**Abstract  
  
** Medicare coverage of hospice depends on a physician's certification that an
individual's prognosis is a life expectancy of six months or less if the
terminal illness runs its normal course. This LCD describes guidelines to be
used by National Government Services (NGS) in reviewing hospice claims and by
hospice providers to determine eligibility of beneficiaries for hospice
benefits. Although guidelines applicable to certain disease categories are
included, this LCD is applicable to all hospice patients. It is intended to be
used to identify any Medicare beneficiary whose current clinical status and
anticipated progression of disease is more likely than not to result in a life
expectancy of six months or less.  
  
Clinical variables with general applicability without regard to diagnosis, as
well as clinical variables applicable to a limited number of specific
diagnoses, are provided. Patients who meet the guidelines established herein
are expected to have a life expectancy of six months or less if the terminal
illness runs its normal course. Some patients may not meet these guidelines,
yet still have a life expectancy of six months or less. Coverage for these
patients may be approved if documentation otherwise supporting a less than
six-month life expectancy is provided.  
  
Section 322 of BIPA amended section 1814(a) of the Social Security Act by
clarifying that the certification of an individual who elects hospice "shall
be based on the physician's or medical director's clinical judgment regarding
the normal course of the individual's illness.'' The amendment clarified that
the certification is based on a clinical judgment regarding the usual course
of a terminal illness, and recognizes the fact that making medical
prognostications of life expectancy is not always exact.  
  
However, the amendment regarding the physician's clinical judgment does not
negate the fact that there must be a basis for a certification. A hospice
needs to be certain that the physician's clinical judgment can be supported by
clinical information and other documentation that provide a basis for the
certification of 6 months or less if the illness runs its normal course.  
  
If a patient improves and/or stabilizes sufficiently over time while in
hospice such that he/she no longer has a prognosis of six months or less from
the most recent recertification evaluation or definitive interim evaluation,
that patient should be considered for discharge from the Medicare hospice
benefit. Such patients can be re-enrolled for a new benefit period when a
decline in their clinical status is such that their life expectancy is again
six months or less. On the other hand, patients in the terminal stage of their
illness who originally qualify for the Medicare hospice benefit but stabilize
or improve while receiving hospice care, yet have a reasonable expectation of
continued decline for a life expectancy of less than six months, remain
eligible for hospice care.  
  
 **Indications**  
  
A patient will be considered to have a life expectancy of six months or less
if he/she meets the non-disease specific **"Decline in clinical status"**
guidelines described in Part I. Alternatively, the baseline non-disease
specific guidelines described in Part II plus the applicable disease specific
guidelines listed in Part III will establish the necessary expectancy.  
  
 **Part I. Decline in clinical status guidelines**  
  
Patients will be considered to have a life expectancy of six months or less if
there is documented evidence of decline in clinical status based on the
guidelines listed below. Since determination of decline presumes assessment of
the patient's status over time, it is essential that both baseline and follow-
up determinations be reported where appropriate. Baseline data may be
established on admission to hospice or by using existing information from
records. Other clinical variables not on 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 whose decline is not
considered to be reversible. They are examples of findings that generally
connote a poor prognosis. However, some are clearly more predictive of a poor
prognosis than others; significant ongoing weight loss is a strong predictor,
while decreased functional status is less so.  
  

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

    1. Recurrent or intractable serious infections such as pneumonia, sepsis or pyelonephritis;
    2. Progressive inanition as documented by: 
      1. Weight loss of at least 10% body weight in the prior six months, not due to reversible causes such as depression or use of diuretics;
      2. Decreasing anthropomorphic measurements (mid-arm circumference, abdominal girth), not due to reversible causes such as depression or use of diuretics;
      3. Observation of ill-fitting clothes, decrease in skin turgor, increasing skin folds or other observation of weight loss in a patient without documented weight;
      4. Decreasing serum albumin or cholesterol.
      5. Dysphagia leading to recurrent aspiration and/or inadequate oral intake documented by decreasing food portion consumption.
  
Symptoms:  

    1. Dyspnea with increasing respiratory rate;
    2. Cough, intractable;
    3. Nausea/vomiting poorly responsive to treatment;
    4. Diarrhea, intractable;
    5. Pain requiring increasing doses of major analgesics more than briefly.
  
Signs:  

    1. Decline in systolic blood pressure to below 90 or progressive postural hypotension;
    2. Ascites;
    3. Venous, arterial or lymphatic obstruction due to local progression or metastatic disease;
    4. Edema;
    5. Pleural/pericardial effusion;
    6. Weakness;
    7. Change in level of consciousness.
  
