care professionals involved in thepatient's care (excluding telephone calls to patients andfamily members)
• adjustment and integration of medical treatments.
MYTH: Physicians willlose income
FACT: While hospice'shome-care focus andinterdisciplinary teaminvolvement canpotentially reduce thenumber of physicianoffice visits and hospitalstays, attendingphysicians can billMedicare and othercarriers for regular visitsrelated to the hospicecare plan.
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✓✓✓
✓✓ ✓
✓✓ ✓
✓✓✓
attending consulting
attending consulting
This table reflects the provision of care and services related to the terminal illness coveredby the Hospice Medicare Benefit.
DESCRIPTION BILL MEDICARE BILL HOSPICE* BILL HOSPICEPART B INTERMEDIARY PAYS HOSPCE COVERED UNDER HOSPICE BENEFIT
ATTENDING PHYSICIANProfessional Fee
COVERING (Stand in)PHYSICIANProfessional Fee
CONSULTINGPHYSICIANProfessional Fee
X-RAYSTechnicalComponent
X-RAYSPhysicianComponent
RADIATION THERAPYTechnicalComponent
RADIATION THERAPYPhysicianComponent
LABS
CHEMOTHERAPY
PRESCRIPTIONMEDICATIONS
* The Medicare intermediary pays the hospice an amount equivalent to 100% of allowable chargesfor those physician services furnished under arrangements with the hospice. Payment is then pro-vided to the physician by the hospice. Billing through hospice is required when the patient is cov-ered by the Hospice Medicare Benefit. A written agreement between the Hospice and the covering(stand in) or consulting physician is needed.
Attending Physician is the physician designated by the patient to have the most significant role in the determinations and delivery of the individual’s medical care.Bill Medicare Part B.
Covering Physician is the physician who sees the patient on behalf of the AttendingPhysician as part of vacation coverage or on-call status.Bill Hospice using HCFA 1500.
Consulting Physician is the physician who provides direct patient care to a hospicepatient for a condition related to the terminal illness.Bill Hospice using HCFA 1500.
Adapted with permission from Hope Hospice
Physician Billing Guidelines for Medicare
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Other Payer Sources
HOSPICE MEDICAID BENEFIT
The Michigan MedicaidHospice Benefit generallyfollows the Medicare HospiceBenefit, with recertificationrequired according toMedicare benefit periods.
PRIVATE INSURANCE COVERAGE
The majority of commercialinsurance providers coverhospice care either through aspecific hospice benefit orthrough a home care benefit.Several providers haverecently developed or aredeveloping hospice benefitsthat reimburse on a per diembasis (like Medicare). Whenthere is no specific hospicebenefit, insurance companiesoften reimburse through ahome health care benefit.Patients should be encouragedto contact their insurancecarrier about coverage forhospice.
NON-MEDICARE-CERTIFIEDHOSPICE PROGRAMS
Services from hospices thatare not Medicare certified canbe billed under regularMedicare Part A. Many of thehospice services are providedfree of charge, and the patientcan access grants to cover billable services.
Hospice Admission Guidelines
MYTH: Medicare andMedicaid patients can onlyreceive hospice care for sixmonths
FACT: The patient’scondition is reviewedwhenever medicallynecessary (e.g., a change intheir medical condition) but ata minimum must be reviewedat the end of each benefitperiod. These reviews mustcontinue after all benefitperiods, regardless of thenumber of benefit periodsused. If the patient’scondition stabilizes at anypoint during the hospicecare, the patient may bedischarged from hospice.However, the patient can bereadmitted later if theirmedical condition againmeets eligibility requirementsfor hospice care. If thepatient is discharged fromhospice in any benefit period,they will be eligible for furtherhospice care under the newlegislation for the MedicareHospice Benefit, whichallows for two 90-day benefitperiods, followed by anunlimited number of 60-daybenefit periods.
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For More Information
ABOUT HOSPICE OR REFERRAL TO A HOSPICE IN MICHIGAN:
Michigan Hospice & Palliative Care Organization5123 W. St. Joseph Hwy, Suite 204Lansing, MI 48917517-886-6667 - phone800-536-6300 - toll free referal line517-886-6737 - fax
FOR A REFERRAL IN ANOTHER STATE:
National Hospice & Palliative Care Organization1700 Diagonal Road, Suite 300Alexandria, VA 22314800-658-8898 or 1-703-837-1500
TO FILE A COMPLAINT ABOUT AHOSPICE AGENCY IN MICHIGAN:Michigan Department of Consumerand Industry ServicesLaw Building, Fourth Floor525 W. OttawaP.O. Box 30004Lansing, MI 48909800-882-6006
FOR REGULATORY INFORMATION:Michigan Department of Consumerand Industry ServicesP.O. Box 30004Lansing, MI 48909517-334-8420
MEDICAID MANAGED CAREINFORMATION:Michigan Department of CommunityHealthLewis Cass Building320 South WalnutLansing, MI 48913517-373-6440
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MHPCO STATEMENTON END OF LIFEDECISION MAKING:
The Michigan Hospice &Palliative CareOrganization supports apatient’s right to self-determination, topalliative care, and apatient’s right to refuseunwanted interventionincluding the provision ofartificially suppliedhydration and nutrition.We believe that assistedsuicide is not acomponent of hospicecare, and further, theMichigan Hospice &Palliative CareOrganization does notsupport the legalizationof voluntary euthanasiaor assisted suicide in thecare of the terminally ill.
For More Inform
ation
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Bibliography
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Edward Creagan, M.D., "How to Break Bad News — And NotDevastate the Patient," Mayo Clin Proc, 1994, 69:1015-17.
William Fletcher, M.D., American Journal of Surgery, May, 1992,163:460-62.
Michael E. Frederich, M.D., Academy of Hospice PhysiciansHospice Update, December, 1991, 6-7.
Lewin-VHI, Inc. "An Analysis of the Cost Savings of theMedicare Hospice Benefit", May 2, 1995.
D. MacDonald, "Non-Admissions: The Other Side of theHospice Story." American Journal of Hospice Care, March/April1989: 17-21.
National Hospice Organization Standards and AccreditationCommittee Medical Guidelines Task Force, Medical Guidelinesfor Determining Prognosis in Selected Non-Cancer Diseases, 1996.
Flora Johnson Skelly, "Hospice," American Medical News, March28, 1994.
U.S. Department of Health and Human Services Health CareFinancing Administration, The Medicare Hospice Benefit, 1995.
U.S. Government Printing Office, Rules and Regulations,Federal Register, December 8, 1994, 59, (235), 63423.
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Medical Guidelines for
Determining Prognosis
Table of ContentsIntroduction and Overview (NHPCO) ................................................................. 30Hospice Local Coverage Determination (LCD) ACTIVE Final 10-01-04 (UGS) ......... 36
Indications and limitations of Coverage and/or Medical Necessity ................. 36Documentation Requirements ................................................................ 41Cancer Diagnosis .................................................................................... 48Non-Cancer Diagnosis ............................................................................ 48
Amyotrophic Lateral Sclerosis ............................................. 48Dementia due to Alzheimer’s ............................................. 51Heart Disease ....................................................................... 52HIV Disease .......................................................................... 53Liver Disease ........................................................................ 54Pulmonary Disease .............................................................. 55Renal Disease ....................................................................... 56Stroke and Coma ................................................................. 58
References ............................................................................................................ 43Appendices
I. Reasons for Denial, Coding Guidelines, Comments (UGS) ......... 44II. Type, Strength and Consistency of Evidence .............................. 60III. Karnofsky Performance Status Scale ............................................ 62IV. New York Heart Association Functional Classification ................ 63V. Functional Assessment Staging (FAST) Scale: Dementia ............. 64VI. Typical Time Course of Alzheimer’s Disease ............................... 66VII. Diagnostic Imaging Factors Indicating Poor Prognosis After Stroke ... 67
Sources of Information and Basis for Decision .................................................. 68Worksheets ....................................................................................................... 70-78
ADDENDUM
Medical GuidelinesFor DeterminingPrognosis in SelectedNon-Cancer DiseasesThe National Hospice & Palliative Care Organization (NHPCO)United Government Services, LLC (UGS)
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Introduction and Overview
This document is written to help identify which patients withnon-oncologic terminal illness are likely to have a significantlydecreased prognosis if the disease runs its normal course.These Guidelines may also be helpful in determining patienteligibility under the Medicare/Medicaid Hospice Benefit bydefining a population that may have a life expectancy ofapproximately six months.
Increased access to hospice services for patients withdiagnoses across the medical spectrum is also a goal of thiseffort. Until recently, hospice in the US has been identifiedwith care of the end-stage cancer patient.
3 Dissemination of
these Guidelines to hospice programs and the medicalcommunity should facilitate hospice referrals for patients withheart, lung, liver, Alzheimer’s dementia, HIV and other non-cancer diseases.
Recent studies support this effort as timely and relevant.Christakis and Escarce
4 reported that in 1990, less than twenty
percent of hospice referrals in five major states carried a non-cancer diagnosis. Since that time, the proportion of hospiceadmissions for diseases other than cancer has risen steadily.However, because of inherent challenges in predictingprognosis in non-cancer disease, a large proportion of patientssurviving longer than six months are in this category. In theChristakis and Escarce cohort, for example, hospice patientswith dementia had a median survival of 74 days, and 34.7percent of these patients survived for longer than six months.These findings suggest that physicians and hospice programsmight benefit from help in determining which non-cancerpatients are likely to have a prognosis of approximately sixmonths.
These Guidelines are a starting point, both for hospiceprograms evaluating patients for admission andrecertification, and for critically-needed research on prognosisin end-stage disease. Pending confirmation and refinementthrough ongoing research with hospice patients, they providea set of working criteria to use in determining prognosis. The
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Guidelines do not pretend to predict prognosis exactly in eachcase. In fact, even if based directly on clinical research, any setof criteria defines a range of probabilities for mortality in aspecific population. Prediction of prognosis in individualcases cannot be expected; clinical judgment is always requiredon the original assessment and throughout the admission.
