Supported by evidence-based data, this webinar helped clinicians identify hospice-eligible patients with advanced cancer, cardiac disease, lung disease, dementia, liver disease, stroke, and HIV/AIDS.

1. Determining Prognosis in
Cancer and Non-Cancer Diagnoses

2. Satisfactory Completion
Learners must complete an evaluation form to receive a certificate of completion. You must participate
in the entire activity as partial credit is not available. If you are seeking continuing education credit for a
specialty not listed below, it is your responsibility to contact your licensing/certification board to determine
course eligibility for your licensing/certification requirement.
Physicians
In support of improving patient care, this activity has been planned and implemented by Amedco LLC and
VITAS® Healthcare, Marketing Division. Amedco LLC is jointly accredited by the Accreditation Council for
Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and
the American Nurses Credentialing Center (ANCC) to provide continuing education for the healthcare team.
Credit Designation Statement – Amedco LLC designates this live activity for a maximum of 1 AMA
PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of
their participation in the activity.
CME Provider Information

3. CE Provider Information
VITAS®
Healthcare programs are provided CE credits for their Nurses/Social Workers and Nursing Home Administrators through:
VITAS Healthcare Corporation of Florida, Inc./CE Broker Number: 50-2135. Approved by: Florida Board of Nursing/Florida Board of
Nursing Home Administrators/Florida Board of Clinical Social Workers, Marriage and Family Therapy & Mental Health Counseling.
VITAS®
Healthcare programs in California/Connecticut/Delaware/ Illinois/Northern/Virginia/Ohio/Pennsylvania/Washington DC/
Wisconsin are provided CE credit for their Social Workers through VITAS Healthcare Corporation, provider #1222, is approved as
a provider for social work continuing education by the Association of Social Work Boards (ASWB) www.aswb.org, through the
Approved Continuing Education (ACE) program. VITAS Healthcare maintains responsibility for the program. ASWB Approval
Period: (06/06/2021-06/06/2024). Social Workers participating in these courses will receive 1 clinical continuing education clock
hour. {Counselors/MFT/IMFT are not eligible in Ohio}.
VITAS Healthcare, #1222, is approved to offer social work continuing education by the Association of Social Work Boards (ASWB)
Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved as ACE providers. State and
provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing
education credit. VITAS Healthcare maintains responsibility for this course. ACE provider approval period: 06/06/2021-06/06/2024.
Social workers completing this course receive 1.0 continuing education credits.
VITAS Healthcare Corporation of California, 310 Commerce, Suite 200, Irvine, CA 92602. Provider approved by the California Board
of Registered Nursing, Provider Number 10517, expiring 01/31/2025. Exceptions to the above are as follows: AL: No NHAs, DE:
No NHAs, DC: No NHAs, GA: No NHAs, KS: No NHAs, NJ: No NHAs, OH: No NHAs, PA: No NHAs, TX: No NHAs, VA: No NHAs,
WI: No NHAs and Nurses are not required – RT only receive CE Credit in Illinois.

4. Goal
The goal of this presentation is to help healthcare
professionals identify when patients are entering
the end stages of cancer and non-cancer diagnoses
that support hospice eligibility.

5. Objectives
• Appreciate the role of determining a patient’s prognosis
• Define the Medicare Hospice Benefit, including
eligibility requirements
• Understand the theoretical trajectories of dying
• Recognize six general domains of decline that
support poor prognosis and clinical progression
of disease
• Describe disease-specific factors that help
determine prognosis in patients with cancer
and non-cancer diagnoses

6. “Medicine is a science of uncertainty
and an art of probability.”
—Sir William Osler
"Father of Modern Medicine"

7. Prognosis and Practice of Medicine
• What to expect from an
individual’s disease course
• Clinicians’ prognostic estimates are
a framework to make informed
decisions about care
– Health screening
– Disability outcomes
– Disease management
– Advance care planning
– End-of-life decisions, including
hospice enrollment

8. Medicare Hospice Benefit
Medicare Benefit Policy Manual (Rev. 246, 09-14-18).
Terminal illness: “A medical prognosis (of a) life
expectancy of 6 months or less, as determined by
2 physicians, if the illness runs its normal course.”

9. Medicare Hospice Benefit (cont.)
Benefits Protection and Improvement Act (BIPA) of 2000
Certification of terminal illness of an individual who elects
hospice “shall be based on the physician’s or medical
director’s clinical judgment regarding the normal
course of the individual’s illness.”

