Referral Guidelines for Non-Cancer Diagnoses
Referral Guidelines for Non-Cancer Diagnoses
|Yes |No |The patient should meet the following general criteria: |
| | |Terminal condition either due to a specific diagnosis or a combination of disease. |
| | |Patient and/or family have elected a course of palliative care. |
| | |Patient/caregiver/physician agree exacerbation of terminal illness will not be treated aggressively. |
| | | |
|Renal Disease—Acute Renal Failure |
|1, 2, and 3 must be present; factors from 4 will lend supporting documentation. |
| | |1. Patient not seeking dialysis or renal transplant. |
| | |2. Creatinine clearance 8.0 mg/dl (>6.0 mg/dl for diabetes) |
| | |4. Comorbid conditions: |
| | |Ventilator |
| | |Malignancy (other system) |
| | |Chronic lung disease |
| | |Advanced cardiac disease |
| | |Sepsis |
| | |Immunosuppression/AIDS |
| | |Albumin 7.5% in previous 3 months |
| | |Serum albumin 1.5 mg/dl |
| | | |
|Heart Disease |
|Both of the following must be present: |
| | |Optimal treatment with diuretics and vasodilators (or medical reason to refuse, e.g. hypotension or hyperkalemia) OR Angina pectoris, at rest, |
| | |resistant to standard nitrate therapy and not candidate for invasive procedures |
| | |Significant symptoms of recurrent congestive heart failure at rest with NHYA Class IV |
|The following will support eligibility: |
| | |Treatment resistant symptomatic supraventricular or ventricular arrhythmias |
| | |History of unexplained syncope |
| | |History of cardiac arrest or resuscitation |
| | |Brain embolism of cardiac origin |
| | |Concomitant HIV disease |
| | |Ejection fraction of 20% or less, documented |
| | | |
|Dementia |
|All of the following should be present: |
| | |( Stage Seven FAST scale |
| | |Unable to walk without assistance |
| | |Unable to dress without assistance |
| | |Unable to bathe without assistance |
| | |Urinary and fecal incontinence, intermittent or constant |
| | |No meaningful verbal communication, ( six words |
|AND Patient must have had one of the following within the past 12 months: |
| | |Aspiration pneumonia |
| | |Pylenephritis or other upper urinary tract infection |
| | |Septicemia |
| | |Decubitus ulcers, multiple, stage 3-4 |
| | |Fever, recurrent after antibiotics |
| | |Weight loss of >10% during past six months OR serum albumin < 2.5 gm/dl |
| | | |
|HIV Disease |
|Factors 1 and 2 must be present: |
| | |1. CD4+ Count100,000 copies/ml plus one of the following: |
| | |CNS lymphoma |
| | |Wasting (loss of 33% lean body mass), untreated or not responsive to treatment |
| | |MAC bacteremia, untreated, unresponsive to treatment, or treatment refused |
| | |Progressive multifocal leukoencephalopathy |
| | |Systemic lymphoma, with advanced HIV disease and partial response to chemotherapy |
| | |Cryptosporidium infection |
| | |Toxoplasmosis, unresponsive to therapy |
| | |2. Decreased performanc status with Karnofsky Scale of < 50% |
|Supporting factors: |
| | |Chronic persistent diarrhea for one year |
| | |Persistent serum albumin 50 years |
| | |Absence of antiretroviral, chemotherapeutic, and prophylactic drug therapy related specifically to HIV disease |
| | |Advanced AIDS dementia complex |
| | |Toxoplasmosis |
| | |Congestive heart failure, symptomatic at rest |
| | | |
|Adult Failure to Thrive |
|Both 1 and 2 must be present: |
| | |1. Severe nutritional impairment. BMI 5 sec. Over control or INR > 1.5 and Serum albumin ................
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