1 and 2 should be met
1. Severe Chronic Lung Disease (a and be should be met)
a. Disabling dyspnea at rest as evidenced by; (one must be met)
i. Poorly responsive or unresponsive to bronchodilators, resulting in decreased fuctional capacity (e.g. bed to chair existence, fatigue and cough)?
ii. Documentation of Forced Expiratory Volume in One Second (FEV1) after bronchodilator, less than 30% of predicted (if available)?
b. Progression of end-stage pulmonary disease as evidenced by; (one must be met)
i. Increasing visits to ER?
ii. Hospitalization for pulmonary infections?
iii. Respiratory failure?
iv. Increasing physician home visits (prior to hospice admission)?
v. Documentation of serial decrease of FEV1 > 40 ml/year (if available)?
2. Hypoxia (at lease one should be met)
a. Hypoxemia at rest on room air, as evidenced by pO2 < less than or equal to 55 mmHg?
b. O2 Sat less than or equal to 88% determined either by arterial blood gases or O2 saturation monitors? (these values may be ovtained from recent hospital records)
c. Hypercapnia, as evidenced by pCO2 greater than or equal to 50 mmHg? (This value may be obtained from recent (within 3 months) hospital records)
3. Right Heart Failure (RHF) - Supporting Factors
- Right Heart Failure (RHF) secondary to pulmonary disease (Cor pulmonale)? (e.g. not secondary to left heart disease or valvulopathy)
4. Unintentional Progressive Weight Loss - Supporting Factors
- Unintentional progressive weight loss > or = 10% of body weight over last six months?
5. Resting Tachycardia - Supporting Factors
- Resting Tachycardia > 100/min