10. Predicting Prognosis
Christakis, N., et al. (2000). Extent and determination of error in physicians’ prognoses in terminally ill patients: Prospective cohort study. British Medical Journal, 320:269.
• 20% of the doctors’ predictions
were accurate, 63% were
over-optimistic, and 17%
over pessimistic
• Greater experience =
better prediction accuracy
• Longer relationship with
a clinician = worse
prediction accuracy
A recent study found palliative clinicians overestimate survival
by 85%, leading to less hospice use and shorter stays.

11. Lunney, J., et al. (2003). Patterns of functional decline at the end of life. JAMA, 289:2387-2392.
Lunney, J., et al. (2018). Mobility trajectories at the end of life: Comparing clinical conditions and latent class approaches. Journal of the American Geriatric Society, 8;66: 503-508.
Theoretical Trajectories of Dying
Dependence on ADLs Prior to Death
1 year 1 month
Terminal Illness 0.77 4.09
Organ Failure 2.10 3.66
Frailty 2.92 5.84

12. General Domains to Consider
• Clinical judgment
• Nutrition
• Physical function
• Cognition
• Healthcare utilization
• Symptoms

13. Clinical Judgment
• Would you be surprised if this patient
were to die in the next year?

14. Surprise Question
Downar, J., et al. (2017). The "surprise question" for predicting death in seriously ill patients: A systematic review and meta-analysis. CMAJ, 189(13):E484-E493.
• Would you be surprised if this patient were to die in the next year?
• Recent meta-analysis
– Sensitivity
– Specificity
– PPV
– NPV
– AUC
67.0% (55.7%–76.7%)
80.2% (73.3%–85.6%)
37.1% (30.2%–44.6%)
93.1% (91.0%–94.8%)
0.81 (95% CI 0.78–0.86)

15. Nutritional Status
• Weight change
– ≥ 10% of normal body weight
in 6 months
– ≥ 5% of normal body weight
in 1 month
• BMI change (BMI < 22)
• Albumin level
• Choking and/or pocketing food
• Wounds
• Muscle wasting
– Sarcopenia
– Temporal wasting

16. Long-Term Care
153 residents
• 24 lost 5% weight
in 1 month
• 5.1 times more likely
to die in 1 year
Outpatient
Prospective evaluation of 91
patients with weight loss
• 35% no identifiable cause
• 25% died over the ensuing year
Weight Loss and Prognosis
Ryan, C., et al. (1995). Unintentional weight loss in long term care: Predictor of mortality in the elderly. Southern Medical Journal, 88(7):721-724.
Marton, K., et aI. (1981). Involuntary weight loss: Diagnostic and prognostic significance. Annals of Internal Medicine, (5):568-74.

17. Cabre, M., et al. (2010). Prevalence and prognostic implications of dysphagia in elderly patients with pneumonia. Age Ageing, 39:39-45.
Dysphagia and Survival
Mortality with dysphagia:
30-day: 22.9%
1-year: 55.4%

18. Malnutrition
The criterion in only one of the columns needs to be achieved in order to qualify for that type
of malnutrition.
Type of Malnutrition % of Normal Weight BMI Serum Albumin*
Normal: No Malnutrition 90-100 19-24 3.5-5.0
Mild 85-89 18-18.9 3.1-3.4
Moderate 75-84 16-17.9 2.4-3.0
Severe < 75 < 16 < 2.4

19. Physical Function
Palliative Performance Scale (PPS)
• Scale of 0% (dead) to 100% (normal)
• Activities of daily living
– Bathing
– Continence
– Dressing
– Transferring
– Ambulation
– Eating
• Homebound status
• Taking to bed
• Falls

20. Anderson, F., et al. (1996). Palliative performance scale (PPS): A new tool. Journal of Palliative Care, 12(1):5-11.
Mobility IADLs ADLs
% Ambulation
Activity and Evidence
of Disease
Self-Care Intake
Level of
Consciousness
100 Full Normal Activity Full Normal Full
No Evidence of Disease
90 Full Normal Activity Full Normal Full
Some Evidence of Disease
80 Full Normal Activity With Effort Full Normal or Reduced Full
Some Evidence of Disease
70 Reduced
Unable to Do Normal
Job/Work
Full Normal or Reduced Full
Some Evidence of Disease
60 Reduced
Unable to Do
Hobby/Housework
Occasional Assistance
Necessary
Normal or Reduced Full or Confusion
Significant Disease
50 Mainly Sit/Lie Unable to Do Any Work
Considerable Assistance
Required
Normal or Reduced Full or Confusion
Extensive Disease
40 Mainly in Bed As Above Mainly Assistance Normal or Reduced
Full or Drowsy
or Confusion
30 Totally Bed Bound As Above Total Care Reduced
Full or Drowsy
or Confusion
20 As Above As Above Total Care Minimal Sips Full or Drowsy
or Confusion
10 As Above As Above Total Care
Mouth
Care Only
Drowsy or
Coma
0 Death -- -- -- --
Based on
what the
patient
can do!
Generally Hospice
Eligible
Palliative Performance Scale

