Criteria

How to use

• Find the diagnosis matching that of the patient.
• Check the indicators under the diagnosis. If the patient matches ANY of the criteria listed (unless otherwise stated), a referral may be made for a hospice care consultation with Catholic Community Hospice.

Please feel free to direct any other questions regarding palliative or hospice care to 913-621-5090 or toll-free at 877-621-5090.

Breast cancer | Dementia | Failure to thrive | Heart disease | Liver disease | Lung cancer | Prostate cancer | Pulmonary disease | Renal disease | Stroke & coma | All other conditions

Karnofsky Score Performance Status

The Karnofsy Score may be requested under certain diagnoses.

• 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
• 70 – Cares for self , unable to carry on normal activity or to do work
• 60 – Requires occasional assistance from others but able to care for most needs
• 50 – Requires considerable assistance from others ; frequent medical care
• 40 – Disabled , requires special care and assistance
• 30 – Severely disabled , hospitalization indicated; death not imminent
• 20 – Very sick , hospitalization necessary, active supportive treatment necessary
• 10 – Moribund

Breast cancer

Progressive disease

• Worsening clinical signs – see below
• Worsening lab values
• Decreasing functional status
• Evidence of metastatic disease

Clinical signs

• Pain, nausea or vomiting
• Thrombosis or DIC
• Bone marrow involvement requiring transfusion
• Superior vena cava syndrome

Disease stage

• Stage IV (any T, any N, M1) at presentation
• Progression of any earlier stage of disease to metastatic with either of the following:
  • Patient continues to decline in spite of definitive therapy
  • Patient refuses further treatment

Performance status

• Karnofsky score 50% or less
• Karnofsky score 70% or higher, if patient has progressive disease, declines therapy, or does not qualify for therapy

Dementia

Must have 2 of the following

• Ability to speak is limited to 6 words or fewer
• Ambulatory ability is lost
• Cannot sit up without assistance
• Loss of ability to smile
• Cannot hold up head

Patient should show all of the following characteristics

• Inability to ambulate independently
• Unable to dress without assistance
• Unable to bathe properly
• Incontinence of urine and stool
• Unable to speak or communicate meaningfully

Failure to thrive/debility

Clinical signs

• Progression of disease documented by symptoms or test results
• Decline in Karnofsky score
• Weight loss supported by decreasing albumin or cholesterol
• Dependence with 2 or more of the following:
  • Feeding
  • Ambulation
  • Continence
  • Transfers
  • Bathing and dressing
  • Dysphagia leading to inadequate nutritional intake or recurrent aspiration
  • Increasing emergency visits, hospitalizations, or MD follow-ups related to their primary medical diagnosis
  • A score of 6 or 7 in the Functional Assessment Staging Test (FAST) for dementia
  • Progressive stage 3-4 pressure ulcers in spite of care

Heart disease

Clinical signs

• Signs and symptoms of CHF at rest
• Optimal dose of diuretic and vasodilator therapy
• Ejection fraction of 20% or less
• Cardiac symptoms:
  • Arrhythmias resistant to therapy
  • History of cardiac arrest
  • History of syncope
  • Cardiogenic brain embolism

Liver disease

• Cirrhosis/hepatic failure - not a candidate for liver transplant
• Ascites refractory to medical management (Dietary sodium restriction and diuretics)
• Hepatorenal syndrome
  • Oliguria
  • Urine Na < 10 mEq/L
  • Elevated BUN/creatinine
• Hepatic encephalopathy refractory to medical management
• Hepatocellular carcinoma
• Recurrent variceal bleeding/spontaneous bacterial peritonitis

Lung cancer

Progressive disease

• Worsening clinical signs – see below
• Worsening lab values
• Decreasing functional status
• Evidence of metastatic disease, especially brain

Clinical signs

• Pain, nausea or vomiting
• Dyspnea
• Significant hemoptysis
• Superior vena cava syndrome
• Recurrent pneumonia
• Pericardial effusion/pleural effusion
• Any metastasis

Disease stage

• Stage IV (any T, any N, M1) at initial diagnosis
• Stage III disease with pleural effusion
• A patient with stage III disease who continues to decline in spite of therapy, or refuses therapy
• Performance status Karnofsky score of 70% or less

Prostate cancer

Progressive disease

• Worsening clinical signs – see below
• Decreasing functional status
• Evidence of metastatic disease

Clinical signs

• Pain, nausea or vomiting
• Thrombosis or DIC
• Bone marrow involvement requiring transfusion

Disease stage

• Stage IV (any T,N,or M1) at initial diagnosis
• Progression of an earlier stage of disease with either of the following:
  • Patient continues to decline despite definitive therapy
  • The patient is refractory or refuses further treatment

Performance status

• Karnofsky score of 50% or less
• Karnofsky score of 70% or less, if patient has progressive disease on therapy, or declines therapy

Pulmonary disease

Clinical signs

• Progression of disease documented by any of these symptoms:
  • Dyspnea at rest
  • Dyspnea on exertion
  • Homebound/chairbound
  • Oxygen dependent
  • Copius/purulent sputum
  • Cyanosis: fingertips, lips
  • Barrel chested
  • Poor response to bronchodilators

Functional status

• Decline in Karnofsky score
• Increased hospitalizations for pulmonary infections
• Decrease in FEV1 on serial testing of greater than 40 ml/year
• Hypoxemia at rest on supplemental oxygen
• Unintentional weight loss in the past 6 months
• Resting tachycardia (more than 100 per minute)

Renal disease

Clinical signs

• Uremia: clinical signs of renal failure:
• Confusion, obtundation
• Intractable nausea and vomiting
• Generalized pruritus
• Restlessness
• Oliguria: urine output of less than 400 cc/24 hours
• Intractable hyperkalemia: persistent serum potassium more than 7.0 not responsive to medical treatment
• Uremic pericarditis
• Hepatorenal syndrome
• Intractable fluid overload

Laboratory criteria

• Both must be present:
  • Creatinine clearance of less than 10 cc/minute
  • Serum creatinine of more than 8.0 mg/dl

Stroke and coma

Clinical/functional status

• A continuous decline in clinical or functional status means the patient's prognosis is poor acute phase patients
• Comatose state lasting more than 3 days
• Comatose patients with any 4 of the following on day 3 of a stroke have 97% mortality by 2 months:
  • Abnormal brain stem response
  • Absent verbal response
  • No response to pain
  • Serum creatinine of more 1.5 mg/dl
  • Age 70 or more
  • Dysphagia severe enough to prevent them from receiving food or fluids

All other conditions

• The patient has a life-limiting condition
• The patient and family have been informed that the condition is life-limiting
• There is documentation of clinical progression of the disease
  • serial physician assessment
  • laboratory studies
  • radiologic or other studies
  • multiple ER visits
  • inpatient hospitalizations
  • home health nursing assessment if patient is homebound
• There's a recent decline in functional status, such as:
  • requires considerable assistance and frequent medical care
  • is disabled, requires special care and assistance, is unable to care for self, disease may be progressing rapidly
  • Severely disabled, although death is not imminent
  • Very sick, active supportive treatment is necessary
  • Moribund, fatal processes progressing rapidly
    and/or
  • Patient is dependent in at least 3 of these activities: bathing, dressing, feeding, transfers, continence of urine and stool, ambulation to bathroom
    and/or
  • recent impaired nutritional status, as evidenced by unintentional, progressive weight loss of 10% over past six months, or serum albumin less than 2.5 gh/dl (may be helpful prognostic indicator but should not be used by itself)