Laboratory (When available. Lab testing is not required to establish hospice
eligibility.):  

    1. Increasing pCO2 or decreasing pO2 or decreasing SaO2;
    2. Increasing calcium, creatinine or liver function studies;
    3. Increasing tumor markers (e.g. CEA, PSA);
    4. Progressively decreasing or increasing serum sodium or increasing serum potassium.
  2. Decline in Karnofsky Performance Status (KPS ) or Palliative Performance Score (PPS) due to progression of disease.  
  

  3. Progressive decline in Functional Assessment Staging (FAST) for dementia (from 7A on the FAST).  
  

  4. Progression to dependence on assistance with additional activities of daily living (see Part II, Section 2).  
  

  5. Progressive stage 3-4 pressure ulcers in spite of optimal care.  
  

  6. History of increasing ER visits, hospitalizations, or physician visits related to the hospice primary diagnosis prior to election of the hospice benefit.

**Part II. Non-disease specific baseline guidelines (both A and B should be
met)**  
  

  1. Physiologic impairment of functional status as demonstrated by: Karnofsky Performance Status (KPS) or Palliative Performance Score (PPS) < 70%. Note that two of the disease specific guidelines (HIV Disease, Stroke and Coma) establish a lower qualifying KPS or PPS.  
  

  2. Dependence on assistance for two or more activities of daily living (ADLs):  
  

    1. Ambulation;
    2. Continence;
    3. Transfer;
    4. Dressing;
    5. Feeding;
    6. Bathing.
  3. Co-morbidities - although not the primary hospice diagnosis, the presence of disease such as the following, the severity of which is likely to contribute to a life expectancy of six months or less, should be considered in determining hospice eligibility.  
  

    1. Chronic obstructive pulmonary disease
    2. Congestive heart failure
    3. Ischemic heart disease
    4. Diabetes mellitus
    5. Neurologic disease (CVA, ALS, MS, Parkinson's)
    6. Renal failure
    7. Liver Disease
    8. Neoplasia
    9. Acquired immune deficiency syndrome
    10. Dementia
    11. Aquired Immune Deficiency Syndrome/HIV
    12. Refractory severe autoimmune disease (e.g. Lupus or Rheumatoid Arthritis)
  4. See Part III for disease specific guidelines to be used with these baseline guidelines. The baseline guidelines do not independently qualify a patient for hospice coverage.  
  
 **Note:** The word "should" in the disease specific guidelines means that on
medical review the guideline so identified will be given great weight in
making a coverage determination. It does not mean, however, that meeting the
guideline is required. The only requirement is that the documentation supports
the beneficiary's prognosis of six months or less, if the illness runs its
normal course.

**Part III. Disease Specific Guidelines**  
  
 **Note:** These guidelines are to be used in conjunction with the "Non-
disease specific baseline guidelines" described in Part II.  
  
 ** _Cancer Diagnoses_**  
  

  1. Disease with metastases at presentation **OR**
  2. Progression from an earlier stage of disease to metastatic disease with either:  

    1. A continued decline in spite of therapy; or
    2. Patient declines further disease directed therapy.

**Note:** Certain cancers with poor prognoses (e.g., small cell lung cancer,
brain cancer and pancreatic cancer) may be hospice eligible without fulfilling
the other criteria in this section.  
  
 ** _Non-Cancer Diagnoses_**  
  
 **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 fairly constant and predictable, unlike many other non-cancer diseases.
  2. However, no single variable deteriorates at a uniform rate in all patients. Therefore, multiple clinical parameters are required to judge the progression of ALS.
  3. Although ALS usually presents in a localized anatomical area, the location of initial presentation does not correlate with survival time. By the time patients become end-stage, muscle denervation has become widespread, affecting all areas of the body, and initial predominance patterns do not persist.
  4. Progression of disease differs markedly from patient to patient. Some patients decline rapidly and die quickly; others progress more slowly. For this reason, the history of the rate of progression in individual patients is important to obtain to predict prognosis.
  5. In end-state ALS, two factors are critical in determining prognosis: ability to breathe, and to a lesser extent ability to swallow. The former can be managed by artificial ventilation, and the latter by gastrostomy or other artificial feeding, unless the patient has recurrent aspiration pneumonia. While not necessarily a contraindication to Hospice care, the decision to institute either artificial ventilation or artificial feeding may significantly alter six month prognosis.
  6. Examination by a neurologist within three months of assessment for hospice is advised, both to confirm the diagnosis and to assist with prognosis.

