We Care Hospice

Pulmonary Disease

          1 and 2 must be present.  Factors from 3 - 5 will add supporting documentation.

                    1. Does the patient have severe chronic lung disease as documented by both A and B

                        (Check all that apply)

                        A. _____Disabling dyspnea at rest, poorly or unresponsive to bronchodilators, resulting in decreased

                            functional capacity, e.g., bed to chair existence, fatigue and cough.

                        B. _____Progression of end stage pulmonary disease, as evidenced by increasing visits to the emergency

                            department or hospitalizations for pulmonary infections and / or respiratory failure.

                    2. Does the patient have hypoxemia at rest on room air as evidenced by pO2 <, 55mmHg and  oxygen saturation         < 88% on supplemental oxygen or hypercapnia, as evidenced by PCO2 > 50mmHg?_____________

                    3. Does the patient have Cor Pulmonale and right heart failure secondary to pulmonary disease?_____________

                    4. Does the patient have unintentional progressive weight loss greater than 10% of body weight over the

preceeding 6 months?______________________

                    5. Does the patient have resting tachycardia >100/min?_____________________