Patient must meet all criteria:

  1. Clinical findings of malignancy with widespread, aggressive, or progressive disease as evidenced by increasing symptoms, worsening lab values, and/or evidence of metastatic disease.
  2. Palliative Performance Scale (PPS) < 70%
  3. Refuses further life-prolonging therapy or continues to decline in spite of definitive therapy.

Supporting documentation

  • Hypercalcemia > 12
  • Cachexia or weight loss of 5% in past 3 months
  • Recurrent disease after surgery/radiation/chemotherapy
  • Signs or symptoms of advanced disease (e.g. nausea, requirement for transfusions, malignant ascites or pleural effusion, etc.)

See another guide:
Cachexia/Protein Calorie Malnutrition (Weight Loss)
CVA (Stroke)/Coma
Heart Disease/CHF (Congestive Heart Failure)
Huntington’s Disease
Neurological Diseases
      ALS (Amyotrophic Lateral Sclerosis)
      Muscular Dystrophy
      Myasthenia Gravis
      MS (Multiple Sclerosis)
Pulmonary Disease/COPD (Chronic Obstructive Pulmonary Disease)
Renal (Kidney) Failure

Referenced Tables 
Palliative Performance Scale (PPS)
New York Heart Association (NYHA) Functional Classes
Functional Assessment Staging (FAST) Scale

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