• Fast scale of Stage 7C or beyond
• Inability to ambulate without assistance
• Inability to dress without assistance
• Urinary and fecal incontinence, intermittent or constant
• No consistent meaningful/reality based verbal communications, stereotypical phrases or the ability to speak is limited to a few intelligible words
• Aspiration pneumonia within the last 12 months
• Pyelonephritis or other upper urinary tract infection
• Septicemia
• Decubitus ulcers, Multiple and/or stage 3-4
• Fever, recurrent after antibiotics
• Inability to maintain sufficient fluid and caloric intake demonstrated by either of the following:
  • 10% weight loss during the previous six months
  • Serum albumin <2.5 gm/dl

• Dyspnea at rest
• Vital capacity less than 30%
• The requirement of supplement oxygen at rest
• The patient declines artificial ventilation
• Decline from independent to wheelchair/bedbound status
• Decline from normal to pureed diet
• Oral intake of nutrients and fluid insufficient
• Continuing weight loss
• Dehydration or hypovolemia
• Recurrent aspiration pneumonia
• Stage 3 or Stage 4 decubitus ulcer(s)

• Clinical findings of malignancy with widespread, aggressive, or progressive disease as evidenced by increase symptoms, worsening lab values and/or evidence of metastatic disease
• Palliative Performance <70%
• Refuses curative therapy or continues to decline despite definitive therapy
• Hypercalcemia >12
• Cachexia or weight loss of 5% in 3 months
• Recurrent disease after surgery/radiation/chemo
• Refusal to pursue additional curative or prolonging cancer
• Signs and symptoms of advance disease

• Disabling Dyspnea at rest
• Poor response to bronchodilators
• Decreased functional capacity (ie. Bed to chair existence, fatigue and cough)
• An FEV1 <30% is objective evidence for disabling dyspnea but is not required AND
• Progression of disease as evidenced by a recent history of increase visits to MD office, home or emergency room and/or hospitalizations for pulmonary infection and/or respiratory failure AND
• Documentation within the past three (3) months of a or b or both:
  • Hypoxemia at rest (pO2<55mgHg by ABG) or oxygen saturation <88%
  • Hypercapnia evidence by pC02>55mm Hg
• Cor pulmonale and right heart failure secondary to pulmonary disease
• Unintentional progressive weight loss >10% over the preceding six (6) months
• Resting tachycardia >100bpm

• Poor response to (or patients/loved one’s choice to not pursue) optimal treatment with diuretics, vasodilators, and/or angiotensin converting enzyme inhibitors
• Angina pectoris at rest resistant to standard nitrate therapy and is not a candidate for invasive procedures and/or has declined revascularization procedures
• NYHA Class IV CHF
• Ejection fraction 20% or less
• Treatment resistant symptomatic dysrhythmias
• CVA secondary to cardiac embolism
• History of cardiac arrest or resuscitation

• CD4+ Count <25 cells/mm or persistent viral load >100,000 copies/ml from 2 or more assays at least 1 month apart

AND

• At least one of the following conditions:
  • CNS lymphoma
  • Untreated or refractory wasting loss of >33% lean body mass
  • Mycobacterium avium complex (MAC) bacteremia, untreated, refractory or treatment refused
• Progressive multifocal leukoencephalopathy
• Systemic lymphoma
• Refractory visceral Kaposi’s sarcoma
• Renal failure in the absence of dialysis

• The patient has both 1 and 2:
  • Stage 7 or beyond according to the Functional Assessment Staging Scale with all of the following:
    • Inability to ambulate without assistance
    • Inability to dress without assistance
    • Urinary and fecal incontinence, intermittent or constant
    • No consistent meaningful verbal communication
  • AND 2. Has had at least one of the following conditions within the past 12 months:
    • Aspiration pneumonia
    • Pyelonephritis or other upper urinary tract infection
    • Septicemia
    • Multiple Stage 3 or Stage 4 pressure ulcers
    • Toxoplasmosis unresponsive to therapy
    • Fever, recurrent after antibiotics
    • Inability to maintain sufficient fluid and caloric intake with one or more of the following during the preceding 12 months:
      • 10% weight loss during the previous six months OR
      • Serum albumin

• Prothrombin time PTT prolonged more than five (5) seconds over control or INR>1.5
• Serum albumin <2.5gm/dl
• End-stage liver disease is present, and the patient has one or more of the following conditions:
  • Ascites, refractory to treatment or patient declines or is non-compliant
  • History of spontaneous bacterial peritonitis
  • Hepatorenal syndrome (elevated creatinine with oliguria <400ml/day)
  • Hepatic encephalopathy, refractory to treatment or patient non-compliant
  • History of recurrent variceal bleeding despite intensive therapy or patient declines therapy
• Progressive malnutrition
• Muscle wasting with reduced strength
• Ongoing alcoholism (.80gm ethanol/day)
• Hepatocellular carcinoma
• Hepatitis B surface antigen positive
• Hepatitis C refractory to interferon treatment

• Severely impaired breathing capacity with all of the following findings:
  • Dyspnea at rest
  • Vital capacity less than 30%
  • The requirement of supplement oxygen at rest
  • The patient declines artificial ventilation
  • Decline from Independent to wheelchair/bedbound status
  • Decline from normal to pureed diet
  • Oral intake of nutrients and fluid insufficient
  • Continuing weight loss
  • Dehydration or hypovolemia
  • Recurrent aspiration pneumonia

• Severely impaired breathing capacity
• Dyspnea at rest
• Vital capacity less than 30%
• Progression from independent ambulation to wheelchair/bed bound
• Progression from normal to barely intelligible or unintelligible speech
• Oral intake of nutrients/fluids insufficient to sustain life
• Recurrent aspiration pneumonia
• Upper urinary tract infection
• Sepsis
• Recurrent fever after antibiotic therapy

• Creatinine clearance <10cc/min and <15cc/min for diabetics
• Serum creatinine >8.0 and 6.0 in diabetics
• Not seeking dialysis or transplant
• Uremia
• Oliguria (urine output is less than 400cc in 24 hours)
• Intractable hyperkalemia (greater than 7.0) not responsive to treatment
• Uremia pericarditis
• Hepatorenal syndrome
• Immunosuppression/AIDS
• Intractable fluid overload, not responsive to treatment

• Severely impaired breathing capacity
• Dyspnea at rest
• Vital capacity less than 30%
• The requirement of supplemental oxygen at rest
• The patient declines artificial ventilation
• Progression from independent ambulation to wheelchair/bed bound
• Progression from normal to barely intelligible or unintelligible speech
• Oral intake of nutrients/fluids insufficient to sustain life
• Continuing weight loss
• Dehydration or hypovolemia
• Absence of artificial feeding
• Recurrent aspiration pneumonia
• Upper urinary tract infection
• Sepsis
• Recurrent fever after antibiotic therapy
• Stage 3 or 4 decubitus ulcer(s)

• Palliative Performance Scale 40% or less
• Body Mass Index <22
• Unintentional weight loss (despite tube feeding); 10% in 6 months
• Dysphagia without tube feeding
• Pulmonary aspiration not responsive to speech pathology intervention
• Age >70
• Post stroke dementia, with FAST score of 7C or >
• Medical complications related to progressive clinical decline
• Aspiration pneumonia
• UTIs
• Sepsis
• Skin breakdown; decubitus ulcers; refractory stage 3-4