Stroke & Coma

Hospice Eligibility Guidelines for Stroke & Coma

Coverage Guidance

The following criteria are provided directly from Medicare guidelines and are used by physicians to support hospice eligibility.

Patients will be considered to be in the terminal stage of stroke or coma (life expectancy of six months or less) if they meet the following criteria.

Stroke:

1. Karnofsky Performance Status (KPS) or Palliative Performance Scale (PPS) of 40% or less;

2. Inability to maintain hydration and caloric intake with one of the following:

   1. Weight loss >10% in the last 6 months or >7.5% in the last 3 months;

   2. Serum albumin <2.5 gm/dl

   3. Current history of pulmonary aspiration not responsive to speech language pathology intervention;

   4. Sequential calorie counts documenting inadequate caloric/fluid intake

   5. Dysphagia severe enough to prevent the patient from receiving food and fluids necessary to sustain life, in a patient who declines or does not receive artificial nutrition and hydration.

Documentation of diagnostic imaging factors which support poor prognosis after stroke include:

For non-traumatic hemorrhagic stroke:

1. Large-volume hemorrhage on CT:

   1. Infratentorial: ≥20 ml.;

   2. Supratentorial: ≥50 ml.

2. Ventricular extension of hemorrhage;

3. Surface area of involvement of hemorrhage ≥30% of cerebrum;

4. Midline shift ≥1.5 cm.;

5. Obstructive hydrocephalus in patient who declines, or is not a candidate for, ventriculoperitoneal shunt.

For thrombotic/embolic stroke:

1. Large anterior infarcts with both cortical and subcortical involvement;

2. Large bihemispheric infarcts;

3. Basilar artery occlusion;

4. Bilateral vertebral artery occlusion.

Coma (any etiology):
Comatose patients with any 3 of the following on day three of coma:

1. Abnormal brain stem response;

2. Absent verbal response;

3. Absent withdrawal response to pain;

4. Serum creatinine >1.5 mg/dl.
   

Documentation of the following factors will support eligibility for hospice care:

Documentation of medical complications, in the context of progressive clinical decline, within the previous 12 months, which support a terminal prognosis:

1. Aspiration pneumonia;

2. Upper urinary tract infection (pyelonephritis);

3. Sepsis;

4. Refractory stage 3-4 decubitus ulcers;

5. Fever recurrent after antibiotics.

Important note

Hospice eligibility is determined by a physician based on the patient’s overall clinical condition. Patients may still qualify even if they do not meet every criterion listed above, as long as documentation supports advanced disease and limited life expectancy.

Download a PDF of these guidelines.

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