THE MEDICAL NATURE OF THE GUIDELINES
These Guidelines are based on medical findings. However,decisions to admit patients to hospice are often not based onmedical factors alone. They are routinely influenced bynonmedical factors which would generally be reflected in thetreatment plan, e.g. patient decisions to receive strict symptomcontrol rather than life-prolonging care, or selection of“optimal” rather than “maximal” treatment regimenstempered by intolerance or refusal of medication due to side-effects.
In addition, it is important to make a distinction betweenadmitting a patient to the hospice program and certifying a patientfor the Medicare Hospice Benefit. Individual hospice programsmay establish admission criteria that reflect the uniquecharacteristics and values of their communities. This maymean that some patients could be admitted to hospice care priorto an estimated six months before death. However, care mustbe taken to certify patients for the Benefit only when it isreasonable to conclude that their prognosis is six months orless. In other cases alternative modes of reimbursement, oftenprovided through community support, can be sought outsidethe Medicare Hospice Benefit.
Emphasis should be placed on evaluating the whole personand the entirety of the illness. It is important to note, forexample, that a patient may have multiple medical problems,none of which individually amount to a terminal diagnosis, butwhen taken together indicate a terminal condition. In short,clinical judgment that takes both medical and nonmedicalfactors into account is necessary for accurate estimation ofprognosis.
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POTENTIAL LIMITATIONS
Several caveats are in order when using these Guidelines forprognostic purposes. They are a first attempt at extrapolatinga large amount of heterogeneous evidence from many studiesto predict survival in non-cancer diseases (see Appendix II).Their accuracy will need to be validated by further research.These Guidelines should be applied to individual cases verycautiously, for at least the following reasons:
1. Many of the studies referenced here indicate an increasedlikelihood of death, sometimes within an uncertain timeframe. The six month definition of terminal illnessadopted for the Medicare Hospice Benefit has rarely beenused as a specific outcome measure in most of thisresearch. Further studies with larger populations ofhospice patients are needed to determine median survivalaccurately with reference to the six month standard.
2. Clinical judgment must always be applied in eachindividual case to supplement these Guidelines. Allstudies are performed on large enough populations toattain statistical significance, so that individual differencesin disease progression are averaged and lost to view. Anindividual patient who may meet Guideline criteria thatwere significant in a study of a large cohort might respondin unpredictable ways and have unexpected outcomes ashis or her disease runs its own unique course. Thereforethe Guidelines must be applied to patients not only onadmission, but at intervals throughout the patient’s coursein hospice.
3. Many of the studies referenced here were done ininstitutionalized populations. They may or may not begeneralizable to patients living at home with familycaregivers.
4. Many studies pool patients at all stages of disease. Studiesdone with selected cohorts of end-stage patients mightyield different conclusions. For instance, for a largepopulation of patients with dementia at all stages ofseverity, antibiotics may be shown to postpone mortality.
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However, the same drugs have not been shown to lengthensurvival in the subpopulation with very end-stagedementia.
6 Again, further research is needed in the
terminal population.
5. Almost all studies have been done with patients whoreceived standard medical therapy when they becameacutely ill, thus prolonging the course of the illness. Littlerecent research has been done to study the natural courseof untreated end-stage disease. Thus, much of theliterature may be defining length of life as inappropriatelylong for patients who choose a non-curative approach.
6. The course of most non-cancer disease is inherentlydifficult to predict. The natural history of most non-cancerdiseases is characterized by periods of relative stabilitypunctuated by acute downturns, as opposed to thecomparatively relentless, and thus more predictable,downhill course in cancer. This natural tendency towardstabilization in non-cancer disease may be augmented byhospice intervention, which may bring about aprolongation of the terminal phase due to improvedpatient compliance, symptom control and prevention ofcomplications.
7. This difficulty in predicting mortality in non-cancerdisease is compounded by the fact that palliation of non-cancer disease is frequently similar, and sometimesidentical, to standard medical treatment. Thereforehospice can and frequently does coincidentally extend thelife of the non-cancer patient in the act of palliatingsymptoms. This situation is new to many hospices, whohave been trained to treat cancer pain but to leavetreatment of cancer itself to the oncologist. To palliatecancer symptoms, hospice employs medications and otherinterventions which in most cases do not prolong life.Chemotherapy or radiation for palliation are generallyused by hospices only when pain and symptoms can notbe managed by other interventions. On the other hand,hospice frequently uses the same medications andinterventions to palliate non-cancer symptoms that theprimary physician or medical specialist uses for active
34
treatment. For instance, skillful palliation of end-stagecongestive heart failure requires not only morphine fordyspnea, but also judicious use of diuretics andvasodilators. But these drugs do more than make thepatient comfortable — it is well established that they alsoprolong life significantly.
5 Thus good hospice care can
stabilize patients with non-cancer disease, creating adilemma for the program if the patient survives for longerthan six months without evidence of serious clinicaldecline.
Fiscal intermediaries and hospice programs alike wouldbenefit from a thorough awareness of these factors. TheseGuidelines are just a starting point in decision making in non-cancer disease. It is clear that they must be supplemented byclinical judgment at the time of admission. But frequentclinical reassessment, decisions concerning recertificationversus possible discharge from the Medicare/MedicaidHospice Benefit, thorough documentation of medical evidenceof continued disease progression and cooperative review ofappropriateness of care with intermediaries are all importantongoing considerations.
ACKNOWLEDGMENT
Recognition should be given to other systems ofprognostication already devised for use in advanced medicalillness.
6 However, these Guidelines were developed de novo
for several reasons. First, previous systems were developedfor predicting prognosis in seriously ill hospitalized patientswho were all receiving aggressive medical therapy. This is adifferent population than those who are generally consideredhospice candidates, although this situation could change.Also, prior prognostic systems require large amounts ofdetailed clinical and laboratory data. This quantity andquality of information is primarily utilized in research studies,and generally unavailable to providers in the field.Additionally, unlike other systems, these Guidelines weredesigned for ease of application by the average hospiceprogram, whose staff may not have access to the computerhardware, software and programming expertise needed to use
35
more sophisticated prognostic systems. The medicalknowledge and clinical experience needed to understand andapply these Guidelines should be well within the existingcapabilities of the hospice staff, ideally under the activeleadership of a qualified and enthusiastic Medical Director.
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Hospice Local CoverageDetermination (LCD)ACTIVE Final 10-01-04 (UGS)
Indications and Limitations ofCoverage and/or Medical NecessityMedicare coverage of hospice depends on a physician’scertification that an individual’s prognosis is a life expectancyof six months or less if the terminal illness runs its normalcourse. This LCD describes guidelines to be used by RegionalHome Health Intermediaries in reviewing hospice claims andby hospice providers to determine eligibility of beneficiariesfor hospice benefits. Although guidelines applicable to certaindisease categories are included, this LCD is applicable to allhospice patients. It is intended to be used to identify anyMedicare beneficiary whose current clinical status andanticipated progression of disease is more likely than not toresult in a life expectancy of six months or less.
Clinical variables with general applicability without regard todiagnosis, as well as clinical variables applicable to a limitednumber of specific diagnoses, are provided. Patients whomeet the guidelines established herein are expected to have alife expectancy of six months or less if the terminal illnessruns its normal course. Some patients may not meet theseguidelines, yet still have a life expectancy of six months orless. Coverage for these patients may be approved ifdocumentation of clinical factors supporting a less than six–month life expectancy not included in these guidelines isprovided.
If a patient improves and/or stabilizes sufficiently over timewhile in hospice such that he/she no longer has a prognosisof six months or less from the most recent recertificationevaluation or definitive interim evaluation, that patient
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should be considered for discharge from the Medicare hospicebenefit. Such patients can be re–enrolled for a new benefitperiod when a decline in their clinical status is such that theirlife expectancy is again six months or less. On the other hand,patients in the terminal stage of their illness who originallyqualify for the Medicare hospice benefit but stabilize orimprove while receiving hospice care, yet have a reasonableexpectation of continued decline for a life expectancy of lessthan six months, remain eligible for hospice care.
A patient will be considered to have a life expectancy of sixmonths or less if he/she meets the non–disease specificdecline in clinical status guidelines described in Part I.Alternatively, the baseline non–disease specific guidelinesdescribed in Part II plus the applicable disease specificguidelines listed in the appendix will establish the necessaryexpectancy.
PART I. DECLINE IN CLINICAL STATUS GUIDELINES
Patients will be considered to have a life expectancy of sixmonths or less if there is documented evidence of decline inclinical status based on the guidelines listed below. Sincedetermination of decline presumes assessment of the patient’sstatus over time, it is essential that both baseline and follow–up determinations be reported where appropriate. Baselinedata may be established on admission to hospice or by usingexisting information from records. Other clinical variables noton this list may support a six–month or less life expectancy.These should be documented in the clinical record.
These changes in clinical variables apply to patients whosedecline is not considered to be reversible. They are listed inorder of their likelihood to predict poor survival, the mostpredictive first and the least predictive last. No specificnumber of variables must be met, but fewer of those listedfirst (more predictive) and more of those listed last (leastpredictive) would be expected to predict longevity of sixmonths or less.
a. Progression of disease as documented by worseningclinical status, symptoms, signs and laboratory results.
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• Clinical Status
a. Recurrent or intractable infections such aspneumonia, sepsis or upper urinary tract.
b. Progressive inanition as documented by:
i. Weight loss not due to reversible causes such asdepression or use of diuretics
ii. Decreasing anthropomorphic measurements(mid–arm circumference, abdominal girth), notdue to reversible causes such as depression or useof diuretics
iii. Decreasing serum albumin or cholesterol
c. Dysphagia leading to recurrent aspiration and/orinadequate oral intake documented by decreasingfood portion consumption.
