We Care Hospice

Renal Disease

          Acyte Renal Failure - 1, 2 and 3 must be present (factors from 4 will lend supporting

          documentation)

          (Check all that apply)

          _____1. The patient is not seeking dialysis or renal transplant or dialysis discontinued

          _____2. Creatinine clearance > 10 cc/min (<15cc/min for diabetics)

          _____3. Serum creatinine > 8.0 mg/dl (> 6.0 mg/dl for diabetics)

          _____4. Comorbid conditions (check all that apply)

                      _____Mechanical Ventilation

                      _____Malignancy (other organ system)

                      _____Chronic lung disease

                      _____Advanced cardiac disease

                      _____Advanced liver disease

                      _____Sepsis

                      _____Immunosuppression/AIDS

                      _____Albumin < 3.5 gm/dl

                      _____Cachexia

                      _____Platelet count < 25,000

                      _____Disseminated intravascular coagulation

                      _____Gastrointestinal bleeding

          Chronic Renal Failure - 1, 2 and 3 must be present (factors from 4 will lend supporting

          documentation)

          (Check all that apply)

          _____1. The patient is not seeking dialysis or renal transplant or dialysis discontinued

          _____2. Creatinine clearance > 10 cc/min (<15cc/min for diabetics)

          _____3. Serum creatinine > 8.0 mg/dl (> 6.0 mg/dl for diabetics)

          _____4. Signs and symptoms of renal failure

                      _____Uremia

                      _____Oliguria

                      _____Intractable hyperkalemia not responsive to treatement

                      _____Uremic pericarditis

                      _____Hepatorenal syndrome

                      _____Intractable fluis overload, not responsive to treatment

WORKSHEET FOR DETERMINING PROGNOSIS - RENAL DISEASE

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