Both 1 and 2 must be present as evidence of hospice appropriateness.

1. Is patient severely demented?
Patient should be at or beyond Stage 7 of the Functional Assessment Staging Scale.

_____ 7A Ability to speak is limited to approximately 6 intelligible words or fewer, in the course of an average day or in the course of an intensive interview.
_____ 7B Speech ability is limited to the use of a single intelligible word in an average day or in the course of an intensive interview (the person may repeat the word over and over).
_____ 7C Ambulatory ability is lost (cannot walk without personal assistance).
_____ 7D Cannot sit up without assistance (e.g. patient will fall over if there are not lateral rests (arms) on the chair).
_____ 7E Loss of ability to smile.
_____ 7F Loss of ability to hold up head independently.

Patient should show all of the following characteristics.

_____ inability to ambulate independently (cannot walk without personal assistance)
_____ unable to dress without assistance
_____ unable to bathe properly
_____ incontinence of urine and stool (occasionally or more frequently, over the past weeks as reported by a knowledgeable informant or caregiver)
_____ unable to speak or communicate meaningfully (see 7A above)

2. Has the patient had one or more of the following medical complications related to dementia during the past year? (Conditions should have been severe enough for hospitalization, whether or not hospitalization occurred)

_____ aspiration pneumonia
_____ decubitus ulcers, multiple, stage 3-4
_____ upper urinary tract infection
_____ septicemia
_____ fever recurrent after antibiotics
_____ inability or unwillingness to take food or fluids sufficient to sustain life;
not a candidate for feeding tube or parenteral nutrition

Patients who are receiving tube feedings must have documented impaired nutritional status as indicated by either:

_____ unintentional, progressive weight loss of greater than 10% over prior 6 months, or
_____ serum albumin less than 2.5 gm/dl
(may be helpful prognostic indicator but should not be used by itself)