• Symptoms
a. Dyspnea with increasing respiratory rate
b. Cough, intractable
c. Nausea/vomiting poorly responsive to treatment
d. Diarrhea, intractable
e. Pain requiring increasing doses of major analgesicsmore than briefly.
• Signs
a. Decline in systolic blood pressure to below 90 orprogressive postural hypotension
b. Ascites
c. Venous, arterial or lymphatic obstruction due to localprogression or metastatic disease
d. Edema
e. Pleural/pericardial effusion
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f. Weakness
g. Change in level of consciousness
• Laboratory (When available. Lab testing is not requiredto establish hospice eligibility.)
a. Increasing pCO2 or decreasing pO2 or decreasing SaO2
b. Increasing calcium, creatinine or liver function studies
c. Increasing tumor markers (e.g. CEA, PSA)
d. Progressively decreasing or increasing serum sodiumor increasing serum potassium
i. Decline in Karnofsky Performance Status (KPS )or Palliative Performance Score (PPS) from < 70%due to progression of disease.
ii. Progressive decline in Functional AssessmentStaging (FAST) for dementia (from =7A on the FAST)
iii. 5, Progression to dependence on assistance withadditional activities of daily living See Part II,Section 2.
iv. Progressive stage 3–4 pressure ulcers in spite ofoptimal care.
v. Increasing emergency room visits, hospitalizations,or physician’s visits related to hospice primarydiagnosis
PART II. NON–DISEASE SPECIFIC BASELINE GUIDELINES(BOTH OF THESE SHOULD BE MET)
a. Physiologic impairment of functional status asdemonstrated by: Karnofsky Performance Status(KPS) or Palliative Performance Score (PPS) from <70%. Note that two of the disease specific guidelines(HIV Disease, Stroke and Coma) establish a lowerqualifying KPS or PPS.
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b. Dependence on assistance for two or more activitiesof daily living (ADLs)
1. Ambulation
2. Continence
3. Transfer
4. Dressing
5. Feeding
6. Bathing
See Appendix for disease specific guidelines to be used withthese (Part II) baseline guidelines. The baseline guidelines donot independently qualify a patient for hospice coverage.
Note: The word “should” in the disease specific guidelinesmeans that on medical review the guideline so identified willbe given great weight in making a coverage determination. Itdoes not mean, however, that meeting the guideline isobligatory.
PART III. CO–MORBIDITIES
Although not the primary hospice diagnosis, the presence ofdisease such as the following, the severity of which is likely tocontribute to a life expectancy of six months or less, should beconsidered in determining hospice eligibility.
a. Chronic obstructive pulmonary disease
b. Congestive heart failure
c. Ischemic heart disease
d. Diabetes mellitus
e. Neurologic disease (CVA, ALS, MS, Parkinson’s)
f. Renal failure
g. Liver Disease
h. Neoplasia
i. Acquired immune deficiency syndrome
j. Dementia
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Documentation RequirementsDocumentation certifying terminal status must containenough information to support terminal status upon review.Documentation of the applicable criteria listed under the“Indications” section of this LCD would meet thisrequirement. If other clinical indicators of decline not listed inthis LCD form the basis for certifying terminal status, theyshould be documented as well. Recertification for hospicecare requires the same clinical standards be met as for initialcertification, but they need not be reiterated. They may beincorporated by specific reference as part (or all) of theindication for recertification.
Documentation should “paint a picture” for the reviewer toclearly see why the patient is appropriate for hospice care andthe level of care provided, i.e., routine home, continuoushome, inpatient respite, or general inpatient. The recordsshould include observations and data, not merelyconclusions. However, documentation expectations shouldcomport with normal clinical documentation practices. Unlesselements in the record require explanation, such as a non–morbid diagnosis or indicators of likely greater than sixmonth survival, as stated below, no extra or additional recordentries should be needed to show hospice benefit eligibility.
The amount and detail of documentation will differ indifferent situations. Thus a patient with metastatic small cellCA may be demonstrated to be hospice eligible with lessdocumentation than a chronic lung disease patient. Thesesituations are obvious. Patients with chronic lung disease,long term survival in hospice, or apparent stability can still beeligible for hospice benefits, but sufficient justification for aless than six–month prognosis should appear in the record.
If the documentation includes any findings inconsistent withor tending to disprove a less than six–month prognosis, theyshould be answered or refuted by other entries, or specificallyaddressed and explained. Most facts and observationstending to suggest a greater than six month prognosis arepredictable and apparent, such as a prolonged stay in hospice
42
or a low immediate mortality diagnosis, as stated above. Butspecific entries can also call for an answer, such as an opinionby one team member or recovery of ADLs when they werepart of the basis for the initial declaration of eligibility. Alsothe lack of certain documentation elements such as a tissuediagnosis for cancer will not create non–eligibility for thehospice benefit, but does necessitate other supportivedocumentation.
Documentation submitted may include information fromperiods of time that fall outside the billing period currentlyunder review. Include supporting events such as a change inthe level of activities of daily living, recent hospitalizations,and the known date of death (if you are billing for a period oftime prior to the billing period in which death occurred.)
Documentation should support the level of care beingprovided to the patient during the time period under review,i.e. routine or continuous home or inpatient, respite orgeneral. The reviewer should be able to easily identify thedates and times of changes in levels of care and the reason forthe change.
FOR SHORT–TERM GENERAL INPATIENT LEVEL OF CARE,SUPPORTING DOCUMENTATION MIGHT INCLUDE:
a. Pain requiring:
1. Complicated technical delivery of medicationrequiring registered nurse to do calibration,tubing change, or site care
2. Frequent evaluation by physician/nurse
3. Aggressive treatment to control pain
4. Frequent medication adjustment
5. Transfusions for symptom relief
b. Symptom changes:
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1. Sudden deterioration requiring intensive nursingintervention
2. Uncontrolled nausea and vomiting
3. Pathological fractures
4. Respiratory distress which becomesunmanageable
5. Open lesions needing frequent skilled care
6. Traction and frequent repositioning requiringmore than one staff member
7. Complex wound care requiring complex dressingchanges
8. New and/or worsening delirium or agitation
c. Psychological and social problems:
1. Acute anxiety, fear of dying and/or depressionrequiring intensive interventions
2. Collapse of family support requiring intensiveskilled care in other than the home environment
d. Patient/family teaching:
1. Complex medications, treatments, etc.
e. Imminent death:
1. Requiring skilled nursing care for pain orsymptom management due to a breakdown in thehome support system.
REFERENCES1 Jablecki CK et al, op. cit.2 Adapted from Jacox A et al, Management of Cancer Pain.. US Department of Health and
Human Services, AHCPR Publication No. 94-0592, March 1994.3 Callahan D. Frustrated mastery — The cultural context of death in America, in Caring for
Patients at the End of Life [Special Issue]. West J Med 1995; 163:226-30.4 Christakis NA et al. Survival of Medicare patients after enrollment in hospice programs.
New Eng J Med 1996;335:172-8.5 Giles TD. Optimizing the treatment of heart failure. Curr Opin Cardiol 1994;9 Suppl 1:S21-7.6 Lynn, J et al. Accurate prognostication of death: opportunities and challenges for
physicians. West J Med 1995;163:250-7.
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APPENDIX Ia. Reasons For Denial
1. Medical review of records of hospice patients that donot document that patients meet the guidelines setforth herein may result in denial of coverage unlessother clinical circumstances reasonably predictive of alife expectancy of six months or less are provided.
2. The condition of some patients receiving hospice caremay stabilize or improve during or due to that care,with the expectation that the stabilization orimprovement will not be brief and temporary. In suchcircumstances, if the patient’s condition changes suchthat he or she no longer has a prognosis of lifeexpectancy of six months or less, and thatimprovement can be expected to continue outside thehospice setting, then that patient should bedischarged from hospice.
b. Coding Guidelines
1. Claims are to include an ICD–9 code for the principaldiagnosis, i.e., the terminal illness. If including codeswhich represent comorbidities, always list these codesas secondary diagnoses.
2. NOTE:The submission of codes reflectingcomorbidities on a claim does not make the hospiceagency financially liable for services and medicationsunless they are related to the terminal diagnosis.Services not related to the terminal illness remaincovered as non–hospice Part A and Part B benefits.
c. Comments:
1. This policy replaces all hospice policies for all of UGS.This policy contains significant changes from allprevious hospice policies and should be considered anew policy.
