General

  1. Compromised ambulation or non-ambulatory
  2. Compromised mental status; confused, disoriented, decreased responsiveness, forgetfulness, difficulty concentrating.
  3. Anorexia
  4. Weight loss of 10% or more in past 4-6 months.
  5. Recurrent infections; respiratory, sepsis secondary to decubitus ulcers, U.T.I.s' skin breakdown.
  6. Increasing somnolence, weakness, fatigue
  7. Failure to thrive
  8. Change in functional abilities
  9. Change in cognitive abilities
  10. History from patient/family of specific decline in condition

Failure to Thrive

  1. Palliative Performance Scale equal to or less than 40% (mainly in bed, requires assistance with ADL's.
  2. Body Mass Index below 22kg/m2; BMI=703 x (patient's weight in pounds) divided by (height in inches)
  3. The patient declines or is not responding to enteral or parenteral nutritional support.

Pulmonary Disease

  1. Confined to bed
  2. Symptomatic at rest; tachypnea, dyspnea
  3. Dyspnea upon exertion (change from prior level of function
  4. Orthopnea
  5. Oxygen dependency
  6. Increasing cyanosis
  7. Progressive cough
  8. No Ventilatory support
  9. On multiple pulmonary medications
  10. Karnofsky score of 5 or less
  11. ADL score of 18 or less
  12. Descriptive score of 20 or less.

Neurological Disease (Parkinson, ALS, MS)

  1. Signs of bulbar involvement; dysphagia, dyspnea, dysphasia
  2. Decreased coordination
  3. Increased weakness
  4. Chair or Bed bound
  5. No venilatory support.
  6. Karnofsky score of 5 or less
  7. ADL score of 8 or less
  8. Descriptive score of 21 or less

AIDS

  1. Must have established AIDS diagnosis
  2. Mostly bed or chair confined
  3. Current treatment is palliative
  4. Weight loss of 10% or more in past three months
  5. Not receiving TPN
  6. CD4 less than 50mm3
  7. History of successive opportunistic infections
  8. Karnofsky score of 5 or less
  9. ADL score of 12 or less
  10. Descriptive score of 16 or less.

Cardiac Disease

  1. Frequent medication adjustments
  2. Refractory edema
  3. Dependent edema
  4. Increasing chest pain - duration and/or frequency
  5. Change in symptomology
  6. Change in acuity level
  7. Confinement to bed
  8. Other current disease
  9. Dyspnea with minimal exertion
  10. Elevated BUN
  11. Multiple cardiac medications
  12. Abnormal EKG or ejection fraction
  13. IF CHF or Cardiomyopathy: Evidence of fluid overload in spite of medications (peripheral edema, ascities, rales)
  14. CHF/ASHD/ASCVD/Ischemic heart disease: History or evidence of angina, arrhythmias, previous myocardial infarctions
  15. Karnofsky score of 6 or less
  16. ADL score of 20 or less
  17. Descriptive score of 20 or less.

End Stage Alzheimer's Disease/Dementia

  1. Speech ability limited to about six words
  2. Intelligible vocabulary limited to a single word
  3. Ambulatory ability lost
  4. Ability to sit up is lost
  5. Ability to smile is lost
  6. Difficulty swallowing
  7. Fecal and urinary incontinence
  8. Score of three of less of Mini Mental Status Exam
  9. Markedly decreased appetite and/or intake
  10. Karnofsky score of 5 or less
  11. ADL score of 12 or less
  12. Descriptive score of 19 or less

7 Stages of Alzheimer's Disease
Stage Difficulties Patient's will experience and skills patient's will lose Average time patient remains at stage before progressing to next stage
Normal Adult None 50 years
Normal Elderly Adult Some forgetfulness; some dificulty recalling names and dates 15 years
Possible Very Elderly Alzheimer's Disease Some problems at work; family and friends notice memory problems; patient may get lost when traveling to new places. 7 years
Mild Alzheimer's Disease Trouble performing complex tasks such as heandling money, planning a dinner for guest, shopping; patient tends to wander and get lost in familiar places. 2 years
Moderate Alzheimer's Disease Needs help putting on clothes, bathing and toleting
Urinary incontinence
Fecal incontinence, may speak in incomplete sentence 		5 months