21. Survival by PPS at Acute-Care Hospital
Olajide, O., et al. (2007). Validation of the palliative performance scale in the acute tertiary care hospital setting. Journal of Palliative Medicine, 10(1):111-7.

22. ADL
Difficulty
Proportion
Population
Median
Survival
None 72.1% 10.6 yrs
Mild 16.1% 6.5 yrs
Moderate 7.0% 5.1 yrs
Severe 4.3% 3.8 yrs
Complete 0.5% 1.6 yrs
Activities of Daily Living: Difficulty and Death
Stineman, M., et al. (2012). All-cause 1-, 5-, and 10-year mortality in elderly people according to activities of daily living stage. Journal of the American Geriatric Society, 60(3):485-92.

23. Homebound Status and 2-Year Mortality
Soones, T., et al. (2017). Two-year mortality in homebound older adults: An analysis of the National Health and Aging Trends Study. Journal of American Geriatric Society, 65:123–129.
Homebound
12.1% Improved and no
longer homebound
26.9% Still homebound
14.9% Semi-homebound
5.8% Nursing home
40.3% Died

24. Taking to Bed and Prognosis
Gill, T., et al. (2019). Taking to bed at the end of life. JAGS, 67(6), 1248–1252.
Bed rest increases as death approaches:
• 24 months before death: 12.4%
• 5 months before death: 19.0%
• 1 month before death: 51.6%
The number of days of bed rest increases
as death approaches:
• 4 months before death: 7 days of bed rest
• 1 month before death: 14 days of bed rest
Almost 90% take to bed prior to death, and number of days in bed increases.

25. 25% of those who fell died within 1 year.
Falls and One-Year Mortality
Wild, D. (1981). How dangerous are falls in old people at home? British Medical Journal (Clinical Research Edition), 282(6260): 266–268.
Cause Fallers Controls
Cerebral vascular accident 7 2
Bronchopneumonia 12 3
Carcinoma 3 1
Congestive cardiac failure 5 1
Myocardial infarction 5 1
Total 32 8
4
0
0 1 2 3 4 5 6 7 8 9 10 11 12
8
24
20
16
12
28
32
Number
of
Deaths
Months After Index Fall
Cumulative mortality in 125 fallers and 125 controls in 12 months after index fall.
Fallers
Controls

26. Cognitive Decline
• Orientation to person, place, and time
• State of consciousness: Awake or
asleep in 24 hours
• Ability to communicate and
follow commands
• Ability to recognize environment

27. Cognition and Survival
Neale, R., et al. (2001). Cognition and survival: An exploration of a large multicenter study of a population aged 65 years and older International. International Journal of Epidemiology, 30:1383-1388.

28. Increased Healthcare Utilization
• Clinic visits
• Subspecialty visits
• Emergency department visits
• Hospitalizations

29. Hospitalization, ADL Change, and Death
Boyd, C., et al. (2008). Recovery in activities of daily living among older adults following hospitalization for acute medical illness. Journal of the American Geriatric Society, 56(12): 2171-2179.
83.8%
33.5%
80.0%
37.4%
73.7%
36.5%
67.0%
30.1%
13.5%
53.0%
12.9%
40.2%
14.9%
32.4%
15.2%
28.6%
2.7%
13.5%
7.1%
22.4%
11.4%
31.2%
17.8%
41.3%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Discharged at
baseline function
Discharged with a
new or additional
disability in ADL
Discharged at
baseline function
Discharged with a
new or additional
disability in ADL
Discharged at
baseline function
Discharged with a
new or additional
disability in ADL
Discharged at
baseline function
Discharged with a
new or additional
disability in ADL
Baseline Decline Death
1 month 3 months 6 months 12 months

