We Care Hospice

Stroke and Coma

          A. Acute phase of hemorrhagic or ishemic stroke (1, 2 or 3 must be present)

          SEE SECTION D

                       1. Is the patient in a coma or persistent vegatative state secondary to stroke, beyond 3 days duration?_______

                       2. Is the patient's post anoxic stroke, coma or severe obtundation, accumpanied by severe myoclonus, persisting beyond 3 days past the anoxic event_______________

                       3. Does the patient have dysphagia, which prevents sufficient intake of foods and fluids to sustain life, and is not receiving artificial nutrition and hydration? ______________

          B. Chronic phase of hemorrhagic or ischemic stroke (1, 2 or 3 must be present)

          SEE SECTION D

                       1. Does the patient have post-stroke dementia demonstrated by all of the following:

                                 (Check all that apply)

                                 _____Stage seven or beyond according to the Functional Assessment Staging Scale

                                             (Refer to NHO guidelines for non-cancer diseases)

                                 _____Unable to ambulate without assistance

                                 _____Unable to dress without assistance

                                 _____Unable to bathe without assistance

                                 _____Urinary and fecal incontinence, intermittent or sonstant

                                 _____No meaningful verbal communication: stereotypical phrases only or the ability to speak is limited to        six or fewer intelligible words

                       2. Does the patient have a Karnofsky score of 40% or less?___________

                       3. Does the patient have a poor nutritional status with the inability to maintain sufficient fluid and calorie intake with > 10% weight loss during rhe previous six months or serum albumin < 2.5 gm/dl?__________

          C. Coma (any etiology)

          SEE SECTION D

          Comatose patients should have any 3 the following on day 3 of coma

          (Check all that apply)

                       _____Abnormal brain stem response

                       _____Absent verbal response

                       _____Absent withdrawal response to pain

                       _____Serum creatinine > 1.5 mg/dl

          D. Documentation of the following factors will support eligibility for all stroke and coma patients

               (Check all that apply) 

                       _____Aspiration pneumonia

                       _____Upper urinary tract infection (pyelonephritis)

                       _____Sepsis

                       _____Refractory stage 3-4 decubitus ulcer

                       _____Fever recurrent after antibiotics

                       _____Age > 70

WORKSHEET FOR DETERMINING PROGNOSIS - STROKE AND COMA

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