Patients are considered eligible for Hospice care if they do not elect
tracheostomy and invasive ventilation and display evidence of critically
impaired respiratory function (with or without use of NIPPV) and / or severe
nutritional insufficiency (with or without use of a gastrostomy tube).  
  
Critically impaired respiratory function is as defined by:  
  

  1. FVC < 40% predicted (seated or supine) and 2 or more of the following symptoms and/or signs:  
Dyspnea at rest;  
Orthopnea;  
Use of accessory respiratory musculature;  
Paradoxical abdominal motion;  
Respiratory rate > 20;  
Reduced speech / vocal volume;  
Weakened cough;  
Symptoms of sleep disordered breathing;  
Frequent awakening;  
Daytime somnolence / excessive daytime sleepiness;  
Unexplained headaches;  
Unexplained confusion;  
Unexplained anxiety;  
Unexplained nausea.  
  

  2. If unable to perform the FVC test patients meet this criterion if they manifest 3 or more of the above symptoms/signs.

Severe nutritional insufficiency is defined as:  
  
Dysphagia with progressive weight loss of at least five percent of body weight
with or without election for gastrostomy tube insertion.  
  
These revised criteria rely less on the measured FVC, and as such reflect the
reality that not all patients with ALS can or will undertake regular pulmonary
function tests.  
  
 **Dementia due to Alzheimer 's Disease and Related Disorders**  
  
Patients will be considered to be in the terminal stage of dementia (life
expectancy of six months or less) if they meet the following criteria.

  1. Patients with dementia should show all the following characteristics:  

    1. Stage seven or beyond according to the Functional Assessment Staging Scale;
    2. Unable to ambulate without assistance;
    3. Unable to dress without assistance;
    4. Unable to bathe without assistance;
    5. Urinary and fecal incontinence, intermittent or constant;
    6. No consistently meaningful verbal communication: stereotypical phrases only or the ability to speak is limited to six or fewer intelligible words.
  2. Patients should have had one of the following within the past 12 months:  

    1. Aspiration pneumonia;
    2. Pyelonephritis;
    3. Septicemia;
    4. Decubitus ulcers, multiple, stage 3-4;
    5. Fever, recurrent after antibiotics;
    6. Inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin < 2.5 gm/dl.

**Note:** This section is specific for Alzheimer's disease and Related
Disorders, and is not appropriate for other types of dementia.  
  
 **Heart Disease**  
  
Patients will be considered to be in the terminal stage of heart disease (life
expectancy of six months or less) if they meet the following criteria. (1 and
2 should be present. Factors from 3 will add supporting documentation.)

  1. At the time of initial certification or recertification for hospice, the patient is or has been already optimally treated for heart disease, or are patients who are either not candidates for surgical procedures or who decline those procedures. (Optimally treated means that patients who are not on vasodilators have a medical reason for refusing these drugs, e.g., hypotension or renal disease.)  
  

  2. Patients with congestive heart failure or angina should meet the criteria for the New York Heart Association (NYHA) Class IV. (Class IV patients with heart disease have an inability to carry on any physical activity. Symptoms of heart failure or of the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased.) Significant congestive heart failure may be documented by an ejection fraction of less than or equal to 20%, but is not required if not already available.  
  

  3. Documentation of the following factors will support but is not required to establish eligibility for hospice care:  

    1. Treatment-resistant symptomatic supraventricular or ventricular arrhythmias;
    2. History of cardiac arrest or resuscitation;
    3. History of unexplained syncope;
    4. Brain embolism of cardiac origin;
    5. Concomitant HIV disease.

**HIV Disease**  
  
Patients will be considered to be in the terminal stage of their illness (life
expectancy of six months or less) if they meet the following criteria. (1 and
2 should be present; factors from 3 will add supporting documentation.)

  1. CD4+ Count < 25 cells/mcl or persistent (2 or more assays at least one month apart) viral load >100,000 copies/ml, plus one of the following:  

    1. CNS lymphoma;
    2. Untreated, or persistent despite treatment, wasting (loss of at least 10% lean body mass);
    3. Mycobacterium avium complex (MAC) bacteremia, untreated, unresponsive to treatment, or treatment refused;
    4. Progressive multifocal leukoencephalopathy;
    5. Systemic lymphoma, with advanced HIV disease and partial response to chemotherapy;
    6. Visceral Kaposi's sarcoma unresponsive to therapy;
    7. Renal failure in the absence of dialysis;
    8. Cryptosporidium infection;
    9. Toxoplasmosis, unresponsive to therapy.
  2. Decreased performance status, as measured by the Karnofsky Performance Status (KPS) scale, of less than or equal to 50%.  
  

