Hospice eligibility guidelines: stroke and coma

Stroke indicators

The guidance looks for row 1 and row 2 together.

Coma indicators

The guidance looks for any three of the four findings on day three.

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.

Complications that add support

The guidance lists medical complications in the context of progressive clinical decline, within the previous 12 months, that support a terminal prognosis:

• Aspiration pneumonia.
• Pyelonephritis or other upper urinary tract infection.
• Refractory stage 3 to 4 pressure ulcers.
• Fever, recurrent after antibiotics.

Acute stroke versus chronic decline after stroke

In the acute phase, families are often asked to decide about feeding tubes and rehabilitation within days. A patient with a large hemispheric or brain stem stroke, persistent coma or severe dysphagia, whose family chooses comfort-focused care and declines artificial nutrition, is usually appropriate for hospice directly from the hospital. General inpatient care may be considered when medically necessary during a symptom crisis. See levels of care criteria and the discharge planner guide.

In the chronic phase the picture looks more like advanced dementia: progressive dependence, weight loss, aspiration and recurrent infection over months. A patient receiving tube feeding can still be eligible. Document continued weight loss or complications in spite of the feeding.

Imaging findings can support the prognosis in acute stroke. See the LCD for the specific findings it lists.

Supporting documentation

• Date and type of stroke, territory, and imaging reports.
• Level of consciousness and neurologic examination, with dates. For coma, the day-three findings.
• Swallow evaluation and the speech-language pathology recommendation.
• The decision about artificial nutrition and hydration and who made it.
• Weights with dates and percent change. Albumin if drawn. Calorie counts if done.
• Infections, pressure injuries and hospitalizations in the past 12 months.
• PPS or KPS score and earlier scores.

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.

Atrial fibrillation, heart failure, diabetes, prior strokes and vascular dementia are common here and should be recorded with their current severity.

Not sure? Call

After a severe stroke, families need time and clear information more than they need a fast decision. 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 after a stroke, 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.