When is a patient appropriate for hospice care?

Transcription

1 End f Life and palliative care When is a patient apprpriate fr hspice care? This infrmatin is designed t help yu determine the apprpriateness fr Aurra VNA Hspice care. If yu have any questins n hw this applies t yur situatin r that f a lved ne, please cnsult with yur dctr. Hw t use Find the diagnsis that matches that f the patient. Check indicatrs under the diagnsis. If the patient matches ANY f the criteria listed (unless therwise stated), a referral may be made fr a hspice care cnsultatin with the Aurra VNA. If the patient des nt meet the criteria listed, but des have a chrnic illness, please click here t learn mre abut the Aurra VNA's palliative care prgram. Karnfsky Scre Perfrmance Status The Karnfsy Scre may be requested under certain diagnses. 100 Nrmal, n cmplaints, n evidence f disease 90 Able t carry n nrmal activity, minr signs r symptms f disease 80 Nrmal activity with effrt, sme signs r symptms f disease 70 Cares fr self, unable t carry n nrmal activity r t d wrk 60 Requires ccasinal assistance frm thers but able t care fr mst needs 50 Requires cnsiderable assistance frm thers; frequent medical care 40 Disabled, requires special care and assistance 30 Severely disabled, hspitalizatin indicated; death nt imminent 20 Very sick, hspitalizatin necessary, active supprtive treatment necessary 10 Mribund Breast cancer Prgressive disease Wrsening clinical signs see belw Wrsening lab values Decreasing functinal status Evidence f metastatic disease

2 Pain, nausea r vmiting Thrmbsis r DIC Bne marrw invlvement requiring transfusin Superir vena cava syndrme Disease stage Stage IV (any T, any N, M1) at presentatin Prgressin f any earlier stage f disease t metastatic with either f the fllwing: Patient cntinues t decline in spite f definitive therapy Patient refuses further treatment Perfrmance status Karnfsky scre 50% r less Karnfsky scre 70% r higher, if patient has prgressive disease, declines therapy, r des nt qualify fr therapy Dementia Must have 2 f the fllwing Ability t speak is limited t 6 wrds r fewer Ambulatry ability is lst Cannt sit up withut assistance Lss f ability t smile Cannt hld up head Patient shuld shw all f the fllwing characteristics Inability t ambulate independently Unable t dress withut assistance Unable t bathe prperly Incntinence f urine and stl Unable t speak r cmmunicate meaningfully

3 Failure t thrive/debility Prgressin f disease dcumented by symptms r test results Decline in Karnfsky scre Weight lss supprted by decreasing albumin r chlesterl Dependence with 2 r mre f the fllwing: Feeding Ambulatin Cntinence Transfers Bathing and dressing Dysphagia leading t inadequate nutritinal intake r recurrent aspiratin Increasing emergency visits, hspitalizatins, r MD fllw-ups related t their primary medical diagnsis A scre f 6 r 7 in the Functinal Assessment Staging Test (FAST) fr dementia Prgressive stage 3-4 pressure ulcers in spite f care Heart disease Signs and symptms f CHF at rest Optimal dse f diuretic and vasdilatr therapy Ejectin fractin f 20% r less Cardiac symptms: Arrhythmias resistant t therapy Histry f cardiac arrest Histry f syncpe Cardigenic brain emblism Liver disease Cirrhsis/hepatic failure - nt a candidate fr liver transplant Ascites refractry t medical management (Dietary sdium restrictin and diuretics)

4 Hepatrenal syndrme Oliguria Urine Na < 10 meq/l Elevated BUN/creatinine Hepatic encephalpathy refractry t medical management Hepatcellular carcinma Recurrent variceal bleeding/spntaneus bacterial peritnitis Lung cancer Prgressive disease Wrsening clinical signs see belw Wrsening lab values Decreasing functinal status Evidence f metastatic disease, especially brain Pain, nausea r vmiting Dyspnea Significant hemptysis Superir vena cava syndrme Recurrent pneumnia Pericardial effusin/pleural effusin Any metastasis Disease stage Stage IV (any T, any N, M1) at initial diagnsis Stage III disease with pleural effusin A patient with stage III disease wh cntinues t decline in spite f therapy, r refuses therapy Perfrmance status Karnfsky scre f 70% r less

5 Prstate cancer Prgressive disease Wrsening clinical signs see belw Decreasing functinal status Evidence f metastatic disease Pain, nausea r vmiting Thrmbsis r DIC Bne marrw invlvement requiring transfusin Disease stage Stage IV (any T,N,r M1) at initial diagnsis Prgressin f an earlier stage f disease with either f the fllwing: Patient cntinues t decline despite definitive therapy The patient is refractry r refuses further treatment Perfrmance status Karnfsky scre f 50% r less Karnfsky scre f 70% r less, if patient has prgressive disease n therapy, r declines therapy Pulmnary disease Prgressin f disease dcumented by any f these symptms: Dyspnea at rest Dyspnea n exertin Hmebund/chairbund Oxygen dependent Cpius/purulent sputum Cyansis: fingertips, lips Barrel chested Pr respnse t brnchdilatrs

6 Functinal status Decline in Karnfsky scre Increased hspitalizatins fr pulmnary infectins Decrease in FEV1 n serial testing f greater than 40 ml/year Hypxemia at rest n supplemental xygen Unintentinal weight lss in the past 6 mnths Resting tachycardia (mre than 100 per minute) Renal disease Uremia: clinical signs f renal failure: Cnfusin, btundatin Intractable nausea and vmiting Generalized pruritus Restlessness Oliguria: urine utput f less than 400 cc/24 hurs Intractable hyperkalemia: persistent serum ptassium mre than 7.0 nt respnsive t medical treatment Uremic pericarditis Hepatrenal syndrme Intractable fluid verlad Labratry criteria Bth must be present: Creatinine clearance f less than 10 cc/minute Serum creatinine f mre than 8.0 mg/dl

7 Strke and cma Clinical/functinal status A cntinuus decline in clinical r functinal status means the patient's prgnsis is pr acute phase patients Cmatse state lasting mre than 3 days Cmatse patients with any 4 f the fllwing n day 3 f a strke have 97% mrtality by 2 mnths: Abnrmal brain stem respnse Absent verbal respnse N respnse t pain Serum creatinine f mre 1.5 mg/dl Age 70 r mre Dysphagia severe enugh t prevent them frm receiving fd r fluids All ther cnditins The patient has a life-limiting cnditin The patient and family have been infrmed that the cnditin is lifelimiting There is dcumentatin f clinical prgressin f the disease serial physician assessment labratry studies radilgic r ther studies multiple ER visits inpatient hspitalizatins hme health nursing assessment if patient is hmebund There's a recent decline in functinal status, such as: requires cnsiderable assistance and frequent medical care is disabled, requires special care and assistance, is unable t care fr self, disease may be prgressing rapidly Severely disabled, althugh death is nt imminent Very sick, active supprtive treatment is necessary Mribund, fatal prcesses prgressing rapidly and/r

8 Patient is dependent in at least 3 f these activities: bathing, dressing, feeding, transfers, cntinence f urine and stl, ambulatin t bathrm and/r recent impaired nutritinal status, as evidenced by unintentinal, prgressive weight lss f 10% ver past six mnths, r serum albumin less than 2.5 gh/dl (may be helpful prgnstic indicatr but shuld nt be used by itself) Surce: Aurra Health Care, 3000 W. Mntana St., Milwaukikee, WI Accessed December 2009 at