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Diseases

ALS/Neurological conditions - For Health Professionals

ALS tends to progress in a linear fashion over time, and the overall rate of decline in each patient is fairly constant and predictable. However, no single variable deteriorates at a uniform rate in all patients, so multiple clinical parameters are required to judge the progression of ALS.

Although ALS usually presents in a localized anatomical area, the location of initial presentation does not correlate with survival time. By the time a patient is end-stage, muscle denervation is widespread , affects all areas of the body, and initial predominance patterns do not exist.

Progression of the disease differs widely from patient to patient, therefore the history of the rate of progression in the individual patient is important to obtain to predict prognosis. In end-stage ALS, two factors are critical in determining prognosis: ability to breathe and, to a lesser extent, ability to swallow.

Examination by a neurologist within three months of assessment for hospice is advised, both to confirm the diagnosis and to assist with the prognosis.

To qualify for hospice, patients must have:

Critically impaired breathing by evidence of all the following characteristics within the 12 months preceding initial hospice certification:

  • Vital capacity < 30% of normal
  • Significant dyspnea at rest
  • Requiring supplemental oxygen at rest
  • Patient declines artificial ventilation

Patients must demonstrate rapid progression of ALS and critical nutritional impairment

  • Progression from independent ambulation to wheelchair or bed bound status
  • Progression from normal to barely intelligible or unintelligible speech
  • Progression from normal to pureed diet
  • Progression from independence in most or all activities of daily living to needing major assistance by a caretaker
  • Oral intake of nutrients and fluids insufficient to sustain life
  • Continuing weight loss
  • Dehydration
  • Artificial feeding methods declines

Patients must demonstrate rapid progression of ALS and life-threatening complications

  • Progression from independent ambulation to wheelchair or bed bound status
  • Progression from normal to barely intelligible or unintelligible speech
  • Progression from normal to pureed diet
  • Progression from independence in most or all activities of daily living to needing major assistance by a caretaker
  • Recurrent aspiration pneumonia
  • Urinary tract infections
  • Sepsis
  • Recurrent fever after antibiotic therapy

ALS/Neurological conditions - For Families

When is is time for end-stage ALS Disease hospice care?

Answering these questions may serve as a guide:

  • Are your (or your loved one’s) medications no longer effective in managing symptoms?
  • Have you (or your loved one) become wheelchair or bed-bound?
  • Has your (or your loved one’s) speech become barely intelligible, unintelligible or impossible?
  • Do you (or your loved one) require major assistance with eating, dressing and grooming or are you (or he or she) totally dependent on others for these activities?
  • Are you (or your loved one) ready to seek “aggressive comfort care” instead of aggressive treatment?


If you answered “yes” to these questions, now may be an appropriate time to discuss Longleaf Hospice with your physician or one of our clinical professionals. Feel free to call us directly at 770-939-9179.

Cancer - For Health Professionals

To qualify for hospice, patients must have:

Progression of disease evidenced by at least one of the following:

  • Increasing symptoms
  • Worsening lab values
  • Metastatic disease evidenced by scans, MRI, x-ray, biopsy, etc.

Disease Stage IV at presentation or progression from an earlier stage of disease to metastatic disease with either of the following.

  • Patient continues to decline in spite of definitive therapy (i.e. chemo, radiation, surgical intervention)
  • Patient is refractory or refuses further disease directed therapy.


The following factors are not absolutely necessary to qualify for hospice, but lend support:

  • Recurrent disease after radiation, chemotherapy, or surgical intervention
  • Weight loss of 5% or more in the last three months
  • Presence of other comorbid conditions


Cancer - For Families

When is is time for end-stage Cancer hospice care?

Answering these questions may serve as a guide:

  • Are your (or your loved one’s) medications no longer effective in managing symptoms?
  • Are you (or your loved one) rapidly weakening while the malignancy progresses?
  • Are you (or your loved one) ready to seek “aggressive comfort care” instead of aggressive treatment?

If you answered “yes” to these questions, now may be an appropriate time to discuss Longleaf Hospice with your physician or one of our clinical professionals. Feel free to call us directly at 770-939-9179.


Liver Disease - For Health Professionals

To qualify for hospice, patients must have:

  • Prothrombin time prolonged more than 5 seconds over control, or International Normalized Ratio > 1.5
  • Serum albumin < 2.5 gm/dl


And exhibit at least one of the following:

  • Ascites, refractory to treatment or patient non-compliant
  • Spontaneous bacterial peritonitis
  • Hepatorenal syndrome
  • Hepatic encephalopathy, refractory to treatment or patient non-compliance
  • Recurrent variceal bleeding, despite intensive therapy

The following factors support a hospital referral:

  • Progressive malnutrition
  • Muscle wasting with reduced strength and endurance
  • Continued active alcoholism (>80 gm ethanol/day)
  • Hepatocellular carcinoma
  • Hepatitis B positivity
  • Hepatitis C refractory to interferon treatment

Patients awaiting liver transplant who otherwise fit the above criteria may be certified for the Medicare hospice benefit, but if a donor organ is procured, the patient must be discharged from hospice.