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2. Hospice– Determining Terminal Status – Comments:during the comment period, we received manythoughtful comments. The following is a compilationof those comments, with our responses.
a. A commenter requested the addition of ICD–9codes to the section “Coding Guidelines”. Wehave elected to delete all the codes containedtherein. The list was a group of suggested codesto be used for relevant comorbidities. The codingof secondary diagnoses is not required, andtherefore the entire list is deleted.
b. A commenter requested the addition of thefollowing to the guidelines for HIV, #3:“resistance to antiretrovirals”. It has been added.
c. A commenter requested the addition to HIV,supporting factors, “advanced liver disease”. Ithas been added.
d. A commenter noted in HIV, number 1, “loss of33% lean body mass”, was too restrictive. Wehave revised this to read “loss of at least 10% leanbody mass”.
e. A commenter suggested that in HIV, the KPS of50% was too low, and should be changed to 70%.We feel that 50% is the more appropriate level.
f. A commenter noted that although the policystates that a patient with Alzheimer’s dementiashould have lost the bulk of his/her verbalabilities, patients sometimes maintain suchabilities well into the disease. If a patientotherwise was within the guidelines, appropriatedocumentation supporting his/her terminalprognosis would be given great weight in theadjudication of a claim.
g. We received questions about Dementia due toAlzheimer’s Disease and Related Disorders. Thissection is specific to Alzheimer’s dementia andclosely related disorders. It may be used as a basis
46
for evaluating patients with other forms ofdementia, if relevant. The non–disease specificsection may also be used if more appropriate.
h. Numerous comments were received regarding thesection on Heart disease, both to change thewording concerning appropriate treatment of thepatient’s condition, and to expand the guidelinesto include other forms of heart disease. We haverevised the heart disease guidelines to encompassheart disease in general. The sentence concerningtreatment has also been slightly revised.
i. A commenter noted that the Heart diseasesection’s discussion of the New York HeartAssociation classification was not consistent withthe Association’s definition of Class IV. We haverevised said section to read “Symptoms ... may bepresent even at rest”.
j. A commenter requested the word “unexplained”be removed from Heart disease, supportingconditions, 3c. History of unexplained syncope.We have elected not to delete this word; syncopethat can be explained, can probably be treated,and thus does not connote as severe acomorbidity.
k. A commenter noted that occasionally a Liverdisease patient may not have elevation of his/herINR. If the patient otherwise fulfilled theguidelines, appropriate documentation to supportthe patient’s terminal prognosis will be givenconsideration.
l. A commenter requested that we add the phrase“or is discontinuing dialysis” to number 1 of boththe Acute and Chronic Renal Failure. It has beenadded.
m. Comments were received urging moreconsideration of psychosocial issues. Weunderstand that these issues are an integral of all
47
hospice care, but we also must note thatpsychosocial issues are not the basis of a patient’seligibility for the Medicare hospice benefit.
n. In the section on ALS, a commenter requestedthat the phrase “Vital capacity less that 30% ofnormal” be extended to include “if available”. Ithas been added.
o. A commenter suggested that in Stroke and Coma,a KPS of 40% was too low; it ought to be 50%. Wefeel that 40% is more appropriate.
p. A commenter suggested that the title of thisdocument be changed to “Local Medical ReviewGuideline”. We appreciate the concern, but “LocalMedical Review Policy (LMRP)” is a CMS title;we do not feel we have the discretion to change it.We do however wish to reiterate that this policy isa group of guidelines, and that there are patientswho may not strictly meet the various criteria fora particular illness, but are most certainly eligiblefor the Medicare hospice benefit. The mostimportant requirement described in this LMRP isthe need for appropriate documentation tosupport the patient’s terminal prognosis.
James W. Cope, MDMedical Director
a. Disease Specific Guidelines Note: These guidelinesare to be used in conjunction with the “Non–diseasespecific baseline guidelines” described in Part II of thebasic LCD.
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SECTION I
Cancer Diagnosesa. Disease with distant metastases at presentation OR
b. Progression from an earlier stage of disease tometastatic disease with either
1. A continued decline in spite of therapy
2. Patient declines further disease directed therapy
Note: Certain cancers with poor prognoses (e.g. small celllung cancer, brain cancer and pancreatic cancer) may behospice eligible without fulfilling the other criteria in thissection.
SECTION II
Non–Cancer Diagnoses
A. Amyotrophic Lateral Sclerosis
General Considerations:
1. ALS tends to progress in a linear fashion over time.Thus the overall rate of decline in each patient is fairlyconstant and predictable, unlike many other non–cancer diseases.
2. However, no single variable deteriorates at a uniformrate in all patients. Therefore, multiple clinicalparameters are required to judge the progression ofALS.
3. Although ALS usually presents in a localizedanatomical area, the location of initial presentationdoes not correlate with survival time. By the timepatients become end–stage, muscle denervation hasbecome widespread, affecting all areas of the body,and initial predominance patterns do not persist.
49
4. Progression of disease differs markedly from patientto patient. Some patients decline rapidly and diequickly; others progress more slowly. For this reason,the history of the rate of progression in individualpatients is important to obtain to predict prognosis.
5. In end–state ALS, two factors are critical indetermining prognosis: ability to breathe, and to alesser extent ability to swallow. The former can bemanaged by artificial ventilation, and the latter bygastrostomy or other artificial feeding, unless thepatient has recurrent aspiration pneumonia. Whilenot necessarily a contraindication to Hospice Care, thedecision to institute either artificial ventilation orartificial feeding will significantly alter six–monthprognosis.
6. Examination by a neurologist within three months ofassessment for hospice is advised, both to confirm thediagnosis and to assist with prognosis.
Criteria: Patients will be considered to be in the terminal stageof ALS (life expectancy of six months or less) if they meet thefollowing criteria. (Should fulfill 1, 2, or 3).
• Patient should demonstrate critically impairedbreathing capacity.
a. Critically impaired breathing capacity asdemonstrated by all the following characteristicsoccurring within the 12 months preceding initialhospice certification:
1. Vital capacity (VC) less than 30% of normal (ifavailable);
2. Dyspnea at rest;
3. Patient declines mechanical ventilation;
• Patient should demonstrate both rapid progression ofALS and critical nutritional impairment.
a. Rapid progression of ALS as demonstrated by all thefollowing characteristics occurring within the 12months preceding initial hospice certification:
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b. Progression from independent ambulation towheelchair to bedbound status;
c. Progression from normal to barely intelligible orunintelligible speech;
d. Progression from normal to pureed diet;
e. Progression from independence in most or allactivities of daily living (ADLs) to needing majorassistance by caretaker in all ADLs.
f. Critical nutritional impairment as demonstratedby all the following characteristics occurringwithin the 12 months preceding initial hospicecertification:
g. Oral intake of nutrients and fluids insufficient tosustain life;
h. Continuing weight loss;
i. Dehydration or hypovolemia;
j. Absence of artificial feeding methods, sufficient tosustain life, but not for relieving hunger.
k. Patient should demonstrate both rapidprogression of ALS and life–threateningcomplications.
l. Rapid progression of ALS, see 2.a above.
m. Life–threatening complications as demonstratedby one of the following characteristics occurringwithin the 12 months preceding initial hospicecertification:
1. Recurrent aspiration pneumonia (with or withouttube feedings);
2. Upper urinary tract infection, e.g., pyelonephritis;
3. Sepsis;
4. Recurrent fever after antibiotic therapy;
5. Stage 3 or 4 decubitus ulcer(s).
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B. Dementia due to Alzheimer ’s Disease andRelated Disorders
Patients will be considered to be in the terminal stage ofdementia (life expectancy of six months or less) if they meetthe following criteria.
• Patients with dementia should show all the followingcharacteristics:
a. Stage seven or beyond according to the FunctionalAssessment Staging Scale;
b. Unable to ambulate without assistance;
c. Unable to dress without assistance;
d. Unable to bathe without assistance;
e. Urinary and fecal incontinence, intermittent orconstant;
f. No consistently meaningful verbal communication:stereotypical phrases only or the ability to speak islimited to six or fewer intelligible words.
• Patients should have had one of the following withinthe past 12 months:
a. Aspiration pneumonia;
b. Pyelonephritis or upper urinary tract infection;
c. Septicemia;
d. Decubitus ulcers, multiple, stage 3–4;
e. Fever, recurrent after antibiotics;
f. Inability to maintain sufficient fluid and calorie intakewith 10% weight loss during the previous six monthsor serum albumin < 2.5 gm/dl.
Note: This section is specific for Alzheimer’s Disease andRelated Disorders, and is not appropriate for other types ofdementia.
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C. Heart Disease
Patients will be considered to be in the terminal stage of heartdisease (life expectancy of six months or less) if they meet thefollowing criteria. (1 and 2 should be present. Factors from 3will add supporting documentation.)
1. At the time of initial certification or recertification forhospice, the patient is or has been already optimallytreated for heart disease, or are patients who areeither not candidates for surgical procedures or whodecline those procedures. (Optimally treated meansthat patients who are not on vasodilators have amedical reason for refusing these drugs, e.g.,hypotension or renal disease.)
2. Patients with congestive heart failure or anginashould meet the criteria for the New York HeartAssociation (NYHA) Class IV. (Class IV patients withheart disease have an inability to carry on anyphysical activity. Symptoms of heart failure or of theanginal syndrome may be present even at rest. If anyphysical activity is undertaken, discomfort isincreased.) Significant congestive heart failure may bedocumented by an ejection fraction of =20%, but is notrequired if not already available.
3. Documentation of the following factors will supportbut is not required to establish eligibility for hospicecare:
a. Treatment resistant symptomatic supraventricularor ventricular arrhythmias;
b. History of cardiac arrest or resuscitation;
c. History of unexplained syncope;
d. Brain embolism of cardiac origin;
e. Concomitant HIV disease.
53
D. HIV Disease
Patients will be considered to be in the terminal stage of theirillness (life expectancy of six months or less) if they meet thefollowing criteria: HIV Disease (1 and 2 should be present;factors from 3 will add supporting documentation)
• CD4+ Count < 25 cells/mcl or persistent (2 or more assaysat least one month apart) viral load >100,000 copies/ml,plus one of the following:
a. CNS lymphoma
b. Untreated, or persistent despite treatment, wasting(loss of at least 10% lean body mass);
c. Mycobacterium avium complex (MAC) bacteremia,untreated, unresponsive to treatment, or treatmentrefused;
d. Progressive multifocal leukoencephalopathy;
e. Systemic lymphoma, with advanced HIV disease andpartial response to chemotherapy;
f. Visceral Kaposi’s sarcoma unresponsive to therapy;
g. Renal failure in the absence of dialysis;
h. Cryptosporidium infection;
i. Toxoplasmosis, unresponsive to therapy.
