1. The patient and/or family have elected treatment goals directed toward relief of symptoms, rather than cure of the underlying disease.
  2. The patient has either of the following:
    1. Documented clinical progression of disease, which may include:
      1. Progression of the primary disease process as listed in disease-specific criteria, as documented by serial physician assessment, laboratory, radiologic, or other studies.
      2. Multiple Emergency Department visits or inpatient hospitalizations over the prior six months.
      3. For homebound patients receiving home health services, nursing assessment may be documented.
      4. For patients who do not qualify under 1, 2 or 3, a recent decline in functional status may be documented.
        1. Functional decline should be recent, to distinguish patients who are terminal from those with reduced baseline functional status due to chronic illness. Clinical judgment is required for patients with a terminal condition and impaired status due to a different nonterminal disease; e.g., a patient chronically paraplegic from spinal cord injury who is recently diagnosed with cancer.
        2. Diminished function status may be documented by either:
          1. Karnofsy Performance Status of less than or equal to 50 percent, or
          2. Dependence in at least three of six Activities of Daily Living. "Activities of Daily Living" are:
            1. bathing
            2. dressing
            3. feeding
            4. transfers
            5. continence of urine and stool
            6. ability to ambulate independently to bathroom

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