30. Uncontrolled Symptoms
• Pain
• Shortness of breath
• Delirium
• Agitation
• Nausea and vomiting
• Constipation
• Exhaustion, fatigue, low activity

31. Acute Neuropsychological Symptoms and Mortality
Zippirich, H., et al. (2020). Outcome of older patients with acute neuropsychological symptoms not fulfilling criteria of delirium. JAGS, 68:1469-1475.
Changes in mental status that may
prompt an evaluation of delirium
Confusion Assessment Method (CAM)
Features of Delirium:
1. Acute onset of changes or
fluctuation in mental status
2. Inattention
3. Disorganized thinking
4. Altered level of consciousness
• Delirium is diagnosed when
features 1 and 2, plus either
feature 3 or 4, are present
• Exhibiting only 2 of the 4 CAM
features indicates symptoms
of delirium
37.7
44.3
36.1
41.8

32. Indicators of Poor Prognosis
in Cancer and Non-Cancer Diagnoses

33. Cancer Trajectory
Christakis, N., et al. (2000). Extent and determinants of error in doctors’ prognoses in terminally ill patients: Prospective cohort study. British Medical Journal, 320(7233):469-72.
Mackillop, W., et al. (1997). Measuring the accuracy of prognostic judgements in oncology. Journal of Clinical Epidemiology, 50:21-29.
Function
Death is more
predictable
Low
Onset of illness Decline usually 3-6 month
Slower trajectory for hormone-sensitive tumors, i.e., breast, prostate
High
Functional Status: Key Determinant Prognosis
ECOG 3: 50% of time in bed
or chair; hospice eligible

34. ECOG
0: Fully active, able to carry on all pre-disease performance
without restriction.
1: Restricted in physically strenuous activity, but ambulatory
and able to carry out work of a light or sedentary nature.
2: Ambulatory. Able to self-care. Unable to carry out
work activities.
3: Limited self-care. Confined to bed/chair > 50%.
4: Disabled. Unable to self-care. Totally confined
to bed/chair.
5: Dead.
Jang, R., et al. (2014). Simple prognostic model for patients with advanced cancer based on performance status. American Society of Clinical Oncology.
Cancer, Function, and Prognosis

35. Cancer Prognosis: Helpful Numbers
Palliative Care Network of Wisconsin. (2015, May). Fast Fact Number 13. Retrieved from: https://www.mypcnow.org/blank-hh45g
Cancer Syndrome Estimated Survival
Malignant hypercalcemia 8 weeks (except newly diagnosed breast or MM)
Malignant pericardial effusion 8 weeks
Carcinomatous meningitis 8-12 weeks
Multiple brain metastases 1-2 months no XRT; 3-6 months with XRT
Malignant ascites Less than 6 months
Malignant pleural effusion Less than 6 months
Malignant bowel obstruction Less than 6 months

36. Heart Failure Trajectory
Lynn, J., et al. (2003) Living well at the end of life. Adapting health care to serious chronic illness in old age. Washington: Rand Health.
Function
Low
NYHA Class III/IV
Hospice Eligible
NL and low EF maintain a similar trajectory and prognosis
High
Death
NYHA Symptoms:
Shortness of breath • Fatigue
Chest pain • Palpitations
Multiple Hospitalizations Death After Exacerbation

37. Median Survival in Heart Failure (HF) Patients by Age1
1
Shah, K., et al. (2017). Heart failure with preserved, borderline, and reduced ejection fraction: 5-year outcomes. Journal of the American College of Cardiology, 70.20: 2476-2486.
2Kheirbek, R., et al. (2015). Discharge hospice referral and lower 30-day all-cause readmission in Medicare beneficiaries hospitalized for heart failure. Circulation: Heart Failure, 8(4), 733-740.
Hospitalization for HF is associated with a poor long-term prognosis and
an elevated risk of cardiovascular (CV) and HF admission, irrespective
of ejection fraction (EF).
• Across all age groups,
patients with HF (regardless
of EF) had a markedly lower
median survival than the life
expectancy of individuals
in the US
• The median survival for
patients with HF was similar
by EF group but declined
with advancing age
• Factors associated with
an even poorer prognosis
include NYHA Class,
hospitalization, weight
loss, O2 use, renal
insufficiency, anemia
18.7
15.1
11.9
9.1
6.8
5
3.6 2.9 2.3 1.7 1.2 0.8
3.3 2.8 2.6
1.8 1.3 1
4 3.4
2.6 2.2 1.5 0.9
0
5
10
15
20
65-69 70-74 75-79 80-84 85-89 ≥90
Median
Survival
in
Years
Ages in Years
Median Survival Stratified by Age
Life Expectancy in US HFrEF Patients HFbEF Patients HFpEF Patients
Only 1 in 10 patients with advanced heart failure is referred to hospice2