• Decreased performance status, as measured by theKarnofsky Performance Status (KPS) scale, of =50%
• Documentation of the following factors will supporteligibility for hospice care:
a. Chronic persistent diarrhea for one year; Persistentserum albumin < 2.5;
b. Concomitant, active substance abuse
c. Age >50 years;
54
d. Absence of or resistance to effective antiretroviral,chemotherapeutic and prophylactic drug therapyrelated specifically to HIV disease;
e. Advanced AIDS dementia complex;
f. Toxoplasmosis;
g. Congestive heart failure, symptomatic at rest.
h. Advanced liver disease
E. Liver Disease
Patients will be considered to be in the terminal stage of liverdisease (life expectancy of six months or less) if they meet thefollowing criteria: (1 and 2 should be present, factors from 3will lend supporting documentation.)
1. The patient should show both a and b:
a. Prothrombin time prolonged more than 5 secondsover control, or International Normalized Ratio(INR) >1.5;
b. Serum albumin < 2.5 gm/dl.
2. End stage liver disease is present and the patientshows at least one of the following:
a. Ascites, refractory to treatment or patient non–compliant;
b. Spontaneous bacterial peritonitis;
c. Hepatorenal syndrome (elevated creatinine andBUN with oliguria (< 400 ml/day) and urinesodium concentration < 10 mEq/l);
d. Hepatic encephalopathy, refractory to treatment,or patient non–compliant;
e. Recurrent variceal bleeding, despite intensivetherapy.
55
3. Documentation of the following factors will supporteligibility for hospice care:
a. Progressive malnutrition;
b. Muscle wasting with reduced strength andendurance;
c. Continued active alcoholism (>80 gm ethanol/day);
d. Hepatocellular carcinoma;
e. HBsAg (Hepatitis B) positivity;
f. Hepatitis C refractory to interferon treatment.
F. Pulmonary Disease
Patients will be considered to be in the terminal stage ofpulmonary disease (life expectancy of six months or less) ifthey meet the following criteria. The criteria refer to patientswith various forms of advanced pulmonary disease whoeventually follow a final common pathway for end stagepulmonary disease. (1 and 2 should be present.Documentation of 3, 4, and 5, will lend supportingdocumentation.):
1. Severe chronic lung disease as documented by both aand b:
a. Disabling dyspnea at rest, poorly or unresponsiveto bronchodilators, resulting in decreasedfunctional capacity, e.g., bed to chair existence,fatigue, and cough: (Documentation of ForcedExpiratory Volume in One Second (FEV1), afterbronchodilator, less than 30% of predicted isobjective evidence for disabling dyspnea, but isnot necessary to obtain.)
b. Progression of end stage pulmonary disease, asevidenced by increasing visits to the emergencydepartment or hospitalizations for pulmonary
56
infections and/or respiratory failure or increasingphysician home visits prior to initial certification.(Documentation of serial decrease of FEV1>40ml/year is objective evidence for diseaseprogression, but is not necessary to obtain.)
2. Hypoxemia at rest on room air, as evidenced by pO2less than or equal to 55 mmHg; or oxygen saturationless than or equal to 88%; determined either byarterial blood gases or oxygen saturation monitors;(These values may be obtained from recent hospitalrecords.) OR Hypercapnia, as evidenced by pCO2greater than or equal to 50 mmHg. (This value may beobtained from recent [within 3 months] hospitalrecords.)
3. Right heart failure (RHF) secondary to pulmonarydisease (Cor pulmonale) (e.g., not secondary to leftheart disease or valvulopathy).
4. Unintentional progressive weight loss of greater than10% of body weight over the preceding six months.
5. Resting tachycardia >100/min.
G. Renal Disease
Patients will be considered to be in the terminal stage of renaldisease (life expectancy of six months or less) if they meet thefollowing criteria:
Acute Renal Failure: (1 and either 2 or 3 should be present.Factors from 4 will lend supporting documentation.)
1. The patient is not seeking dialysis or renal transplant,or is discontinuing dialysis;
2. Creatinine clearance < 10 cc/min (<15 cc/min. fordiabetics); or < 15cc/min (< 20cc/min for diabetics)with comorbidity of congestive heart failure;
3. Serum creatinine >8.0 mg/dl (>6.0 mg/dl fordiabetics);
57
4. Comorbid conditions:
a. Mechanical ventilation;
b. Malignancy (other organ system);
c. Chronic lung disease;
d. Advanced cardiac disease;
e. Advanced liver disease;
f. Immunosuppression/AIDS;
g. Albumin < 3.5 gm/dl;
h. Platelet count < 25,000;
i. Disseminated intravascular coagulation;
j. Gastrointestinal bleeding.
Chronic Renal Failure: (1 and either 2 or 3 should bepresent. Factors from 4 will lend supportingdocumentation.)
1. The patient is not seeking dialysis or renal transplant,or is discontinuing dialysis;
2. Creatinine clearance <10 cc/min (< 15 cc/min fordiabetics); or < 15cc/min (< 20cc/min for diabetics)with comorbidity of congestive heart failure;
3. Serum creatinine >8.0 mg/dl (>6.0 mg/dl fordiabetics);
4. Signs and symptoms of renal failure:
a. Uremia
b. Oliguria (< 400 cc/24 hours);
c. Intractable hyperkalemia (>7.0) not responsive totreatment;
d. Uremic pericarditis;
e. Hepatorenal syndrome;
f. Intractable fluid overload, not responsive totreatment.
58
H. Stroke and Coma
Patients will be considered to be in the terminal stages ofstroke or coma (life expectancy of six months or less) if theymeet the following criteria:
Stroke
1. Karnofsky Performance Status (KPS) or PalliativePerformance Scale (PPS) of < 40% .
2. Inability to maintain hydration and caloric intakewith one of the following:
a. Weight loss >10% in the last 6 months or >7.5% inthe last 3 months;
b. Serum albumin < 2.5 gm/dl;
c. Current history of pulmonary aspiration notresponsive to speech language pathologyintervention;
d. Sequential calorie counts documentinginadequate caloric/fluid intake.
e. Dysphagia severe enough to prevent patient fromcontinuing fluids/foods necessary to sustain lifeand patient does not receive artificial nutritionand hydration.
Coma (any etiology):
1. Comatose patients with any 3 of the following onday three of coma:
a. abnormal brain stem response;
b. absent verbal response;
c. absent withdrawal response to pain;
d. serum creatinine > 1.5 mg/dl.
2. Documentation of the following factors will supporteligibility for hospice care:
59
a. Documentation of medical complications, in thecontext of progressive clinical decline, within theprevious 12 months, which support a terminalprognosis:
1. Aspiration pneumonia;
2. Upper urinary tract infection (pyelonephritis);
3. Refractory stage 3–4 decubitus ulcers;
4. Fever recurrent after antibiotics.
b. Documentation of diagnostic imaging factors whichsupport poor prognosis after stroke include:
1. For non–traumatic hemorrhagic stroke:
1. Large–volume hemorrhage on CT:
a. Infratentorial: =20 ml.;
b. Supratentorial: =50 ml.
2. Ventricular extension of hemorrhage;
3. Surface area of involvement of hemorrhage=30% of cerebrum;
4. Midline shift =1.5 cm.;
5. Obstructive hydrocephalus in patient whodeclines, or is not a candidate for,ventriculoperitoneal shunt.
2. For thrombotic/embolic stroke:
1. Large anterior infarcts with both cortical andsubcortical involvement;
2. Large bihemispheric infarcts;
3. Basilar artery occlusion;
4. Bilateral vertebral artery occlusion.
60
APPENDIX II
Medical Guidelines for Determination ofPrognosis: Type, Strength and Consistency ofEvidence
These guidelines were constructed whenever possible on thebasis of evidence from the medical literature concerning earlymortality in non-cancer diseases. This evidence may begrouped in the following categories:
2
I. Meta-analysis of multiple, well-designed controlledstudies.
II. At least one well-designed experimental study.
III. Well-designed, quasi-experimental studies:
A. Nonrandomized controlled.
B. Single group pre/post.
C. Cohort.
D. Time Series.
E. Matched case-controlled.
IV. Well-designed non-experimental studies.
A. Comparative and correlational descriptive and casestudies.
V. Case reports and clinical examples.
Strength and consistency of evidence may then be sortedas follows:
A. There is evidence of Type I or consistent findings frommultiple studies of Types II, III or IV.
61
B. There is evidence of Types II, III or IV, and findingsare generally consistent.
C. There is evidence of Types II, III or IV, but findings areinconsistent.
D. There is little or no evidence, or there is Type Vevidence only.
There has been no attempt in these Guidelines to classify eachrecommendation individually. In general, most of theseGuidelines would be classified as within Group B, with anumber in Groups A and C. With further more targetedresearch on mortality in end-stage non-cancer disease, itwould be expected that Guidelines would evolve upward inthis classification to Categories A or B.
62
APPENDIX III
Karnofsky Performance Status ScaleDefinitions Rating (%) Criteria
Able to carry on normal 100 Normal no complaints;activity and to work; no no evidence of disease.special care needed.
90 Able to carry on normalactivity; minor signs orsymptoms of disease.
80 Normal activity with effort;some signs or symptoms ofdisease.
Unable to work; able to 70 Cares for self; unable tolive at home and care for carry on normal activity ormost personal needs; varying to do active work.amount of assistance needed.
60 Requires occasionalassistance, but is able to care formost of his needs.
50 Requires considerableassistance and frequent
medical care.Unable to care for self; 40 Disabled; requires specialrequires equivalent of care and assistance.institutional or hospitalcare; disease may beprogressing rapidly.
30 Severely disabled; hospital
admission is indicatedalthough death not imminent.
20 Very sick; hospital admissionnecessary; active supportivetreatment necessary.
10 Moribund; fatal processesprogressing rapidly.
0 Dead
Oxford Textbook of Palliative Medicine, Oxford University Press. 1993;109.
63
APPENDIX IV
New York Heart Association (NYHA) FunctionalClassification
Class I. Patients with cardiac disease, but withoutresulting limitation of physical activity. Ordinaryphysical activity does not cause undue fatigue,palpitation, dyspnea, or anginal pain.