Liver Disease - For Families

When is is time for end-stage Liver Disease hospice care?

Answering these questions may serve as a guide:

  • Are your (or your loved one’s) medications no longer effective in managing symptoms?
  • Have you (or your loved one) experienced sudden or progressive loss of functional independence?
  • Do you (or your loved one) sometimes experience disabling shortness of breath while resting, resulting in decreased ability to do the things you (or he or she) want and need to do?
  • Are you (or your loved one) experiencing issues such as abdominal distention or bowel dysfunction?
  • Are you (or your loved one) experiencing altered mood or behavior?
  • Are you (or your loved one) ready to seek “aggressive comfort care” instead of aggressive treatment?


If you answered “yes” to these questions, now may be an appropriate time to discuss Longleaf Hospice with your physician or one of our clinical professionals. Feel free to call us directly at 770-939-9179.


Dementia/Alzheimer’s Disease - For Health Professionals

To qualify for hospice, patients must have:

  • State seven or beyond according to FAST scale
  • Unable to ambulate without assistance
  • Unable to dress without assistance
  • Unable to bathe without assistance
  • Urinary and fecal incontinence, intermittent or constant
  • No meaningful verbal communication stereotypical phrases only, or ability to speak is limited to six or fewer intelligible words


Must have one of the following at admission or within the past six months:

  • Aspiration pneumonia
  • Pyelonephritis or other urinary tract infection
  • Septicemia
  • Decubitus ulcers
  • Fever; recurrent after antibiotics
  • Inability to maintain sufficient fluids and calorie intake with at least 10% weight lost in past six months OR serum albumin <2.5 gm/dl


Dementia/Alzheimer’s Disease - For Families

When is is time for end-stage Dementia/Alzheimer’s Disease hospice care?

Answering these questions may serve as a guide:

  • Have you (or your loved one) become wheelchair or bed-bound?
  • Has your (or your loved one’s) speech become barely intelligible, unintelligible or impossible?
  • Do you (or your loved one) require major assistance with eating, dressing and grooming or are you (or he or she) totally dependent on others for these activities?
  • Are you (or your loved one) experiencing severe anxiety?
  • Are you (or your loved one) ready to seek “aggressive comfort care” instead of aggressive treatment?


If you answered “yes” to these questions, now may be an appropriate time to discuss Longleaf Hospice with your physician or one of our clinical professionals. Feel free to call us directly at 770-939-9179.


Pulmonary Disease - For Health Professionals

To qualify for hospice, a patient with advanced pulmonary disease must have:

Severe chronic lung disease evidenced by:

  • Disabling dyspnea at rest, poorly or unresponsive to bronchodilators, resulting in decreased functional capacity, e.g., bed to chair existence, fatigue, and cough.
  • Progression of end stage pulmonary disease as evidenced by prior increasing visits to ER or prior hospitalization for pulmonary infections and/or respiratory failure.
  • Hypoxemia at rest on room air, as evidenced by p02 ≤ 55 mmHg or oxygen saturation < or = 88% on supplemental oxygen. Or hypercapnia, as evidenced by p02 ≤ 50 mmHg.
  • Cor pulmonale and right heart failure (RHF) secondary to pulmonary disease (e.g., not secondary to left heart disease or valvulopathy.

The following are not required but support a hospice referral:

  • Unintentional progressive weight loss greater than 10% of body weight in the past six months.
  • Resting tachycardia > 100/min



Pulmonary Disease - For Families

When is is time for end-stage Pulmonary Disease hospice care?

Answering these questions may serve as a guide:

  • Have you (or a loved one) made several trips every few months to the emergency room for respiratory failure or lung infections?
  • Have you (or a loved one) been repeatedly hospitalized every few months and no longer wish to be hospitalized?
  • Do you (or a loved one) no longer wish to be intubated?
  • Are you (or your loved one) ready to seek “aggressive comfort care” instead of aggressive treatment?


If you answered “yes” to these questions, now may be an appropriate time to discuss Longleaf Hospice with your physician or one of our clinical professionals. Feel free to call us directly at 770-939-9179.

Stroke & Coma - For Health Professionals

To qualify for hospice, a stroke patient must have a terminal prognosis as evidenced by:

  • Palliative Performance Scale 40 or less


Inability to maintain hydration and caloric intake with one of the following:

  • Weight loss of 10% of body weight during previous six months
  • Weight loss of 7.5% of body weight during previous three months
  • Serum albumin 2.5 gm/dl
  • Current history of pulmonary aspiration without effective response to speech language pathology interventions
  • Calorie counts documenting inadequate caloric/fluid intake

Any three of the following on day three of coma

  • Abnormal brainstem response
  • Absent verbal response
  • Absent withdrawal response to pain
  • Serum creatinine level level > 1.5 mg/dl

Stroke & Coma - For Families

When is is time for end-stage Stroke & Coma hospice care?

