We Care Hospice

Liver Disease

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

          1. Patient should show both A and B:

                    A. Does the patient have a prothrombin time prolonged more than 5 seconds over control, or

                          International Normalized Ratio (INR) > 1.5______

                    B. Does the patient have a serum albumin < 2.5 gm/dl? __________________

          2. Does the patient have at least one of the following to support end stage liver disease?

              (Check all that apply)

                    _____Ascites, refractory to treatment or patient non-compliant

                    _____Spontaneous bacterial peritonitis

                    _____Hepatorenal syndrome (elevated creatinine and BUN with oliguria (<400 ml/day) and  urine sodium concentration >mEq/l

                    _____Hepatic encephalopathy, refractory to treatment, or patient non-compliant (hand-flapping tremor,          somnolence, coma)

                    _____Recurrent variceal bleeding, despite intensive therapy

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

              (Check all that apply)

                    _____Progressive malnutrition

                    _____Muscle wasting with reduced strength and endurance

                    _____Continued active alcoholism

                    _____Hepatocellular carcinoma

                    _____HBsAg (Hepatitis B positivity)

                    _____Hepatitis C refractory to interferon treatment

          4. Patient is not a candidate for liver transplant or refuses liver transplant

                    _____check if true statement

WORKSHEET FOR DETERMINING PROGNOSIS - LIVER DISEASE

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