Good Samaritan Hospice - Roanoke, Virginia

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PHYSICIAN'S LINK:

Hospice Determining Terminal Status LCD

Welcome to the Physician Test
Determining when a patient is appropriate for hospice is difficult and involves many factors. We have identified the factors that most often indicate that hospice may be appropriate. Please answer the questions below. When you click "Please tally results," we will calculate medical appropriateness for hospice based on these answers. At that time you will be able to print the results or contact us for more information. We have trained staff ready to assist you and your patients. All questions are completely optional. However, to get the most accurate results, please answer as many as you can.
1. Does your patient have a serious chronic or terminal illness?
Yes No
2. How much weight has your patient unintentionally lost in the past month?
No weight loss 1-3 pounds 4-6 pounds More than 6 pounds
3. Has your patient experienced an infection, such as pneumonia or urinary tract infection in the past 3 months?
Yes No
4. Has your patient been hospitalized or seen in the emergency room in the past 3 months?
Yes No
5. Does your patient experience shortness of breath while at rest or sitting?
Yes No
6. What level of assistance with personal care (such as bathing or going to the bathroom) does your patient need?
Total care Some assistance No assistance - completely independent
7. Which of the following diseases does your patient have? (check all that apply)
Lung disease Heart disease Kidney disease Cancer Dementia (such as Alzheimer’s disease) Stroke Diabetes Liver disease HIV / AIDS Other
8. Would you be surprised if the patient died within the next 6-12 months?
Yes No
9. Has the patient or family began to ask probing questions of you, such as "how much longer," "is this really worth it" or simply expressed being "tired?"
Yes No
10. How old is your patient?

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