We Care Hospice

HIV / Aids

      1, 2 and 3 must be present.  Factors from 4 will add supporting documentation.

      1. What is the patients most recent CD4 count__________cells/mcL (must be <25 cells/mcL)

         And

         What is the patients most recent viral load__________copies/ml

      2. Does the patient have a decreased performance status, as measured by the Karnofsky Performance Status Scale,

          of <50% _____________________

          (Must be persistant viral load > 100,000 copies/ml)

      3. Must have at least one of the following:

      _______CNS lymphoma

      _______Untreated, or not responsive to treatment, wasting (loss of 33% lean body mass)

      _______Mycobacterium avium complex (MAC) bacteria, untreated, unresponsive to treatement or treatment refused

      _______Progressive multifocal leukoencephal (PML)

      _______Systemic lymphoma, with advanced HIV disease and partial response to chemotherapy

      _______Visceral Kaposi sarcoma unresponsive to therapy

      _______Renal failure in the absence of dialysis

      _______Cryptosporidium infection

      _______Toxoplasmosis, unresponsive to therapy

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

            (Check all that apply)

      _______Chronic persistent diarrhea for one year

      _______Persistent serum albumin < 2.5 (normal 3.3-4.5 g/dl)

      _______Age > 50 years

      _______Absence of antiretroviral, chemotherapeutic and prophlactic drug therapy related specifically to HIV disease

      _______Advanced AIDS dementia complex

      _______Congestive heart failure, symptomatic at rest 

      _______Tuberculosis

      _______Pneumocustis Carnii Pneumonia (PCP)

      _______Cytomegalovirus

WORKSHEET FOR DETERMINING PROGNOSIS - HIV / AIDS

This worksheet is designed as a fact-finding tool and is not intended to be used to formulate diagnoses