38. HF and Prognosis
Prognosis Tool Components Comments
NYHA Class
1-year mortality listed
I N/A
II.7%
III.13%
IV.40-60%
Patients can move among classes based
upon response treatment
Cachexia
7.5% weight loss
29% die 6 months
42% die 18 months
Dry weight; independent age,
NYHA, and EF
Seattle Heart Failure
Age, gender, NYHA Class, EF, BP, laboratory
data, medications, and presence of devices.
Predictors survival: NYHA class, EF, Na,
SBP, ischemic etiology
Predicts mean, 1-, 2-, and 5-year
survival; overestimates at patient
level; Based upon reduced EF mostly
Surprise Question in HF
Would you be surprised if this patient
died within next year?
Sensitivity 85%, NPV 88%
Specificity 59%PPV 52%

39. Functional Status Predicts Hospice Eligibility in Cardiac Patients
Creber, R., et al., (2019). Use of the palliative performance scale to estimate survival among home hospice patients with heart failure. ESC Heart Failure, 6(2), 371-378.
Patients with a PPS score of ≤ 50 are generally hospice-eligible; some patients with a higher PPS may
also be eligible.
PPS
Score
Ambulation
Activity and
Evidence of
Disease
Self-Care Intake
Conscious
Level
60 Reduced
Unable to do
hobby/housework
Occasional
assistance
Significant disease necessary Full
or
50
Mainly
sit/lie
Unable to do
any housework
Extensive disease
Considerable
assistance
required Normal
or
confusion
40
Mainly
in bed
Unable to do
most activities
Extensive disease
Mainly
assistance
reduced
Full or
drowsy
30
Totally
bedbound
Unable to do
any activities
Extensive disease
Requires
total care
+/-
confusion

40. Advance Cardiac Hospice Eligibility Guidelines
Patient is:
• Optimally treated
• Not a candidate/pursuing
surgical options
Symptoms include:
• Fatigue
• Dyspnea
• Angina
• Palpitations
NYHA Class III:
• Symptoms during
less-than-ordinary
activity
• Significant
comorbidities
NYHA Class IV:
• Symptoms
at rest
• Physical activity
causes further
discomfort
Or
Functional status and symptom burden are strongest indicators of hospice eligibility
Significant Comorbidities with Poor Prognosis
• Uncontrolled
hypertension/hypotension
• Uncontrolled diabetes
with complications
• Coronary artery disease
• Prior MI or syncope
• Renal dysfunction
or CKD
• Valvular heart disease
• Frailty
• Cognitive impairment
• Malnutrition, cachexia
• Ventricular arrhythmias
• Older age at diagnosis
• Lab/imaging abnormalities:
hyponatremia, elevated
BNP, or NT-proBNP
• Dependence on inotropes

41. COPD Trajectory
Fox, E., et al. (1999). Evaluation of prognostic criteria for determining hospice eligibility in patients with advanced lung, heart, or liver disease. JAMA, 282(17):1638–1645.
Function
Death
Low
High
Multiple Hospitalizations Death After Exacerbation
COPD patients often expire surrounding hospital
Ongoing Lung Function Decline Despite Treatment,
Accompanied by Hospitalizations and Progressive Dyspnea
Hospice Eligible

42. COPD and Prognosis
Fox, E., et al. (1999). Evaluation of prognostic criteria for determining hospice eligibility in patients with advanced lung, heart, or liver disease.
SUPPORT Investigators. Study to understand prognoses and preferences for outcomes and risks of treatments. JAMA, 282(17):1638-45.
Almagro, P., et al. (2017). Palliative care and prognosis in COPD: A systematic review with a validation cohort. International Journal of COPD, 12:1721-1729.
Prognosis of 6 months or less, 2 of 4 criteria
• PaCO2 > 45 mmHg • Cor pulmonale • FEV-1 < 0.75 L • Episode of respiratory failure last 12 months

