1. Difficulty swallowing food or refusal to eat, sufficiently severe that patient cannot maintain sufficient fluid and calorie intake to sustain life, with patient or surrogate refusing tube feedings or parenteral nutritional.
    1. Patients who are receiving tube feedings must have documented impaired nutritional status as indicated by:
      1. unintentional, progressive weight loss of greater than 10 percent over the prior six months.
      2. serum albumin less than 2.5 gm/dl may be a helpful prognostic indicator, but should not be used by itself.

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