All of the following should be present:
(1) The patient's condition is life-threatening, AND The patient and/or family have been informed of this determination.
(2) The patient and/or family have elected treatment goals directed toward relief of symptoms, rather than curing the underlying disease.
(3) The patient has either of the following:
(a) documented clinical progression of the disease, OR
(b) documented recent impaired nutritional status related to the terminal process.
Progression of the disease may include:
• progression of the primary disease based on disease specific criteria, as documented in the medical record
• multiple emergency department visits or inpatient hospitalizations over the past 6 months
• documented deterioration in nursing assessment for homebound patients
• recent decline in functional status
A decline in functional status may be documented by either:
(1) a Karnofsky performance status of < 50%, OR
(2) dependence in at least 3 of 6 activities of daily living (bathing, dressing, feeding, transfers, continence of urine or stool, ability to ambulate independently to the bathroom)
Indications of impaired nutritional status may include:
(1) unintentional, progressive weight loss of > 10% over the past 6 months.
(2) serum albumin < 2.5 g/dL may be a useful indicator but should not be used in isolation from the other factors above