4 months
10 months
Severe Alzheimer's Disease Can only speak about six words
Makes sounds but speaks one word at most
Unable to walk
Cannot sit up
Does not smile, can not hold up head 		12 months
18 months
12 months
18 months
Final Stage

Huntington's Disease

  1. Sever chorea or rigid or bradykientic
  2. Nonverbal
  3. Bedridden
  4. Global dementia (while retaining a degree of comprehension)
  5. Swallowing difficulty with weight loss
  6. Incontinence

End Stage CVA

  1. Markedly decreased appetite and or intake
  2. Chair or bed bound
  3. Karnofsky score of 4 or less
  4. ADL score of 8 or less
  5. Descriptive score of 18 or less

End Stage Renal Disease

  1. BUN greater than 75mg/dll, Creatinine greater than 5U?L
  2. Discontinuing or refusing dialysis
  3. Chronic or acute illness that precipitated renal failure.
  4. Karnofsky score of 6 or less
  5. ADL score of 20 or less
  6. Descriptive score of 22 or less

End Stage Liver Disease

  1. Documentation of specific liver disease in history and physical
  2. Abnormal liver enzymes; Alkaline Phosphates, SGOT, and Bilirubin
  3. Jaundiced
  4. Ascities
  5. Edema
  6. Abnormal coagulation - Elevated prothrombine
  7. Karnofsky score of 6 or less
  8. ADL score of 20 or less
  9. Descriptive score of 19 or less

Cancer/Malignancy

  1. Diagnosis confirmed through pathology or radiology
  2. Patient is no longer receiving curative treatment*
  3. Evidence of end stage disease or metastasis.
  4. Lab/diagnostic studies that show progression
  5. Karnofsky score of 5 or less
  6. ADL score of 18 or less
  7. Descriptive score of 25 or less
*patients who are receving palliative radiation therapy or chemotherapy will be evaluated for admission on an individual basis.

Karnofsky Scale
(circle the appropriate score)

10 Normal, no complaints, no evidence of disease.
9 Able to carry on normal activity; minor signs and symptoms of disease
8 Normal activity with effort; some signs and symptoms of disease
7 Cares for self, but unable to carry on normal activity or do active work
6 Requires occasional assistance, but can care for most of own needs.
5 Requires considerable assistance and frequent medical care
4 Disabled; requires special care and assistance
3 Severely disabled; hospitalization would be indicated although death is not imminent
2 Hospitalization would be necessary, very sick, active supportive treatment necessary.
1 Moribund, fatal process progressing rapidly
0 Dead

Modified ADL
(Activities of Daily Living)
Bathing
4 Independent
3 Uses a device (shower stool, etc)
2 Needs personal assistance (in and out of tub)
1 Completely dependent

Dressing>
4 Independent
3 Uses a device (i.e. reacher)
2 Needs personal assistance (buttoning, choosing clothes)
1 Completely dependent

Toileting
4 Independent
3 Uses a device (walker or cane)
2 Needs personal assistance
1 Completely dependent

Transfer
4 Independent
3 Uses a device (walker or cane)
2 Needs personal assistance
1 Completely Dependent

Continence
4 Independent
3 Uses a device independently (urinal or bedpan)
2 Needs personal assistance (positioning on bedpan, etc)
1 Completely Dependent (catheter or diapers)

Feeding
4 Independent
3 Uses a device
2 Needs personal assistance from another
1 Completely Dependent (feeding tube or not eating)

Score _______

Description Scale
Anorexia No Fluids Some Fluids Some Soft Food Decreased Intake Normal
Cachexia Skin And bones Extreme Cachexia Very thin Normal Heavy build
Mobility Unable to Sits up
Turn over		 Bears weight Limited Normal walking
Pain Incapacitated Severe Moderate Mild None
Dyspnea Incapacitated Severe Moderate Mild None

Score ______
Karnofsky Score _______ ADL Score _______ Description Score _______