Class II. Patients with cardiac disease resulting in slightlimitation of physical activity They arecomfortable at rest. Ordinary physical activityresults in fatigue, palpitation, dyspnea, or anginalpain.
Class III. Patients with marked limitation of physicalactivity. They are comfortable at rest. Less thanordinary activity causes fatigue, palpitation,dyspnea, or anginal pain.
Class IV. Patients with cardiac disease resulting in inabilityto carry on any physical activity withoutdiscomfort. Symptoms of heart failure or of theanginal syndrome may be present even at rest. Ifany physical activity is undertaken, discomfort isincreased.
64
APPENDIX V
Functional Assessment Staging (FAST)(Check highest consecutive level of disability.)
❑ 1. No difficulty either subjectively or objectively.
❑ 2. Complains of forgetting location of objects. Subjective work
difficulties.
❑ 3. Decreased job functioning evident to co-workers. Difficulty in
traveling to new locations. Decreased organizational capacity.*
❑ 4. Decreased ability to perform complex tasks, e.g., planning dinner
for quests, handling personal finances (such as forgetting to paybills), difficulty marketing, etc.
❑ 5. Requires assistance in choosing proper clothing to wear for the
day, season or occasion, e.g., patient may wear the same clothingrepeatedly, unless supervised.*
❑ 6. A) Improperly putting on clothes without assistance or cuing (e.g.,
may put street clothes on over night clothes, or put shoes onwrong feet, or have difficulty buttoning clothing) occasionallyor more frequently over the past weeks.*
❑ B) Unable to bathe properly (e.g., difficulty adjusting bath-water
temperature) occasionally or more frequently over the pastweeks.*
❑ C) Inability to handle mechanics of toileting (e.g., forgets to flush
the toilet, does not wipe properly or properly dispose of toilettissue) occasionally or more frequently over the past weeks.*
65
❑ D) Urinary incontinence (occasionally or more frequently over the
past weeks).*
❑ E) Fecal incontinence (occasionally or more frequently over the
past weeks).*
❑ 7. A) Ability to speak limited to approximately a half a dozen
intelligible different words or fewer, in the course of anaverage day or in the course of an intensive interview.
❑ B) Speech ability is limited to the use of a single intelligible word
in an average day or in the course of an intensive interview(the person may repeat the word over and over).
❑ C) Ambulatory ability is lost (cannot walk without personal
assistance).
❑ D) Cannot sit up without assistance (e.g., the individual will fall
over if there are not lateral rests (arms) on the chair).
❑ E) Loss of ability to smile.
❑ F) Loss of ability to hold up head independently.
* Scored primarily on the basis of information obtained from a knowledge-able informant and/or category.
Reisberg, B. Functional assessment staging (FAST). Psychopharmacol-ogy Bulletin, 1988; 24:653-659.
66
Clin
ical
Inci
pien
t or
Mild
Mod
erat
eM
oder
ate-
Sev
ere
Ser
ve A
DD
iagn
osis
Que
stio
n A
DA
DA
DA
D
FA
ST
Sta
ge3
45
67
FA
ST
Sub
stag
e
Yea
rs:
07
910
.513
19
Min
i Men
tal
2925
1914
55
0 U
sual
Poi
nt
of
Dea
th
Rei
sber
g. e
t al.,
Alz
heim
er’s
Dis
ease
and
Ass
ocia
ted
Dis
orde
rs, 1
994;
8 (
Sup
pl.)
S 1
88-S
205
.a
b
c
d
e
a
b
c
d
e
f
APPENDIX VI
Typi
cal Ti
me
Cour
se o
f Al
zhei
mer
’s D
isea
se (
AD)
Hos
pice
Par
amet
ers:
“Min
imum
Mag
nitu
deof
Sev
erity
”
67
APPENDIX VII
Diagnostic Imaging FactorsIndicating Poor Prognosis After Stroke
A. For non-traumatic hemorrhagic stroke:
1. Large-volume hemorrhage on CT:
a. Infratentorial: > 20 ml.1
b. Supratentorial: > 50 ml.1
2. Ventricular extension of hemorrhage.1
3. Surface area of involvement of hemorrhage > 30%of cerebrum.
1
4. Midline shift > 1.5 cm. 1
5. Obstructive hydrocephalus in patient whodeclines, or is not a candidate for,ventriculoperitoneal shunt.
1
B. For thrombotic/embolic stroke:
1. Large anterior infarcts with both corticaland subcortical involvement.
1
2. Large bihemispheric infarcts.1
3. Basilar artery occlusion.1
4. Bilateral vertebral artery occlusion.1
68
Sources of Information andBasis for Decision
• ICD–9–CM 2003, ©2002 Practice ManagementInformation Corporation.
• Medicare Contractor Medicare Directors HospiceWorkgroup.
• All previously published UGS Local Medical ReviewPolicies
• B. Friedman, M. Harwood, M. Shields. Barriers andEnablers to Hospice Referrals: An Expert Overview. JPalliative Medicine 2002; 5; 73–84.
• K. Ogle, B. Mavis, G. Wyatt. Physicians and HospiceCare: Attitudes, Knowledge, and Referrals. J PalliativeMedicine 2002; 5; 85–92.
• K. Ogle, B. Mavis, T. Wang. Hospice and Primary CarePhysicians: Attitudes, Knowledge, and Barriers. A JHospice & Palliative Care 2003; 20; 41–51.
• N. Christakis, E. Lamont. Extent and determinants oferror in doctors’ prognoses in terminally ill patients:prospective cohort study. British Medical Journal 2000;320; 469–472.
• E. Lamont, N. Christakis. Prognostic Disclosure toPatients with Cancer near the End of Life. Annals ofInternal Medicine 2001; 134;1097–1143.
• Other Medicare contractors, specialty societies, andspecialty consultants.
69
Documentation should be complete, consistent, concise, specific, measurable, and descriptive.
Diagnosis: Present underlying illness(es) and all other illness(es) affecting the terminal diagnosis:
Co-morbidity that affects the prognosis:
History and progression of the illness(es):
Physical baseline (e.g., weight and weight change, vital signs, heart rhythms, rales, degree of edema):
Laboratory (if pertinent):
Physician's prognosis stating why there is a life expectancy of 6 months or less (e.g., Patient depressed, will
not eat and does not want anything done, or has had optimal therapy for illness.):
RN Signature Date Physician signature
Complete this form and attach it to the appropriate disease specific worksheet
NARRATIVE SUMMARYOF PROGNOSIS DOCUMENTATION
70
The purpose of this worksheet is to guide initial and recertification assessments. It must be accompanied by narrativedocumentation. These are guidelines only: clinical judgement is required in each case. Construct a narrative from theinformation on this worksheet and information from the patient's physician and record on back. The patient should bere-evaluated at specific intervals set by the interdisciplinary team and within 60 days of clinical stabilization. This formmay be used for initial and subsequent re-evaluation.
Pt. Name: ID#: Date:
Both 1 and 2 must be present as evidence of hospice appropriateness.1. Is patient severely demented? .................................................................................................... ❏ Yes ❏ No
Patient should be at or beyond Stage 7 of the Functional Assessment Staging Scale. Check level:____ 7A Ability to speak is limited to approximately 6 intelligible words or fewer, in the course of an aver- age day or in the course of an intensive interview.____ 7B Speech ability is limited to the use of a single intelligible word in an average day or in the course of an intensive interview (the person may repeat the word over and over).____ 7C Ambulatory ability is lost (cannot walk without personal assistance).____ 7D Cannot sit up without assistance (e.g., patient will fall over if there are not lateral rests (arms) on the chair).____ 7E Loss of ability to smile.____ 7F Loss of ability to hold up head independently.
Patient should show all of the following characteristics. Check all that apply:____ inability to ambulate independently (cannot walk without personal assistance)____ unable to dress without assistance____ unable to bathe properly____ incontinence of urine and stool (occasionally or more frequently, over the past weeks as reported by a knowledgeable informant or caregiver)____ unable to speak or communicate meaningfully (see 7A above)
2. Has the patient had one or more of the following medical complications related to dementiaduring the past year? .................................................................................................................. ❏ Yes ❏ No(conditions should have been severe enough for hospitalization whether or not hospitalization occurred).Check all that are appropriate:____ aspiration pneumonia____ upper urinary tract infection____ septicemia____ decubitus ulcers, multiple, stage 3-4____ fever recurrent after antibiotics____ inability or unwillingness to take food or fluids sufficient to sustain life; not a candidate for feeding tube or parenteral nutritionPatients who are receiving tube feedings must have documented impaired nutritional status as indicated byeither:____ unintentional, progressive weight loss of greater than 10% over prior 6 months, or____ serum albumin less than 2.5 gm/dl (may be helpful prognostic indicator but should not be used by itself)
Attach completed "Narrative Summary of Prognosis Documentation" form to this form
WORKSHEETFOR DETERMINING PROGNOSIS
Dementia
71
WORKSHEETFOR DETERMINING PROGNOSIS
General Guidelines - All Diagnoses
The purpose of this worksheet is to guide initial and recertification assessments. It must be accompanied by narrativedocumentation. These are guidelines only: clinical judgment is required in each case. Construct a narrative from theinformation on this worksheet and information from the patient's physician and record on back. The patient should bere-evaluated at specific intervals set by the interdisciplinary team and within 60 days of clinical stabilization. This formmay be used for initial and subsequent re-evaluation.
