We Care Hospice

All Other Diagnoses

          1. The patient should meet the following criteria:

                    _____Life limiting condition

                    _____Pt/Family elected palliative care

          2. Documentation of clinical progression of disease evidenced by

                    _____physician assessment

                    _____laboratory studies

                    _____radiologic or other studies

                    _____multiple ER visits

                    _____Inpatient hospitalizations

                    _____home health nursing assessment if homebound

                         and/or

          3. Recent decline in functional status as evidenced by:  

                    Karnofsky Performance Status < 50% 

                    Check Level:

                    _____50% Requires considerable assistance and frequent medical care

                    _____40% Disabled; requires special care and assistance.  Unable to care for self;

                          disease may be progressing rapidly

                    _____30% Severely disabled; although death is not imminent

                    _____20% Very sick; active supportive treatment necessary

                    _____10% Moribund: fatal process progressing rapidly

                    and/or

          4. Dependence in 3 of 6 Activities of Daily Living

                    Check activities in which patient is dependent:

                    _____bathing

                    _____dressing

                    _____feeding

                    _____transfers

                    _____continence of urine and stool

                    _____ambulation

                    and/or

          5. Recent impairment of nutritional status evidenced by:

                    (check all appropriate)

                    _____unintentional, progressive weight loss of 10% over past 6 months

                    _____serum albumin less than 2.5 gm/dl  (may be helpful prognostic indicator,

                    but should not be used by itself.)                

WORKSHEET FOR DETERMINING PROGNOSIS - ALL OTHER DIAGNOSES

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