A stroke occurs when blood flow is interrupted to part of the brain. Without blood to supply oxygen and nutrients and to remove waste products, brain cells quickly begin to die. Depending on the region of the brain affected, a stroke may cause paralysis, speech impairment, loss of memory and reasoning ability, coma, or death. A stroke also is sometimes called a brain attack or a cerebrovascular accident (CVA).
Patients will be considered to be in the terminal stage of stroke or coma if they meet the following criteria. Criteria 1 & 2 are important indicators of functional and nutritional status and will support a terminal prognosis for patients with diagnosis of stroke. Number 3 will lend support.
1. Poor functional status with a Palliative Performance Scale (PPS) of 40 or less. All criteria in number 1 should be met:
- Mainly bed-bound
- Unable to work
- Requires maximal assistance to perform self-care
- Food/fluid intake are normal/reduced
- Either fully conscious or drowsy/confused
2. Inability to maintain hydration and caloric intake with ONE of the following:
- Weight loss >10% during previous 6 months
- Weight loss > 7.5% in previous 3 months
- Serum albumin
- Current history of pulmonary aspiration without effective response to speech language pathology interventions to improve dysphagia and decrease aspiration events.
- Calorie counts documenting inadequate caloric/fluid intake.
- Dysphagia severe enough to prevent the patient from receiving food/fluid that is necessary to sustain life in a patient who does not receive artificial nutrition/hydration.
3. Documentation of medical complications within the previous 12 months, in the context of progressive clinical decline, will help support eligibility for hospice care.
- Recurrent or intractable infections such as pneumonia or other URI
- Urinary tract infection
- Refractory stage 3-4 decubitus ulcers
- Fever recurrent after antibiotics
The medical criteria listed below would support a terminal prognosis for individuals with a diagnosis of coma (any etiology). Comatose patients with any 3 of the following on day three of coma are considered terminal:
- Abnormal brain stem response
- Absent verbal response
- Absent withdrawal response to pain
- Serum creatinine >1.5 mg/dl
If a patient meets the medical criteria above, they are by definition eligible to receive hospice services. Some patients may not meet the criteria, but may still be eligible for hospice care due to comorbidities or rapid functional decline. Contact your local Compassus program for further information.