Pt. Name: ID#: Date:
The patient should meet the following criteria:1. Life limiting condition ................................................................................................................... ❏ Yes ❏ No2. Pt/family informed condition is life limiting................................................................................... ❏ Yes ❏ No3. Pt/family elected palliative care ................................................................................................... ❏ Yes ❏ No4. Documentation of clinical progression of disease ....................................................................... ❏ Yes ❏ No
Evidenced by (check all that apply and secure copies of documentation for hospice record):____ serial physician assessment____ laboratory studies____ radiologic or other studies____ multiple Emergency Dept. visits____ inpatient hospitalizations____ home health nursing assessment if patient homebound
and/or5. Recent decline in functional status.............................................................................................. ❏ Yes ❏ No
Evidenced by either:A. Karnofsky Performance Status < 50%............................................................................ ❏ Yes ❏ No
Check level: ____ 50% Requires considerable assistance and frequent medical care ____ 40% Disabled; requires special care and assistance Unable to care for self; disease may be progressing rapidly ____ 30% Severely disabled; although death is not imminent ____ 20% Very sick; active supportive treatment necessary ____ 10% Moribund; fatal processes progressing rapidlyand/orB. Dependence in 3 of 6 Activities of Daily Living ................................................................ ❏ Yes ❏ No Check activities in which patient is dependent: ____ bathing ____ dressing ____ feeding ____ transfers ____ continence of urine and stool ____ ambulation to bathroomand/or
6. Recent impaired nutritional status ............................................................................................... ❏ Yes ❏ NoEvidenced by (check all appropriate):____ unintentional, progressive weight loss of 10% over past six months____ serum albumin less than 2.5 gm/dl (may be helpful prognostic indicator but should not be used by itself)
Attach completed "Narrative Summary of Prognosis Documentation" form to this form
72
3. Does patient have ejection fraction of < 20% (only if test results available)? ................................ ❏ Yes ❏ No
4. The following factors are further indications of decreased survival time. Check all that apply:
____ symptomatic supraventricular or ventricular arrhythmias resistant to antiarrhythmic therapy
____ history of cardiac arrest and resuscitation in any setting
____ history of syncope of any cause, cardiac or otherwise
____ cardiogenic brain embolism, i.e. embolic CVA of cardiac origin
____ concomitant HIV disease
Attach completed "Narrative Summary of Prognosis Documentation" form to this form
The purpose of this worksheet is to guide initial and recertification assessments. It must be accompanied by narrativedocumentation. These are guidelines only: clinical judgement is required in each case. Construct a narrative from theinformation on this worksheet and information from the patient's physician and record on back. The patient should bere-evaluated at specific intervals set by the interdisciplinary team and within 60 days of clinical stabilization. This formmay be used for initial and subsequent re-evaluation.
Pt. Name: ID#: Date:
1. Does the patient have symptoms and signs of congestive heart failure at rest? ........................... ❏ Yes ❏ NoCheck all that apply:
2. Has the physician verified that the patient is on optimal diuretic and vasodilator therapy? ........... ❏ Yes ❏ No
Diuretics (patient should be on optimal dose of one of the following). Check all that apply:
____ Furosemide (Lasix)
____ Bumetanide (Bumex)
____ Ethacrynic Acid (Edecrin)
____ Torsemide (Demedex)
WORKSHEETFOR DETERMINING PROGNOSIS
Heart Disease
____ Metolazone (Zarloxlyn, Mykrox)
(may be combined with the above, but not used alone)
____ Lisinopril (Prinvil, Zestril)
____ Quinapril (Accupril)
____ Ramipril (Altace)
Vasodilators (patient should be on optimal dose of one of the following). Check all that apply:
A. Nitrates (e.g., Nitro patch, Isosorbide) plus Hydralazine _____
B. Apresoline Anglotensin Converting Enzyme (ACE) Inhibitor:
____ Benazepril (Lotensin)
____ Captopril (Capoten)
____ Enalapril (Vasotec)
____ Fosinopril (Monopril)
____ dyspnea at rest: "short winded", "Can't breathe"____ dyspnea on exertion: "Can't breathe with exercise"____ orthopnea: "Can't breathe lying down"____ paroxysmal nocturnal dyspnea (PND): "Waking up at night short of breath"____ edema "Swollen ankles, legs"____ syncope____ weakness____ chest pain
____ diaphoresis: sweating____ cachexia: profound weight loss____ jugulovenous distension (JVD)____ neck veins distended above clavicle____ rales: wet crackles in lungs heard on inspiration____ gallop rhythm: S3, S4____ liver enlargement____ edema, pitting edema
Symptoms Signs
73
The purpose of this worksheet is to guide initial and recertification assessments. It must be accompanied by narrativedocumentation. These are guidelines only: clinical judgement is required in each case. Construct a narrative from theinformation on this worksheet and information from the patient's physician and record on back. The patient should bere-evaluated at specific intervals set by the interdisciplinary team and within 60 days of clinical stabilization. This formmay be used for initial and subsequent re-evaluations.
Pt. Name: ID#: Date:
Patient has severe lung disease ........................................................................................................... ❏ Yes ❏ NoEvidenced by (check all that apply):
____ poor response to bronchodilators
____ forced expiratory volume in one second (FEV1) after bronchodilator, less than 30% of predicted*
____ increased visits to Emergency Department
____ increased hospitalizations for pulmonary infections/respiratory failure
____ decrease in FEV1 on serial testing of greater than 40 ml per year*
____ presence of cor pulmonale or right heart failure due to lung disease evidenced by:
____ echocardiographic documentation*
____ EKG*
____ chest x-ray*
____ physical signs of RHF
____ hypoxemic at rest on supplemental oxygen
____ pO2 , < 55 mm Hg on supplemental O2
____ O2 saturation < 88% on supplemental O2
____ hypercapnia (pCO2 > 50 mm Hg)
____ unintentional weight loss > 10% of body weight in past six months
____ resting tachycardia (heart rate > 100 per minute)
* These tests are helpful evidence but should not be required if not readily available.
Attach completed "Narrative Summary of Prognosis Documentation" form to this form
WORKSHEETFOR DETERMINING PROGNOSIS
Pulmonary Disease
____ dyspnea at rest____ dyspnea on exertion____ housebound, chairbound____ oxygen-dependent____ copious/purulent sputum____ recurrent infections____ severe cough
____ cyanosis: blue lips, fingertips____ pulmonary hyperinflation: barrel-chested____ pursed-lip breathing____ accessory muscles of respiration____ retractions: supraclavicular____ increased expiratory phase: slowed forced expiration____ wheezing____ diminished breath sounds____ depressed diaphragm
Symptoms Signs
74
The purpose of this worksheet is to guide initial and recertification assessments. It must be accompanied by narrativedocumentation. These are guidelines only: clinical judgement is required in each case. Construct a narrative from theinformation on this worksheet and information from the patient's physician and record on back. The patient should bere-evaluated at specific intervals set by the interdisciplinary team and within 60 days of clinical stabilization. This formmay be used for initial and subsequent re-evaluation.
Pt. Name: ID#: Date:
The following factors combined with clinical judgment, may help decide whether individual patients arehospice appropriate:
1. CD4+ count____ > 50 cells/mc/L: Patient probably has a prognosis of > 6 months unless there is a non-HIV-related co-
existing life-threatening disease____ < 25 cells/mc/L:
____ measured during a period when patient is relatively free of acute illness____ observed disease progression and decline in functional status
2. Viral load____ > 100,000 copies/ml: Patient may have a prognosis of less than 6 months____ < 100,000 copies/ml and meet the following criteria:
____ patient has elected to forego antiretroviral and prophylactic medication____ functional status is declining____ experiencing complications (see 4 below)
3. Life-threatening complications with median survival (check all that are present):
WORKSHEETFOR DETERMINING PROGNOSIS
HIV Disease
____ CNS lymphoma 2.5 months____ Progressive multifocal leukoenephalopathy 4 months____ Cryptosporidiosis 5 months____ Wasting (loss of 33% lean body mass) < 6 months____ MAC bacteremia, untreated < 6 months____ Visceral Kaposi's sarcoma unresponsive to therapy 6 months mortality 50%____ Renal failure, refuses or fails dialysis < 6 months____ AIDS dementia complex 6 months____ Toxoplasmosis 6 months
4. The following factors have been shown to decrease survival significantly and should be documented ifpresent:____ chronic persistent diarrhea for one year, regardless of etiology____ persistent serum albumin < 2.5 gm/dl____ concomitant substance abuse____ age greater than 50____ decisions to forego antiretroviral, chemotherapeutic, and prophylactic drug therapy related specifically to HIV disease____ congestive heart failure, symptomatic at rest
Attach completed "Narrative Summary of Prognosis Documentation" form to this form
USUAL LIFE EXPECTANCYCOMPLICATION
75
The purpose of this worksheet is to guide initial and recertification assessments. It must be accompanied by narrativedocumentation. These are guidelines only: clinical judgement is required in each case. Construct a narrative from theinformation on this worksheet and information from the patient's physician and record on back. The patient should bere-evaluated at specific intervals set by the interdisciplinary team and within 60 days of clinical stabilization. This formmay be used for initial and subsequent re-evaluation.
Pt. Name: ID#: Date:The following factors have been shown to correlate with poor short-term survival in advanced cirrhosis of the liverdue to alcoholism, hepatitis, or uncertain causes (cryptogenic). Their effects are additive, i.e., prognosis worsenswith the additional of each one and clinical judgement is vital. The following factors should be followed and reviewedover time.