43. Lung Disease Hospice Eligibility Guidelines
Disabling dyspnea as demonstrated by:
• Dyspnea at rest or with minimal
exertion while on oxygen therapy
• Dyspnea unresponsive
or poorly responsive to
bronchodilators
Progressive pulmonary disease manifested by
one or more of the following:
• Hospitalizations, ER visits, or doctor’s office visits
• Frequent episodes of bronchitis or pneumonia
• Frequent infections or respiratory failure
requiring intubation
• Cor pulmonale
Supportive Features (ANY)
• Unintentional weight loss of > 10% body
weight over last 6 months
• Resting tachycardia > 100/minute
• Progressive inability to independently
perform various activities of daily living (ADLs)
• Abnormal tests (if available, but not necessary):
– pO2 < 55 mmHg
– pCO2 > 50 mmHg
– O2 saturation < 88% on RA
– FEV-1 < 30% predicted, post-bronchodilator
And

44. CAGR=5.45%,
P=.029
CAGR=13.12%,
P<.001
CAGR=11.95%,
P<.001
CAGR=7.69%,
P=.009
CAGR=11.99%,
P<.001
COPD and Over-Medicalized Hospital Deaths: 2010 to 2014
Shen, J., et al. (2018). Life sustaining procedures, palliative care consultation, and do-not resuscitate status in dying patients with COPD in US hospitals: 2010-2014.
Journal of Palliative Care, 33(3):159-166.
The use of ventilation, vasopressors,
dialysis, and CPR all increased
significantly for COPD patients who
died in the hospital from 2010 to 2014.
48.9% of COPD patients who died
in the hospital had at least one
life-sustaining treatment, with
25% receiving multiple treatments.
Compounded Annual Growth Rates by Life-Sustaining Treatment
for COPD Patients with Hospital Deaths

45. Dementia Trajectory
Lynn, J., et al. (2003) Living well at the end of life. Adapting health care to serious chronic illness in old age. Washington: Rand Health.
Function
Death
Low
ADL Dependency Slow decline
High
Functional Dependency and Disease-Related Complication
Hospice-Eligible
Dependence in 3/6 ADLs (bathing, dressing,
feeding, continence, ambulation, transferring)
Disease-related complication within last 6 months

46. Wright, J., et al. (2011). End-of-life care: A practical guide. New York: McGraw Hill, p. 19.
• Pneumonia
• Pyelonephritis or upper
urinary tract infection
• Septicemia
• 2 or more pressure
ulcers: Stage III or IV
• Febrile episodes
• Altered nutritional status
(weight loss 10% in 6 mo
or 5% in 1 mo)
• Eating difficulty, including
feeding tube decision
• Frequent falls or fall
with fracture
Patient experienced one or more of the following complications
in the last 6 months:
Dementias and Other End-Stage Neurodegenerative Disorders
• Hip fracture, with
or without repair
• Delirium

47. Mitchell, S., et al. (2009). The clinical course of advanced dementia. New England Journal of Medicine, 361:1529-1538.
• Median survival was 478
days, 24.7% within 6
months
• 54.8% died, 93.8% in NH
6-month mortality 38.6%
6-month mortality 44.5%
6-month mortality 46.7%
Natural History of Dementia

48. Morrison, R., et al. (2000). Survival in end-stage dementia following acute illness. JAMA, 284(1):47-52.
Hip Fracture
If impaired
55%
Survival After Acute Illness: Severe Dementia vs. Cognitively Intact
6-month
mortality
If intact
12%
Pneumonia
If impaired
53%
6-month
mortality
If intact
13%

49. 1-Year Survival From Baseline by FT Status
Teno, J., et al. (2012). Does feeding tube insertion and its timing improve survival? JAGS, 60(10):1918–1921.

50. Teno, J., et al. (2013). Survival after multiple hospitalizations for infections and dehydration in nursing home residents with advanced cognitive impairment. JAMA, 310(3).
Two or More Hospitalizations of Nursing Home Residents
With Dementia in One Year

51. Dementia Hospice Eligibility Guidelines
Alzheimer’s Disease
Lose ability to speak or communicate
meaningfully (FAST 7A)
Non-Alzheimer’s Disease or Mixed
Dress • Incontinence of bowel and bladder
Transferring • Ambulation • Eating • Bathing
Plus have either
A comorbidity resulting in structural/functional impairment:
• Heart Disease (e.g., Heart Failure,
Advanced Cardiac Disease, etc.)
• Advanced Lung Disease (COPD)
Or
A clinical complication indicative of disease progression:
• Febrile episode
• Infection requiring antibiotics
(aspiration pneumonia, UTI, sepsis)
• Eating difficulty including
dysphagia
• Delirium
• Feeding tube decision
• Pressure ulcers
• Dehydration requiring hospitalization
• Weight loss (10% in 6 mo or 5% in 1 mo)
• Frequent falls/fall with fracture