  3. Documentation of the following factors will support eligibility for hospice care:  

    1. Chronic persistent diarrhea for one year;
    2. Persistent serum albumin < 2.5;
    3. Concomitant, active substance abuse;
    4. Age > 50 years;
    5. Absence of or resistance to effective antiretroviral, chemotherapeutic and prophylactic drug therapy related specifically to HIV disease;
    6. Advanced AIDS dementia complex;
    7. Toxoplasmosis;
    8. Congestive heart failure, symptomatic at rest;
    9. Advanced liver disease.

**Liver Disease**  
  
Patients will be considered to be in the terminal stage of liver disease (life
expectancy of six months or less) if they meet the following criteria. (1 and
2 should be present, factors from 3 will lend supporting documentation.)

  1. The patient should show both a and b:  

    1. Prothrombin time prolonged more than 5 seconds over control, or International Normalized Ratio (INR) > 1.5;
    2. Serum albumin < 2.5 gm/dl.
  2. End stage liver disease is present and the patient shows at least one of the following:  

    1. Ascites, refractory to treatment or patient non-compliant;
    2. Spontaneous bacterial peritonitis;
    3. Hepatorenal syndrome (elevated creatinine and BUN with oliguria (< 400 ml/day) and urine sodium concentration < 10 mEq/l);
    4. Hepatic encephalopathy, refractory to treatment, or patient non-compliant;
    5. Recurrent variceal bleeding, despite intensive therapy.
  3. Documentation of the following factors will support eligibility for hospice care:  

    1. Progressive malnutrition;
    2. Muscle wasting with reduced strength and endurance;
    3. Continued active alcoholism (> 80 gm ethanol/day);
    4. Hepatocellular carcinoma;
    5. HBsAg (Hepatitis B) positivity;
    6. Hepatitis C refractory to interferon treatment.

**Pulmonary Disease**  
  
Patients will be considered to be in the terminal stage of pulmonary disease
(life expectancy of six months or less) if they meet the following criteria.
The criteria refer to patients with various forms of advanced pulmonary
disease who eventually follow a final common pathway for end stage pulmonary
disease. (1 and 2 should be present. Documentation of 3, 4, and 5, will lend
supporting documentation.)

  1. Severe chronic lung disease as documented by both a and b:  

    1. Disabling dyspnea at rest, poorly or unresponsive to bronchodilators, resulting in decreased functional capacity, e.g., bed to chair existence, fatigue, and cough; (Documentation of Forced Expiratory Volume in One Second (FEV1), after bronchodilator, less than 30% of predicted is objective evidence for disabling dyspnea, but is not necessary to obtain.)
    2. Progression of end stage pulmonary disease, as evidenced by increasing visits to the emergency department or hospitalizations for pulmonary infections and/or respiratory failure or increasing physician home visits prior to initial certification. (Documentation of serial decrease of FEV1>40 ml/year is objective evidence for disease progression, but is not necessary to obtain.)
  2. Hypoxemia at rest on room air, as evidenced by pO2 less than or equal to 55 mmHg, or oxygen saturation less than or equal to 88%, determined either by arterial blood gases or oxygen saturation monitors, (these values may be obtained from recent hospital records) OR hypercapnia, as evidenced by pCO2 greater than or equal to 50 mmHg. (This value may be obtained from recent [within 3 months] hospital records.)  
  

  3. Right heart failure (RHF) secondary to pulmonary disease (Cor pulmonale) (e.g., not secondary to left heart disease or valvulopathy).  
  

  4. Unintentional progressive weight loss of greater than 10% of body weight over the preceding six months.  
  

  5. Resting tachycardia > 100/min.

**Renal Disease**  
  
Patients will be considered to be in the terminal stage of renal disease (life
expectancy of six months or less) if they meet the following criteria.  
  
 **Acute Renal Failure** (1 and either 2, 3 or 4 should be present. Factors
from 5 will lend supporting documentation.)

  1. The patient is not seeking dialysis or renal transplant, or is discontinuing dialysis. As with any other condition, an individual with renal disease is eligible for the Hospice benefit if that individual has a prognosis of six months or less, if the illness runs its normal course. There is no regulation precluding patients on dialysis from electing Hospice care. However, the continuation of dialysis will significantly alter a patient's prognosis, and thus potentially impact that individual's eligibility.  
  
