We Care Hospice

Amyotrophic Lateral Sclerosis

Patient must fulfill 1, 2 or 3

1. Does the patient demonstrate critically impaired breathing capacity?

(Check all that apply)

_________Is the patient's vital capacity (average normal 4000-5000ml) less than 30% of normal

_________Does the patient have significant dyspnea at rest

_________Does the patient require supplemental oxygen at rest

_________Does the patient decline artificial ventilation

2. Does the patient demonstrate both rapid progression of ALS and critical nutritional impairment?

(Check all that apply)

Rapid Progression occuring within the 12 months preceeding certification

_________Is the patient wheelchair or bedbound

_________Does the patient have barely intelligible or unintelligible speech

_________Does the patient require a pureed diet

_________Does the patient require major assistance in all ADLs

Nutritional impairment occuring within the 12 months preceeding certification

_________Oral intake of nutrients insufficient to sustain life

_________Continuing weight loss

_________Dehydration of hypovolemia

_________Absence of artificial feeding methods

3. Does the patient have both rapid progression and life threatening complications demonstrated by

the following characteristics?

Rapid Progression - see number 2 above.

Life threatening complications occuring within the 12 months preceeding certification should

have at least one of the following

(Check all that apply)

_________Recurrent aspiration pneumonia

_________Upper urinary tract infection, e.g.pyelonephritis

_________Sepsis

_________Recurrent fever after antibiotic therapy

WORK SHEET FOR DETERMINING PROGNOSIS - AMYOTROPHIC LATERAL SCLEROSIS

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