52. End-Stage Liver Disease Trajectory
Natural History of Liver Disease
Function
Death
Low
Few Symptoms Many Symptoms
High
Three Hospitalizations
last year of life
Decompensated cirrhosis + hospitalization-
jaundice, ascites, hepatic encephalopathy,
and/or variceal hemorrhage
30% one-month readmit rate; one-month
hospital last year life; 70% Die in ICU
Etiology liver disease: ETOH (45%), Hep C (41%), NASH (26%)
Symptoms of
Decompensated Cirrhosis
• Muscle cramps, 64%
• Poor-quality sleep, 63%
• Pruritus, 39%
• Sexual dysfunction, 53%
• Depression, >50%
• Anxiety, >50%
• Anorexia, >50%
• Fatigue, >50%

53. Evidence-Based Disease Management
Tapper, et al. (2023). "Diagnosis and Management of Cirrhosis and Its Complications: A Review." JAMA 329.(18):1589-1602.
Median survival rates:
• Variceal bleed:
17.7% 6-wk death
• Ascites: 1.1 y
• SBP 11%/y: 11 weeks
• HRS 8%/y : < 2 weeks
• HE: 0.95 y ≥ 65 and 2.5 y (<65)
• HE: 0.95 y ≥ 65 & 2.5 y (<65)
• HCC: 1-4% per/yr 5-yr
survival 20%

54. ESLD and Hospice Eligibility
1 and 2 must be met
1. The patient should show both an
INR>1.5 and a serum albumin <2.5 gm/dl
2. End-stage liver is present, and patient
shows at least one of the following:
• Ascites, refractory to treatment or
patient non-compliant
• Spontaneous bacterial peritonitis
• HRS (elevated Cr/BUN with oliguria
<400ml/day and urine NA <10meq/l)
• Hepatic encephalopathy, refractory
to treatment or patient noncompliant
• Recurrent variceal bleeding, despite
intensive therapy
Supportive Factors
• Progressive malnutrition
• Muscle wasting with reduced
strength and endurance
• Continued active alcoholism
• Hepatocellular carcinoma
• HBsAg (Hepatitis B) positive
• Hepatitis C refractory treatment

55. Background: Sepsis Epidemiology
2019 VITAS Healthcare Corporation Adapted from Prescott, H. & Angus, D. (2018). Enhancing Recovery from Sepsis: A Review. JAMA, 319(1):62-75.
• 41% of patients
admitted with
sepsis die within
90 days
• 42% of patients
who survive are
readmitted within
90 days

56. Sepsis and Hospice Eligibility: Hospital
• Hospice-eligible, not previously identified:
– Cancer, solid tumor, and hematologic
– Advanced cardiac disease
– Advanced lung disease
– Dementia
Rhee, C., et al. (2019). Prevalence, underlying causes, and preventability of sepsis-associated mortality in US acute care hospitals. JAMA Network Open, 2(2), e187571-e187571.
• Clinical complications of sepsis
associated with death:
– Vasopressors
– Mechanical ventilation
– Hyperlactatemia
– Acute kidney injury
– Hepatic injury
– Thrombocytopenia

57. Factors Associated With Hospital-Related Death
Rhee, C., et al. (2019). Prevalence, underlying causes, and preventability of sepsis-associated mortality in US acute care hospitals. JAMA Network Open, 2(2), e187571-e187571.
0 10 20 30 40 50 60
Thrombocytopenia
Hepatic injury
Acute kidney injury
Hyperlactatemia
Mechanical
ventilation initiation
Vasopressor
initiation
Organ Dysfunction or Associated Mortality
A greater number
of organs with
dysfunction
increases the
likelihood of hospital
death and the need
for a goals-of-care
conversation.
Organ dysfunction or mortality, %
0 20 40 60 80 100
≥4
≥3
≥2
≥1
Associated Mortality by Number of
Organ Dysfunction Criteria Met
Organ dysfunction or mortality, %
Number
of
criteria
met
Proportion of sepsis cases with organ dysfunction Associated mortality

