The patient should meet the following criteria:

1. Life limiting condition

2. Patient/Family informed that condition is life threatening

3. Patient/Family elected palliative care

4. Documentation of clinical progression of disease evidenced by:

___ serial physician assessment
___ laboratory studies
___ radiologic or other studies
___ multiple Emergency Department visits
___ inpatient hospitalizations
___ home health nursing assessment if patient is home bound

and/or

5. Recent decline in functional status, evidenced by either:

A. Karnofsky Performance status < 50%

___ 50% Requires considerable assistance and frequent medical care
___ 40% Disabled; required special care and assistance
Unable to care for self; disease may be progressing rapidly
___ 30% Severely disabled; although death is not imminent
___ 20% Very sick; active support treatment necessary
___ 10% Moribund; fatal processes progressing rapidly

and/or

B. Dependence in 3 of 6 Activities of Daily Living

___ Bathing
___ Dressing
___ Feeding
___ Transfers
___ Continence of urine and stool
___ Ambulation to bathroom

and/or

6. Recent impaired nutritional state, evidenced by:

___ Unintentional, progressive weight loss of 10% over past 6 months
___ Serum albumin less than 2.5 gm/dl
(may be helpful prognostic indicator but should not be used by itself)