When an individual elects Hospice care for end stage renal disease (ESRD) or
for a condition to which the need for dialysis is related, the Hospice agency
is financially responsible for the dialysis. In such cases, there is no
additional reimbursement beyond the per diem rate. The only situation in which
a beneficiary may access both the Hospice benefit and the ESRD benefit is when
the need for dialysis is not related to the patient's terminal illness.  
  

  2. Creatinine clearance < 10 cc/min (<15 cc/min. for diabetics); or < 15cc/min (< 20cc/min for diabetics) with comorbidity of congestive heart failure.  
  

  3. Serum creatinine > 8.0 mg/dl (>6.0 mg/dl for diabetics).  
  

  4. Estimated glomerular filtration rate (GFR) <10 ml/min.  
  

  5. Comorbid conditions: 
    1. Mechanical ventilation;
    2. Malignancy (other organ system);
    3. Chronic lung disease;
    4. Advanced cardiac disease;
    5. Advanced liver disease;
    6. Immunosuppression/AIDS;
    7. Albumin < 3.5 gm/dl;
    8. Platelet count < 25,000;
    9. Disseminated intravascular coagulation;
    10. Gastrointestinal bleeding.

**Chronic Kidney Disease** (1 and either 2, 3 or 4 should be present. Factors
from 5 will lend supporting documentation.)

  1. The patient is not seeking dialysis or renal transplant, or is discontinuing dialysis; As with any other condition, an individual with renal disease is eligible for the Hospice benefit if that individual has a prognosis of six months or less, if the illness runs its normal course. There is no regulation precluding patients on dialysis from electing Hospice care. However, the continuation of dialysis will significantly alter a patient's prognosis, and thus potentially impact that individual's eligibility.  
  
When an individual elects Hospice care for end stage renal disease (ESRD) or
for a condition to which the need for dialysis is related, the Hospice agency
is financially responsible for the dialysis. In such cases, there is no
additional reimbursement beyond the per diem rate. The only situation in which
a beneficiary may access both the hospice benefit and the ESRD benefit is when
the need for dialysis is not related to the patient's terminal illness.  
  

  2. Creatinine clearance <10 cc/min (< 15 cc/min for diabetics); or < 15cc/min (< 20cc/min for diabetics) with comorbidity of congestive heart failure.  
  

  3. Serum creatinine > 8.0 mg/dl (>6.0 mg/dl for diabetics).  
  

  4. Signs and symptoms of renal failure:  

    1. Uremia;
    2. Oliguria (< 400 cc/24 hours);
    3. Intractable hyperkalemia (> 7.0) not responsive to treatment;
    4. Uremic pericarditis;
    5. Hepatorenal syndrome;
    6. Intractable fluid overload, not responsive to treatment.
  5. Estimated glomerular filtration rate (GFR) <10 ml/min.

**Stroke and Coma**  
  
Patients will be considered to be in the terminal stages of stroke or coma
(life expectancy of six months or less) if they meet the following criteria:  
  
 **Stroke**

  1. Karnofsky Performance Status (KPS) or Palliative Performance Scale (PPS) of < 40% .  
  

  2. Inability to maintain hydration and caloric intake with one of the following: 
    1. Weight loss > 10% in the last 6 months or > 7.5% in the last 3 months;
    2. Serum albumin < 2.5 gm/dl;
    3. Current history of pulmonary aspiration not responsive to speech language pathology intervention; Sequential calorie counts documenting inadequate caloric/fluid intake;
    4. Dysphagia severe enough to prevent patient from continuing fluids/foods necessary to sustain life and patient does not receive artificial nutrition and hydration.

**Coma (any etiology):**

  1. Comatose patients with any 3 of the following on day three of coma:  

      1. abnormal brain stem response;
      2. absent verbal response;
      3. absent withdrawal response to pain;
      4. serum creatinine > 1.5 mg/dl.
  
