Hospice eligibility guidelines: renal disease

What are the hospice eligibility indicators for renal disease?

Hospice eligibility for renal disease under the Medicare LCD guidance requires row 1, a patient not seeking or discontinuing dialysis or transplant, plus either row 2, creatinine clearance, or row 3, serum creatinine. The remaining rows add 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.

Dialysis and the hospice benefit

A patient who stops dialysis is appropriate for hospice at the time of the decision, because most patients who stop dialysis die within days to a few weeks, depending on residual renal function. A referral before the last treatment allows symptom plans to be in place.

A patient on dialysis can elect hospice. When end-stage renal disease is the terminal diagnosis, dialysis is related to the terminal illness, so continuing it is a plan-of-care and payment question for the hospice. When the terminal diagnosis is unrelated to the kidney failure, for example a cancer, Medicare can continue to pay for dialysis under the ESRD benefit. Tell us the dialysis status at referral. When the terminal diagnosis is renal, dialysis goals and the hospice plan are reviewed before admission, including who would provide dialysis, how transport and coordination would work, and who pays; no routine continuation or separate payment is assumed.

Estimated GFR is what most records now report in place of measured creatinine clearance. The guidance was written in terms of creatinine clearance. Report what you have, and note body size and muscle mass, because a low serum creatinine in a frail, wasted patient can understate the degree of failure.

What documentation supports hospice eligibility in renal disease?

Documentation that supports hospice eligibility in renal disease includes:

• Cause and duration of kidney disease. Recent creatinine, estimated GFR, potassium and bicarbonate with dates.
• Nephrology note documenting the discussion of dialysis and transplant and the patient's decision.
• For patients stopping dialysis: schedule, access, date of last planned treatment, and residual urine output.
• Volume status, urine output, and response to diuretics.
• Uremic symptoms: nausea, pruritus, confusion, restless legs, anorexia.
• Weight and albumin trends. PPS or KPS score.
• Hospitalizations in the past six months.

How do comorbidities affect hospice eligibility in renal disease?

The Medicare hospice LCD guidance weighs comorbidities as well as the primary diagnosis. 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.

Diabetes and heart failure are written into the renal thresholds themselves. Dementia, peripheral vascular disease and frailty also shorten survival in this group and often drive the decision to forgo dialysis.

What if you are not sure a patient is eligible for hospice?

If you are not sure a patient is eligible for hospice, call Beta Hospice 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. Conservative kidney management without dialysis can last months, and the point at which hospice fits is not always obvious. Prognosis is rarely clear cut.

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

Beta Hospice's family guide, hospice care for kidney failure, 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. Families often ask the same questions you are weighing, in different words. You are welcome to share it before or after a goals-of-care conversation.