58. Sepsis and Hospice Guidelines: Hospitals Discharge
• Hospice-eligible, not previously identified
– Cancer, solid tumor, and hematologic
– Advanced cardiac disease
– Advanced lung disease
– Dementia
• Pre-hospital functional ability
– Physical impairment
• 1 of 6 ADL or 1 of 5 IADL
– Cognitive status
• Any degree of dementia

59. Pre-Sepsis Function and Cognition on Post-Hospital Survival
Iwashyna, T., et al. (2010). Long-Term Cognitive Impairment and Functional Disability Among Survivors of Severe Sepsis. JAMA, 304(16):1797-1794.
• Patients with functional
and cognitive impairment
prior to sepsis who
survive hospitalization
have a high 6-month
mortality that supports
hospice as a relevant
and important post-acute
care option
Pre-Sepsis Disability and Survival Pre-Sepsis Cognition and Survival

60. ESRD: Age and Survival
Kurella, M., et al. (2007). Octogenarians and nonagenarians starting dialysis in the United States. Annals of Internal Medicine, 146(3):177-83.

61. ESRD: Functional Status and Survival
Kurella, M., et al. (2007). Octogenarians and nonagenarians starting dialysis in the United States. Annals of Internal Medicine, 146(3):177-83.

62. Change in Functional Status After Initiation of Dialysis
Tamura, M. (2009). Functional status of elderly adults before and after initiation of dialysis. New England Journal of Medicine, 361:1539-1547.
0 20 40 60 80 100
3
6
9
12
Residents (%)
Months
Since
Initiation
of
Dialysis
Died Functional status decreased Functional status maintained

63. Dialysis Withdrawal
O’Connor, N., et al. (2013). Survival after dialysis discontinuation and hospice enrollment for ESRD. Clinical Journal of the American Society of Nephrology, 8(12):2117-2122.
Factor Median Survival (days)
PPS 10 – 20 3 (1 – 4)
PPS > 20 7 (3 – 9)
Oxygen Use 6 (3 – 9)
No Oxygen Use 7 (4 – 9)
Peripheral Edema 4 (2 – 5)
No Peripheral Edema 8 (5 – 11)
(Mean Survival – 7.4 days)

64. Dialysis
related to
dying
process
Patient wishes
to discontinue
dialysis
Dialysis unrelated
to terminal
prognosis
No change in
treatment approach
Discontinuation
of dialysis
Continue dialysis
as prior to hospice
Once discontinued,
average survival 7 to
10 days
Dialysis unrelated to
dying process so
reimbursed separately
from hospice
Patient Type Dialysis Approach Considerations
Not consistent with
hospice plan of care
Collaboration
among hospice
and dialysis
partner2
YES
YES
Admit to Hospice?
Anticipated stop
date or prognosis
2 month or less1
Palliative dialysis
Primary goal of symptom
management and
consistent with hospice
plan of care
Work to identify
discontinuation date
and rationale
Collaboration among
hospice and
dialysis partner2
NO
1. Often patients endorse a
comfort-focused approach
to care and either:
• Have a stop date to reach
a milestone or to attend an
event a month or less away
• Maintain a prognosis
of 2 months or less
2. Collaboration incorporates
GM and medical director
with dialysis partner about
number of sessions, treatments
(reuse, filters,” and solutions),
electrolyte management,
access, nephrology/professional
support, and transportation needs.
VITAS®
Healthcare ESRD Care Considerations
for Patients Receiving Dialysis

65. Summary
• Prognosis is an important
determination as part of
medical care
• Ability improves with
clinical experience, but
declines with patient-
clinician experience
• Hospice prognosis threshold
is 6 months or less if the
illness runs its normal course
• Incorporate general domains
of decline along with
disease-specific factors

66. Questions?

67. Scan now to
download the
VITAS app.
Additional Hospice Resources
• The VITAS mobile app includes
helpful tools and information:
• Interactive Palliative Performance
Scale (PPS)
• Body-Mass Index (BMI) calculator
• Opioid converter
• Disease-specific hospice
eligibility guidelines
• Hospice care discussion guides
We look forward to having you attend
some of our future webinars!

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Boyd, C., et al. (2008). Recovery in activities of daily living among older adults following hospitalization for acute medical illness.
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Cabre, M., et al. (2010). Prevalence and prognostic implications of dysphagia in elderly patients with pneumonia. Age Ageing.
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Downar, J., et al. (2017). The “surprise question" for predicting death in seriously ill patients: A systematic review and
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