1. ____ Patient is not a candidate for liver transplantation2. Laboratory indicators of severely impaired liver function should show both of the following:
____ Prothrombin time prolonged more than 5 sec. over control____ Serum albumin < 2.5 gm/dl
3. Clinical indictors of end-stage liver disease (patient should show at least one of the following):____ Ascites
____ refractory to sodium restriction and diuretics: spironolactone 75-150 mg/day plus furosemide > 40mg/day
____ patient non-compliant____ Spontaneous bacterial peritonitis (median survival 30% at one year; high mortality even when infection
cured initially if liver disease is severe or accompanied by renal disease.)____ Hepatorenal syndrome (usually occurs during hospitalization; survival generally days to weeks)
____ patient has cirrhosis and ascites____ elevated creatinine and BUN____ oliguira 400 ml/da____ urine sodium concentration < 10 mEq/l
____ Hepatic encephalopathy,____ refractory to protein restriction and lactulose or neomycin____ patient non-compliant
____ Recurrent variceal bleeding: patient should have re-bled despite therapy which currently includes:____ injection sclerotherapy or band ligation, if available____ oral beta blockers____ transjugular intrahepatic portosystemic shunt (TIPS)____ patient refused further therapy
4. The following factors have been shown to worsen prognosis and should be documented if present:____ progressive malnutrition____ muscle wasting with reduced strength and endurance____ continued active alcoholism (> 80 g ethanol per day)____ hepatocellular carcinoma____ HBsAg positivity
Attach completed "Narrative Summary of Prognosis Documentation" form to this form
WORKSHEETFOR DETERMINING PROGNOSIS
Liver Disease
Sypmtoms Signs
____ decreased awareness of environment ____ flapping tremor of asterixis (in earlier stages)____ sleep disturbance ____ stupor (late-stage)____ depression ____ coma (late-stage)____ emotional lability____ somnolence____ slurred speech____ obtundation
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The purpose of this worksheet is to guide initial and recertification assessments. It must be accompanied by narrativedocumentation. These are guidelines only: clinical judgement is required in each case. Construct a narrative from theinformation on this worksheet and information from the patient's physician and record on back. The patient should bere-evaluated at specific intervals set by the interdisciplinary team and within 60 days of clinical stabilization. This formmay be used for initial and subsequent re-evaluation.
Pt. Name: ID#: Date:
Absent other comorbid conditions, the patient should not be seeking dialysis or renal transplant. Patients who dorefuse dialysis or transplant are generally appropriate for hospice services if they fit dialysis criteria.
1. Laboratory criteria for renal failure (both must be present)____ creatine clearance of < 10cc/min (<15cc/min for diabetics), and____ serum creatinine > 8.0 mg/dl (>6.0 mg/dl for diabetics)
NOTE: Creatinine clearance may be estimated by using the following formula: C = (140 - age in yrs.) (body wt. in kg) multiply by 0.85 for women
(72) (serum creat in mg/dl)
2. Clinical signs and syndromes associated with renal failure (check all which are present):____ uremia: clinical signs of renal failure:
____ confusion, obtundation____ intractable nausea and vomiting____ generalized pruritis____ restlessness, "restless legs"
____ oliguria: urine output < 400 cc/24 hrs.____ intractable hyperkalemia: persistent serum potassium > 7.0 not responsive to medical management____ uremic pericarditis____ hepatorenal syndrome____ intractable fluid overload
3. In hospitalized patients with ARF, these comorbid conditions predict early mortality (check all that apply forthis patient:____ mechanical ventilation____ malignancy -- other organ systems____ chronic lung disease____ advanced cardiac disease____ advanced liver disease____ sepsis____ immunosuppression/AIDS____ albumen < 3.5 gm/dl____ cachexia____ platelet count < 25,000____ age > 75____ disseminated intravascular coagulation____ gastrointestinal bleeding
Attach completed "Narrative Summary of Prognosis Documentation" form to this form
WORKSHEETFOR DETERMINING PROGNOSIS
Renal Disease
creat
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The purpose of this worksheet is to guide initial and recertification assessments. It must be accompanied by narrativedocumentation. These are guidelines only: clinical judgement is required in each case. Construct a narrative from theinformation on this worksheet and information from the patient's physician and record on back. The patient should bere-evaluated at specific intervals set by the interdisciplinary team and within 60 days of clinical stabilization. This formmay be used for initial and subsequent re-evaluation.
Pt. Name: ID#: Date:
After stroke, patients who do not die during the acute hospitalization tend to stabilize with supportive care only. Continu-ous decline in clinical or functional status over time means that the patient's prognosis is poor.
1. Acute phase patients. Immediately following a hemorrhgic or ischemic stroke, any of the following are strongindicators of early mortality:____ Coma or persistent vegetative state secondary to stroke, beyond three days' duration____ In post-anoxic stroke, coma or severe obtundation, accompanied by severe myoclonus, persistent beyond 3 days past the anoxic event____ Comatose patients with any 4 of the following on day 3 of coma had 97% mortality by two months:
____ abnormal brain stem response____ absent verbal response____ absent withdrawal response to pain
____ serum creatinine >1.5mg/dl ____ age > 70____ Dysphagia severe enough to prevent the patient from receiving food and fluids necessary to sustain life, ina patient who declines or is not a candidate for artificial nutrition and hydration____ If available, CT or MRI scans may indicate decreased likelihood of survival (see Appendix V for list)
2. Chronic phase patients. The following clinical factors may correlate with poor survival and should bedocumented.____ Age > 70____ Poor functional status as evidenced by Karnofsky score of < 50%
____ 50% Requires considerable assistance and frequent medical care____ 40% Disabled; requires special care and assistance; unable to care for self; requires equivalent of
institutional or hospital care; disease may be progressing rapidly____ 30% Severely disabled; hospital admission is indicated although death is not imminent____ 20% Very sick; hospital admission necessary; active supportive treatment necessary____ 10% Moribund; fatal processes progressing rapidly
____ Post stroke dementia as evidenced by a FAST score greater than 7____ 7A Ability to speak is limited to approximately 6 intelligible words or fewer, in the course of an average day or in
the course of an intensive interview____ 7B Speech ability is limited to the use of a single intelligible word in an average day or in the course of an
intensive interview (the person may repeat the word over and over)____ 7C Ambulatory ability is lost (cannot walk without personal assistance)____ 7D Cannot sit up without assistance (e.g., patient will fall over if there are not lateral rests (arms on the chair)____ 7E Loss of ability to smile____ 7F Loss of ability to hold up head independently
____ Poor nutritional status, whether on artificial nutrition or not: ____ unintentional progressive weight loss of greater than 10% over prior six months ____ serum albumin less than 2.5 gm/dl (may be helpful prognostic indicator but should not be used by itself)
____ Medical complications related to debility and progress clinical decline____ aspiration pneumonia____ upper urinary tract infection (pyelonephritis)____ sepsis____ refractory stage 3-4 decubitus ulcers____ fever recurrent after antibiotics
Attach completed "Narrative Summary of Prognosis Documentation" form to this form
WORKSHEETFOR DETERMINING PROGNOSIS
Stroke and Coma
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The purpose of this worksheet is to guide initial and recertification assessments. It must be accompanied by narrativedocumentation. These are guidelines only: clinical judgement is required in each case. Construct a narrative from theinformation on this worksheet and information from the patient's physician and record on back. The patient should bere-evaluated at specific intervals set by the interdisciplinary team and within 60 days of clinical stabilization. This formmay be used for initial and subsequent re-evaluation.
Pt. Name: ID#: Date:
WORKSHEETFOR DETERMINING PROGNOSIS
Amyotrophic Lateral Sclerosis (ALS)
In determining prognosis for the ALS patient, examination by a neurologist within three months of assessment is advised.All patients must meet criteria #1-rapid progression of ALS as well as either 2A-critically impaired ventilatory capacity, 2B-critical nutritional impairment, or 2C-life-threatening complications.
1. Rapid progression of ALS. Most of disability should have developed in past 12 months. Check examples whichapply:____ progression from independent ambulation to wheelchair or bed-bound____ progression from normal to barely intelligible or unintelligible speech____ progression from normal to blenderized diet____ progression from independence in all or most ADLs to requiring assistance in all ADLsPatients with slow progression may survive for longer periods, although clinical judgment may still indicate theymay be within six months of death.
2. At least one of the following must also apply:A. Critically impaired ventilatory capacity
____ vital capacity (VC) less than 30% of predicted____ significant dyspnea at rest____ supplemental oxygen required at rest____ intubation or tracheostomy and mechanical ventilation considered (Note: patients receiving ventila-tion assistance may survive longer than six months unless there is a life-threatening comorbid condition.)
B. Critical nutritional impairment____ artificial feeding not elected or discontinued____ oral intake insufficient____ continued weight loss____ dehydration or hypovolemia
C. Life-threatening complications____ recurrent aspiration pneumonia____ decubitus ulcers, multiple, stage 3-4, particularly if infected____ upper urinary tract infection, e.g. pyelonephritis____ sepsis____ fever recurrent after antibiotics
Attach completed "Narrative Summary of Prognosis Documentation" form to this form
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This Publication’s copyright is owned by theNational Hospice & Palliative Care Organization. The Michigan
Hospice & Palliative Care Organization thanks the NationalHospice & Palliative Care Organization for the privilege of
publishing this guide in a Michigan version.
Funding for printing the “Hospice Care — A Physician’s Guide”has been generously provided by:
The Michigan Department of Community Health and administered bythe Michigan Public Health Institute in support of the MichiganCancer Consortium’s priority objective on end-of-life, which is asfollows: By 2010, prevent and reduce avoidable suffering up to andduring the last phase of life for persons with cancer as measured byspecified data markers. Information about the Michigan CancerConsortium and its priority objectives can be found atwww.michigancancer.org.
The Maggie Allesee Center forQuality of Life (MACQL), with themission “to empower people onlife’s journey,” is located at Hospiceof Michigan’s corporateheadquarters in the historic BrushPark neighborhood in downtownDetroit. The MACQL was startedwith a generous $3 millionendowment from Detroit-area
philanthropist Maggie Allesee, and is a hub for research, education,innovation and community partnerships. John Finn, M.D., notedspeaker and author in hospice/palliative medicine, is the MACQL’smedical director. The aim of the Maggie Allesee Center for Qualityof Life is to enhance hospice and palliative practice, and its workdistinguishes Hospice of Michigan as one of the leading hospicecare providers in the nation.
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517.886.6667800.536.6300