  

  2. Documentation of the following factors will support eligibility for hospice care:  

    1. Documentation of medical complications, in the context of progressive clinical decline, within the previous 12 months, which support a terminal prognosis: 
      1. Aspiration pneumonia;
      2. Pyelonephritis;
      3. Refractory stage 3-4 decubitus ulcers;
      4. Fever recurrent after antibiotics.
  3. Documentation of diagnostic imaging factors which support poor prognosis after stroke include:  

    1. For non-traumatic hemorrhagic stroke:  

      1. Large-volume hemorrhage on CT:  

        1. Infratentorial: greater than or equal to 20 ml.;
        2. Supratentorial: greater than or equal to 50 ml.
      2. Ventricular extension of hemorrhage;
      3. Surface area of involvement of hemorrhage greater than or equal to 30% of cerebrum;
      4. Midline shift greater than or equal to 1.5 cm.;
      5. Obstructive hydrocephalus in patient who declines, or is not a candidate for, ventriculoperitoneal shunt.
    2. For thrombotic/embolic stroke:  

      1. Large anterior infarcts with both cortical and subcortical involvement
      2. Large bihemispheric infarcts
      3. Basilar artery occlusion
      4. Bilateral vertebral artery occlusion.

**The guidelines contained in this policy are intended to help providers
determine when patients are appropriate for the Medicare Hospice benefit. As
each patient is unique, there are patients for whom a particular guideline
does not match. In such cases, it is important for providers to meticulously
document the factors which specify the individual 's terminal prognosis.  
  
There are also patients who match a guideline at the start of hospice care,
and who continue to do so for a prolonged period, e.g., greater than six
months. While it is true that there is not a strict six month limit on the
Hospice benefit, the underlying precept is that the beneficiary must have a
prognosis of six months or less, if the illness runs its normal course. A
beneficiary may match a guideline, but by virtue of that individual having
lived for a significantly prolonged period thereafter, he/she has shown that
guideline to be inadequate to predict the appropriate terminal prognosis.  
  
  
** ** **ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart
Failure in the Adult: Executive Summary A Report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines
(Committee to Revise the 1995 Guidelines for the Evaluation and Management of
Heart Failure)  
  
Stages of Heart Failure (HF)  
  
Stage A****  
Patients at high risk of developing HF because of the presence of conditions
that are strongly associated with the development of HF. Such patients have no
identified structural or functional abnormalities of the pericardium,
myocardium, or cardiac valves and have never shown signs or symptoms of HF.  
Example:  
Systemic hypertension; coronary artery disease; diabetes mellitus; history of
cardiotoxic drug therapy or alcohol abuse; personal history of rheumatic
fever; family history of cardiomyopathy.  
  
 ** **Stage B****  
Patients who have developed structural heart disease that is strongly
associated with the development of HF but who have never show signs or
symptoms of HF.  
Example:  
Left ventricular hypertrophy or fibrosis; left ventricular dilatation or
hypocontractility; asymptomatic valvular heart disease; previous myocardial
infarction.  
  
 ** **Stage C****  
Patients who have current or prior symptoms of HF associated with underlying
structural heart disease.  
Example:  
Dyspnea or fatigue due to left ventricular systolic dysfunction; asymptomatic
patients who are undergoing treatment for prior symptoms of HF.  
  
 ** **Stage D****  
Patients with advanced structural heart disease and marked symptoms of HF at
rest despite maximal medical therapy and who require specialized
interventions.  
Example:  
Patients who are frequently hospitalized for HF or cannot be safely discharged
from the hospital; patients in the hospital awaiting heart transplantation;
patients at home receiving continuous intravenous support for symptom relief
or being supported with a mechanical circulatory assist device; patients in a
hospice setting for management of HF.  
  
 ** **Karnofsky Performance Scale (KPS)  
  
The Karnofsky Performance Scale Index allows patients to be classified as to
their functional impairment. This can be used to compare effectiveness of
different therapies and to assess the prognosis in individual patients. The
lower the Karnofsky score, the worse the survival for most serious illnesses.  
  
KARNOFSKY PERFORMANCE STATUS SCALE DEFINITIONS RATING (%) CRITERIA****  
  

Able to carry on normal activity and to work; no special care needed.

|

100

|

Normal no complaints; no evidence of disease.  
  
---|---|---  
  
90

|

Able to carry on normal activity; minor signs or symptoms of disease.  
  
80

|

Normal activity with effort; some signs or symptoms of disease.  
  
Unable to work; able to live at home and care for most personal needs; varying
amount of assistance needed.

|

70

|

Cares for self; unable to carry on normal activity or to do active work.  
  
60

|

Requires occasional assistance, but is able to care for most of his personal
needs.  
  
50

|

Requires considerable assistance and frequent medical care.  
  
Unable to care for self; requires equivalent of institutional or hospital
care; disease may be progressing rapidly.

|

40

|

Disabled; requires special care and assistance.  
  
30

|

Severely disabled; hospital admission is indicated although death not
imminent.  
  
