Hospice eligibility guidelines: liver disease

Liver disease indicators

The guidance looks for both laboratory findings in row 1 and at least one complication from row 2.

Read this table together with the general decline indicators and the non-disease-specific baseline (functional status and dependence in activities of daily living) on the eligibility guidelines overview.

Transplant candidates and other practical points

The guidance states that patients awaiting liver transplant who otherwise fit the indicators may be certified for the Medicare hospice benefit, but if a donor organ is procured the patient should be discharged from hospice. Tell us the transplant listing status at referral.

INR is unreliable as a marker of liver function in a patient taking warfarin. Albumin is affected by infusions and by nutrition. Note these where they apply. MELD and Child-Pugh scores are not part of the LCD guidance, but they are useful supporting information if already calculated.

Paracentesis for comfort can be part of a hospice plan of care. We review whether a scheduled paracentesis, care of an existing peritoneal drain or both are needed, and coordinate the ordering clinician, procedure setting, transport, follow-up, supplies and caregiver instructions, confirming the provider and financial arrangement before scheduling.

Supporting documentation

• Cause of liver disease and how cirrhosis was established.
• Recent PT or INR, albumin, bilirubin, creatinine and sodium with dates.
• Ascites history: diuretic doses, frequency and volume of paracentesis, episodes of peritonitis.
• Encephalopathy history: grade, frequency, precipitants, lactulose and rifaximin use and response.
• Variceal bleeding history and any procedures.
• Hepatology or transplant team note on candidacy and the patient's decision.
• Alcohol use status.
• Weight and muscle mass trends, interpreted with fluid status in mind. PPS or KPS score.
• Hospitalizations in the past six months.

Comorbidities

The LCD guidance also weighs comorbidities. The presence and severity of conditions such as chronic obstructive pulmonary disease, congestive heart failure, ischemic heart disease, diabetes, neurologic disease (stroke, ALS, multiple sclerosis, Parkinson's disease), renal failure, liver disease, malignancy, AIDS and dementia can support a prognosis of six months or less even when the primary diagnosis alone does not. Document each one with its current severity and how it limits the patient.

Renal dysfunction is the comorbidity with the strongest effect on survival in cirrhosis. Recurrent infection and hepatocellular carcinoma follow.

Not sure? Call

Patients with decompensated cirrhosis often cycle through admissions for the same complication before anyone raises hospice. Prognosis is rarely clear cut. If you are weighing a referral, call and talk the case through with a hospice nurse, or ask for a physician-to-physician conversation with our medical director. A call is not a referral and does not commit the patient to anything.

If the patient is not hospice eligible now, we will say so and tell you what we would watch for. Some patients are better served by palliative care first. When you are ready, use Refer a patient. The hospice medical director, with the attending physician if there is one, makes the certification decision under 42 CFR 418.22.

A page you can share with the family

Families often ask the same questions you are weighing, in different words. Our family guide, hospice care for liver disease, explains in plain language what hospice does for this illness, what signs are worth raising with a doctor or nurse, and how care is paid for. It does not give an eligibility verdict. You are welcome to share it before or after a goals-of-care conversation.