Hospice eligibility guidelines: pulmonary disease

Pulmonary disease indicators

The guidance looks for severe disease (both parts of row 1) plus a gas exchange finding (row 2). Row 3 adds support.

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.

Applying the guidance to different lung diseases

The guidance says the indicators apply to the various forms of advanced pulmonary disease that follow a final common pathway, so it covers COPD, pulmonary fibrosis, bronchiectasis and others. Bronchodilator response is less relevant in restrictive disease. In pulmonary fibrosis, rapidly rising oxygen needs are often the clearest marker.

Room-air values can be hard to obtain in a patient who cannot safely come off oxygen. Do not remove oxygen only to produce a number. Use recent hospital values if they exist, or document the oxygen flow needed to maintain saturation and why a room-air reading was not attempted.

Supporting documentation

• Dyspnea described in functional terms: at rest, with speech, with dressing, distance walked.
• Oxygen prescription and flow, with changes over time. Use of noninvasive ventilation.
• Most recent blood gas or oximetry values, with date and whether on room air.
• Pulmonary function tests if already done. New tests are not needed.
• Hospitalizations, emergency visits, intubations and steroid or antibiotic courses in the past 12 months.
• Weight trend and body mass index.
• Echocardiogram or clinical evidence of right heart failure.
• The patient's wishes about intubation and hospital transfer.
• PPS or KPS score and dependence in activities of daily living.

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.

Heart failure, lung cancer, and anxiety or panic linked to breathlessness are common in this group. The first two affect prognosis. The last affects symptom burden and is a frequent reason for emergency visits, so the plan of care should address it.

Not sure? Call

COPD has a long, uneven course, and many patients die during an exacerbation that looked like the ones before it. 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 COPD and lung 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.