20

|

Very sick; hospital admission necessary; active supportive treatment
necessary.  
  
10

|

Moribund; fatal processes progressing rapidly.  
  
0

|

Dead  
  
  
  
****NYHA Functional Classification for Congestive Heart Failure****  
  
The New York Heart Association (NYHA) Functional Classification provides a
simple way of classifying heart disease (originally cardiac failure). It
places patients in one of four categories, based on how much they are limited
during physical activity:  
 ** **Class I:**** patients with no limitation of activities; they suffer no
symptoms from ordinary activities.  
 ** **Class II:**** patients with slight, mild limitation of activity; they
are comfortable with rest or with mild exertion.  
 ** **Class III:**** patients with marked limitation of activity; they are
comfortable only at rest.  
 ** **Class IV:**** patients who should be at complete rest, confined to bed
or chair; any physical activity brings on discomfort and symptoms occur at
rest.  
  
 ** **Palliative Performance Scale****  
  
The Palliative Performance Scale (PPS) is a modification of the Karnofsky
Performance Scale intended for evaluating patients requiring palliative care.
The score can help determine which patients can be managed in the home and
which should be admitted to a hospice unit. It was developed in British
Columbia, Canada.  
  

**PPS Level**

|

**Ambulation**

|

**Activity & Evidence of Disease**

|

**Self-Care**

|

**Intake**

|

**Conscious Level**  
  
---|---|---|---|---|---  
  
100%

|

Full

|

Normal activity & work No evidence of disease

|

Full

|

Normal

|

Full  
  
90%

|

Full

|

Normal activity & work Some evidence of disease

|

Full

|

Normal

|

Full  
  
80%

|

Full

|

Normal activity _with_ effort Some evidence of disease

|

Full

|

Normal or reduced

|

Full  
  
70%

|

Reduced

|

Unable Normal Job/Work Significant disease

|

Full

|

Normal or reduced

|

Full  
  
60%

|

Reduced

|

Unable hobby/house work Significant disease

|

Occasional assistance necessary

|

Normal or reduced

|

Full

or Confusion  
  
50%

|

Mainly Sit/Lie

|

Unable to do any work Extensive disease

|

Considerable assistance required

|

Normal or reduced

|

Full

or Confusion  
  
40%

|

Mainly in Bed

|

Unable to do most activity Extensive disease

|

Mainly assistance

|

Normal or reduced

|

Full or Drowsy +/- Confusion  
  
30%

|

Totally Bed Bound

|

Unable to do any activity Extensive disease

|

Total Care

|

Normal or reduced

|

Full or Drowsy +/- Confusion  
  
20%

|

Totally Bed Bound

|

Unable to do any activity Extensive disease

|

Total Care

|

Minimal to

sips

|

Full or Drowsy +/- Confusion  
  
10%

|

Totally Bed Bound

|

Unable to do any activity Extensive disease

|

Total Care

|

Mouth care

only

|

Drowsy or Coma +/- Confusion  
  
0%

|

Death

|

-

|

-

|

-

|

-  
  
  
  

**_The Stages of Alzheimer's Disease_**  
  
---  
| At the New York University Medical Center's Aging and Dementia Research
Center, Barry Reisberg, MD and colleagues have developed the Functional
Assessment Staging (FAST) scale, which allows professionals and caregivers to
chart the decline of people with Alzheimer's disease. The FAST scale has 16
stages and sub-stages:  
  
  
  
  
  
  
  
  
| **FAST Scale Stage** | **Characteristics**  
---|---  
1... normal adult | No functional decline.  
2... normal older adult | Personal awareness of some functional decline.  
3... early Alzheimer's disease | Noticeable deficits in demanding job
situations.  
4... mild Alzheimer's | Requires assistance in complicated tasks such as
handling finances, planning parties,etc.  
5... moderate Alzheimer's | Requires assistance in choosing proper attire.  
6... moderately severe Alzheimer's | Requires assistance dressing, bathing,
and toileting. Experiences urinary and fecal incontinence.  
7... severe Alzheimer's | Speech ability declines to about a half-dozen
intelligible words. Progressive loss of abilities to walk, sit up, smile, and
hold head up.  
  


**Detailed Description of Each of the 7 Stages**  
  

**Stage 1**  
No cognitive decline. No subjective complaints of memory deficit. No memory
deficit evident on clinical interviews.

**Stage2 (Forgetfulness)**  
Very mild cognitive decline.

Subjective complaints of memory deficit, most frequently in the following
area:

  1. forgetting where one has placed familiar objects;
  2. forgetting names on formerly knew well.