Answering these questions may serve as a guide:

  • Do you (or a loved one) feel that improvement is unlikely?
  • Have you (or a loved one) become wheelchair or bed-bound?
  • Do you (or a loved one) wish to discontinue the use of a feeding tube or breathing machine?
  • Has your (or your loved one’s) speech become barely intelligible, unintelligible or impossible?
  • Do you (or your loved one) require major assistance with eating, dressing and grooming or are you (or he or she) totally dependent on others for these activities?
  • Are you (or your loved one) ready to seek “aggressive comfort care” instead of aggressive treatment?

If you answered “yes” to these questions, now may be an appropriate time to discuss Longleaf Hospice with your physician or one of our clinical professionals. Feel free to call us directly at 770-939-9179.


HIV - For Health Professionals

To qualify for hospice, a patient with HIV must have a terminal prognosis as evidenced by:

CD4+ Count < 25 cells/mcL or persistent viral load > 100,000 copies/ml with on of the following:

  • CNS lymphoma
  • Untreated or not responsive to treatment wasting (loss of 33% lean body mass)
  • Mycobacterium avium complex (MAC) bacteremia, untreated, unresponsive to treatment, or treatment refused
  • Progressive multifocal leukoencephalopathy
  • Systemic lymphoma with advanced HIV disease and partial response to chemotherapy
  • Visceral Kaposis Sarcoma unresponsive to therapy
  • Renal failure in absence of dialysis
  • Cryptosporidium infection
  • Toxoplasmosis unresponsive to therapy
  • Decreased performance status, as measured by the Karnofsky Performance scale equal to or less than 50

The following are not required but support a referral:

  • Chronic persistent diarrhea for one year
  • Persistent serum albumin < 2.5
  • Concomitant, active substance abuse
  • Advanced AIDS Dementia complex
  • Age > 50 years
  • Toxoplasmosis
  • Absence of antiretroviral, chemotherapeutic and prophylactic drug therapy related specifically to HIV disease
  • CHF symptomatic at rest

HIV - For Families

When is is time for end-stage HIV hospice care?

Answering these questions may serve as a guide:

  • Have you (or a loved one) developed a serious comorbid illness such as cervical cancer, lymphoma or heart disease?
  • Do you (or a loved one) have a low CD4 count and high viral loads, with poor compliance with antiviral therapy?
  • Have you (or a loved one) been repeatedly hospitalized every few months for the same problem and no longer wish to be hospitalized?
  • Are you (or your loved one) ready to seek “aggressive comfort care” instead of aggressive treatment?


If you answered “yes” to these questions, now may be an appropriate time to discuss Longleaf Hospice with your physician or one of our clinical professionals. Feel free to call us directly at 770-939-9179.

Renal Disease - For Health Professionals

To qualify for hospice, patients must have acute or chronic renal failure evidenced by:

Acute renal failure

  • Creatinine clearance < 10cc/min
  • Serum creatinine > 8.0 mg/dl
  • Patients not seeking dialysis or renal transplant
The following symptoms and comorbid conditions will support a hospice referral:
  • Comorbid conditions:
    • Vascular disease: CHD, PVD, Vascular Dementia, Mechanical ventilation, Malignancy, Chronic lung disease, advanced cardiac disease
    • Immunosuppression/AIDS
    • Cachexia
    • Platelet count < 25,000
    • Albumin < 3.5 gm/dl
    • Disseminated intravascular coagulation
    • Gastrointestinal bleeding
    • Advanced liver disease
    • Sepsis


Chronic renal failure:

  • Creatinine clearance < 10cc/min (<15cc/min for diabetics)
  • Serum creatinine > 8.0 mg/dl (> 6.0 mg/dl for diabetics)
  • Patients not seeking dialysis or renal transplant

The following are signs and symptoms of chronic renal failure that will lend supporting documentation:

  • Uremia
  • Uremic pericarditis
  • Oliguria
  • Intractable hyperkalemia
  • Hepatorenal syndrome
  • Intractable fluid overload
  • Hyperparathyroidism


Renal Disease - For Families

When is it time for end-stage Renal Disease hospice care?

Answering these questions may serve as a guide:

  • Do you (or a loved one) wish to forgo dialysis?
  • Are you (or your loved one) ready to seek “aggressive comfort care” instead of aggressive treatment?


If you answered “yes” to these questions, now may be an appropriate time to discuss Longleaf Hospice with your physician or one of our clinical professionals. Feel free to call us directly at 770-939-9179.