Referral Form
Admission Criteria
Admission criteria for Victory Hospice were established following the Medical Guidelines published by the National Hospice Organization. This criteria is used to help identify and evaluate patients as to their appropriateness for admission to Victory Hospice. Not all criteria must be met for admission.
The attending physician and the Hospice Medical Director must certify that a patient has a prognosis of six months or less to live if health situation continues to decline. |
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End-Stage Alzheimer's Disease
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Bed bound or chair bound |
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Unable to effectively communicate with words |
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Markedly decreased appetite and/or intake |
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Karnofsky score of 5 or less |
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ADL score of 12 or less |
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Descriptive score of 19 or less |
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End-Stage AIDS
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Patient is not receiving TPN |
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Patient is not receiving AZT or IV medications other than for pain relief |
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CD4 less than 50mm3 |
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History of successive opportunistic infections |
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Karnofsky score of 5 or less |
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ADL score of 12 or less |
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Descriptive score of 16 or less |
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End-Stage Cardiac Disease
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Dyspnea with minimal exertion |
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Azptemia as evidenced by elevated BUN |
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Multiple cardiac medications |
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Abnormal EKG or ejection fraction |
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If CHF or Cardiomyopathy: Evidence of fluid overload in spite of medications (peripheral edema, ascites, rales) |
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If CHF/ASHD/ASCVD/Ischemic heart disease; History or evidence of angina arrhythmias, previous myocardial infarctions |
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Karnofsky score of 6 or less |
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ADL score of 20 or less |
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Descriptive score of 20 or less |
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End-Stage Cerebral Vascular Disease
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Markedly decreased appetite and/or intake |
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Bed bound or chair bound |
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Karnofsky score of 4 or less |
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ADL score of 8 or less |
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Descriptive score of 18 or less |
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End-Stage Diabetes
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History of diabetes for more than 20 years |
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Severe vascular disease
Cardiac, MI, Angina, CHF
Cerebral: CVA
Peripheral: Amputation, Ulcers
Hypertension, Severe |
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Frequent infections |
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Karnofsky score of 5 or less |
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ADL score of 12 or less |
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Descriptive score of 21 or less |
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End-Stage Liver
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Documentation of specific liver disease in history & physical |
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Abnormal liver enzymes: |
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Alkane Phosphatase, SGOT, and Bilirubin |
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Jaundiced |
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Ascites |
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Edema |
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Abnormal coagulation |
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Elevated Prothrombine Time |
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Karnofsky score of 6 or less |
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ADL score of 20 or less |
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Descriptive score of 19 or less |
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End-Stage Neurological Disease
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Bed bound or Chair bound |
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Patient has no ventilator support |
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Karnofsky score of 5 or less |
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ADL score of 8 or less |
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Descriptive score of 21 or less |
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End-Stage Pulmonary Disease
COPD, Emphysema, Bronchitis, Cystic Fibrosis, Bronchiectasis, Pulmonary Fibrosis, Black Lung
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No ventilator support |
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On multiple pulmonary medications |
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Oxygen dependent |
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Minimal activity results in severe dyspnea |
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Karnofsky score of 5 or less |
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ADL score of 18 or less |
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Descriptive score of 20 or less
If possible, obtain other information, including:
Recent ABGs or PFTs
Information about most recent hospitalizations
Date last seen by physician |
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End-Stage Renal Disease
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BUN greater than 75mg/dl
Creatimine greater than 5 U/L |
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Discontinuing or refusing dialysis |
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Chronic or acute illness that precipitated renal failure |
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Karnofsky score of 6 or less |
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ADL score of 20 or less |
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Descriptive score of 22 or less |
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Cancer/Malignancy
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Diagnosis confirmed through pathology or radiology |
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Patient is no longer receiving curative treatment* |
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There is evidence of end stage disease and/or metastasis |
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Lab/diagnostic studies have been done recently to support disease progression |
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Karnofsky score of 5 or less |
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ADL score of 18 or less |
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Descriptive score of 25 or less
*patients who are continuing to receive palliative radiation therapy or chemotherapy will be evaluated for admission on an individual basis
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Or you can print out this form to fax or discuss when you contact us.
