The purpose of these worksheets is to guide initial and recertification assessments. These are guidelines only: clinical judgment is required in each case.

In attempting to determine a patient's appropriateness for hospice, many physicians find it helpful to ask themselves: "If my patient continues to decline over the next 6 months as he/she has in the past 6 months, will my patient be with me this time next year?" If your best clinical judgment says, "No," then your patient may benefit from a hospice referral.

Each person's disease process may progress at a different rate, but hospice may be considered as an option for your patient when curative measures are no longer effective and/or appropriate. Because we care for both the patient and his/her family, time is needed to stabilize symptoms and to build relationships so everyone is as prepared as possible for the final transition.

Please select the appropriate worksheet for your patient:

General Guidelines (all diagnoses)

Other supporting documentation specifying a terminal diagnosis may include: co-morbidity that affects the prognosis, history and progression of the illness, physical baseline (e.g. weight and weight change, vital signs, heart rhythms, rales, degree of edema), pertinent laboratory and/or diagnostic results.