No objective evidence of memory deficit on clinical interview. No objective
deficits in employment or social situations. Appropriate concern regarding
symptoms.

**Stage 3 (Early Confusional)**  
Mild cognitive decline. Earliest clear-cut deficits.

Manifestations in more than one of the following areas:

  1. patient may have gotten lost when traveling to an unfamiliar location;
  2. co-workers become aware of patient's relatively low performance;
  3. word and name finding deficit becomes evident to intimates;
  4. patient may read a passage of a book and retain relatively little material;
  5. patient may demonstrate decreased facility in remembering names upon introduction to new people;
  6. patient may have lost or misplaced an object of value;
  7. concentration deficit may be evident on clinical testing.

Objective evidence of memory deficit obtained only with an intensive
interview. Denial begins to become manifest in patient. Mild to moderate
anxiety accompanies symptoms.

**Stage 4 (Late Confusional)** Moderate cognitive decline. Clear-cut deficit
on careful clinical interview.

Deficit manifest in following areas:

  1. decreased knowledge of current and recent events;
  2. may exhibit some deficit in memory of one's personal history;
  3. concentration deficit elicited on serial subtractions;
  4. decreased ability to travel, handle finances, etc.

Frequently no deficit in the following areas:

  1. orientation to time and person;
  2. recognition of familiar persons and faces;
  3. ability to travel to familiar locations.

Inability to perform complex tasks. Denial is dominant defense mechanism.
Flattening of affect and withdrawal from challenging situations occur.

**Stage 5 (Early Dementia)** Moderately severe cognitive decline.

Patient can no longer survive without some assistance. Patient is unable
during interview to recall a major relevant aspect of their current lives,
e.g., an address or telephone number of many  
years, the names of close family members (such as grandchildren), the name of
the high school or college from which they graduated. Frequently some
disorientation to time (date, day of week, season, etc.) or to place. An
educated person may have difficulty counting back from 40 by 4s or from 20 by
2s. Persons at this stage retain knowledge of many major facts regarding
themselves and others. They invariably know their own names and generally know
their spouse's and children's names. They require no assistance with toileting
and eating, but may have some difficulty choosing the proper clothing to wear.

**Stage 6 (Middle Dementia)** Severe cognitive decline.  
  
May occasionally forget the name of the spouse upon whom they are entirely
dependent for survival. Will be largely unaware of all recent events and
experiences in their lives. Retain some knowledge of their past lives but this
is very sketchy. Generally unaware of their surroundings, the year, the
season, etc. May have difficulty counting from 10, both backward and sometimes
forward. Will require some assistance with activities of daily living, e.g.,
may become incontinent, will require travel assistance but occasionally will
display ability to familiar locations. Diurnal rhythm frequently disturbed.
Almost always recall their own name. Frequently continue to be able to
distinguish familiar from unfamiliar persons in their environment.

Personality and emotional changes occur. These are quite variable and include:

  1. delusional behavior, e.g., patients may accuse their spouse of being an impostor, may talk to imaginary figures in the environment, or to their own reflection in the mirror;
  2. obsessive symptoms, e.g., person may continually repeat simple cleaning activities;
  3. anxiety agitation, and even previously nonexistent violent behavior may occur;
  4. cognitive abulia, i.e., loss of willpower because an individual cannot carry a thought long enough to determine a purposeful course of action.

**Stage 7 (Late Dementia)** Very severe cognitive decline. All verbal
abilities are lost.

Frequently there is no speech at all - only grunting. Incontinent of urine,
requires assistance toileting and feeding. Lose basic psychomotor skills,
e.g., ability to walk, sitting and head control. The brain appears to no
longer be able to tell the body what to do. Generalized and cortical
neurologic signs and symptoms are frequently present.

**  
Dr Reisberg has also shown that the decline typical of Alzheimer's disease is
the flip side of normal skill acquisition by infants, children, and young
adults:**

**  
  
  
** **Ability** | **Age of acquisition during normal development** | **  
Alzheimer's stage at which ability is lost**  
---|---|---  
  
Hold a job. Function independently in the world. |  
12 years and older | 3... early Alzheimer's disease  
Handle simple finances. | 8-12 years | 4... mild Alzheimer's  
Select proper clothing. | 5-7 years | 5... moderate Alzheimer's  
  
  
  
Available from ElderCare OnlineTM http://www.ec-online.net/ (C)Barry Reisberg,
MD 1984