Who qualifies for hospice? The guidelines doctors use, illness by illness

Only a doctor can say whether someone qualifies for hospice. Under Medicare’s rules, the hospice physician and the person’s own doctor certify that their life expectancy is six months or less if the illness runs its normal course.² That’s a judgment, and doctors make it with help. The Medicare contractor that reviews hospice care in California publishes guidelines for it, illness by illness, in a coverage policy called “Hospice - Determining Terminal Status.”¹

This note puts those guidelines into plain language, so families know what doctors look for. They’re guidelines, not a test. The policy says so itself: some patients may not meet these guidelines, yet still have a life expectancy of six months or less.¹

The short answer

• Two doctors certify a life expectancy of six months or less if the illness runs its normal course.²
• A person can qualify through a documented decline of any kind, or through general guidelines together with the guidelines for their illness.¹
• Not every item has to be met. The policy allows coverage when other documentation supports the prognosis.¹
• Other illnesses count too, when they add to the picture.¹
• If someone doesn’t qualify yet, palliative care can help now, and the question can be asked again when things change.

Two ways to qualify

A decline that’s documented. The first path is a decline in the person’s condition that the record shows over time.¹ That can look like:

• The illness getting worse, in symptoms, signs or lab results
• Doing less for themselves, measured on scales like the Palliative Performance Scale
• More trips to the emergency room, more hospital stays or more doctor visits
• Needing help with more of daily life
• Pressure sores that keep getting worse despite good care

General guidelines plus the illness. The second path starts with two general guidelines: the person’s ability to function is below 70% on the Karnofsky or Palliative Performance Scale, and they depend on help for two or more everyday activities, such as eating, walking, using the toilet, moving from bed to chair, bathing or dressing.¹ Those two don’t qualify someone on their own. They’re used together with the guidelines for the person’s illness, below.¹

In one picture

Two ways to qualify

1A decline that’s documented.a decline in the person’s condition that the record shows over time

2General guidelines plus the illness.

• below 70% on the Karnofsky or Palliative Performance Scale
• two or more everyday activities
• the guidelines for the person’s illness

Source · cms.gov

Cancer

The guidelines look for cancer that had spread when it was found, or cancer that has progressed to spread from an earlier stage, with a continued decline despite treatment or a decision to stop treatment aimed at the cancer.¹ Some cancers with a poor prognosis, such as small cell lung cancer, brain cancer and pancreatic cancer, may qualify without meeting those items.¹

Heart disease

Two things should be present.¹

• The person is already getting the best treatment for their heart disease, or isn’t a candidate for surgery, or has declined it.
• Their heart failure or chest pain is at Class IV on the New York Heart Association scale, which means discomfort with any physical activity and symptoms that may come even at rest. An ejection fraction of 20% or less supports it but isn’t required.

Other findings add support: heart rhythm problems that resist treatment, a past cardiac arrest, fainting with no clear cause, a stroke caused by a clot from the heart, or HIV.¹

Lung disease

Two things should be present.¹

• Shortness of breath at rest that’s disabling and responds poorly to inhalers, cutting the person’s activity down to something like bed to chair, along with progression such as more emergency visits or hospital stays for lung infections or breathing failure.
• Low oxygen at rest on room air, with an oxygen saturation of 88% or lower, or a high carbon dioxide level.

Right-sided heart failure caused by the lung disease, losing more than 10% of body weight in six months without trying, and a resting heart rate over 100 add support.¹

Dementia

The dementia guideline applies to Alzheimer’s disease and related disorders.¹ It looks for stage 7 or beyond on the Functional Assessment Staging scale, and all of these:

• Can’t walk without help
• Can’t dress without help
• Can’t bathe without help
• Loss of bladder and bowel control, on and off or all the time
• No consistently meaningful speech, with six or fewer words that can be understood

It also looks for at least one of these in the past 12 months: aspiration pneumonia, a kidney infection, sepsis, several deep pressure sores, fever that comes back after antibiotics, or not being able to eat and drink enough, with a 10% weight loss over six months or a low albumin level.¹ There’s more in our note on hospice for dementia.

Stroke and coma

After a stroke, the guidelines look for a very low level of function, below 40% on the Karnofsky or Palliative Performance Scale, and trouble keeping up with food and fluids, shown by weight loss, a low albumin level, choking that speech therapy hasn’t fixed, or severe trouble swallowing.¹ For coma from any cause, they look at specific findings on the third day.¹

ALS

For ALS, the guidelines apply when the person doesn’t choose a tracheostomy with a breathing machine and has critically weakened breathing, severe trouble getting enough nutrition, or both.¹ Breathing is measured by a lung test along with symptoms, and nutrition by trouble swallowing with a weight loss of at least 5%.

Liver disease

The guidelines look for blood tests that show the liver is failing, a raised INR and a low albumin level, along with at least one serious complication: fluid in the belly that doesn’t respond to treatment, an infection of that fluid, kidney failure caused by the liver disease, confusion from the liver disease that doesn’t respond to treatment, or repeated bleeding from swollen veins despite intensive treatment.¹

Kidney disease

The person isn’t seeking dialysis or a transplant, or is stopping dialysis.¹ Lab values then show how far the kidneys have failed, with lower thresholds for people with diabetes. For chronic kidney disease, signs of kidney failure such as very little urine, a dangerously high potassium level or fluid overload that won’t respond to treatment can also support it.¹

When someone doesn’t fit one box

Many people have more than one illness. The guidelines tell doctors to consider other illnesses when their severity is likely to shorten life, including COPD, heart failure, diabetes, neurological disease, kidney failure, liver disease, cancer, HIV and dementia.¹ Two illnesses that each fall short on their own can still add up.

If a doctor says “not yet,” ask what would change the answer, and ask again when the illness changes. In the meantime, palliative care can treat symptoms alongside the person’s other care.

Questions families ask

Does Dad have to meet every item?

No. The policy says some patients may not meet the guidelines yet still have a life expectancy of six months or less, and coverage can be approved when other documentation supports it.¹

Mom has dementia but still says a few words. Can she qualify?

The dementia guideline describes speech limited to six or fewer understandable words, but she may qualify through a documented decline or other illnesses. Ask her doctor.¹

Does someone with cancer have to stop treatment first?

Hospice is for someone who chooses comfort care over treatment meant to cure. The person acknowledges that when they choose hospice.³ The cancer guideline includes declining further treatment aimed at the cancer as one path.¹

Who makes the call?

The hospice physician and the person’s attending physician, if they have one, certify the prognosis.²

Sources

Sources · 3 references

1. Wellpoint Federal, formerly National Government Services, Local Coverage Determination L33393, “Hospice - Determining Terminal Status,” revision effective April 1, 2026. Centers for Medicare & Medicaid Services, Medicare Coverage Database. cms.gov (opens in a new tab)
2. 42 CFR 418.22, “Certification of terminal illness.” Legal Information Institute, Cornell Law School. law.cornell.edu (opens in a new tab)
3. 42 CFR 418.24, “Election of hospice care.” Legal Information Institute, Cornell Law School. law.cornell.edu (opens in a new tab)