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Hospice Admission Guidelines for Patients with End-Stage Sepsis/Septic Shock

Sepsis is a life-threatening organ dysfunction due to a dysregulated immune response to infection. Most commonly, the infection is bacterial, but it may also stem from fungi, viruses or parasites. Sepsis can lead to tissue damage, organ failure and death.

Common locations for the primary infection include: blood, lungs, brain, urinary tract, skin and abdominal organs.

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Clinical Characteristics of Sepsis

Healthcare providers use a quick sepsis-related organ failure assessment (qSOFA) score to identify patients with the highest risk for infection complications. A qSOFA score indicating the presence of at least two critical criteria is associated with heightened mortality rates:

  • Increased breathing rate: ≥22 breaths per min
  • Change in level of consciousness: Glasgow coma scale < 15
  • Low blood pressure: SBP ≤100 mmHg

Clinical Progression of Sepsis

Sepsis manifests in three stages:

  1. Sepsis, in which systemic inflammatory response syndrome occurs due to infection
  2. Severe sepsis, in which sepsis results in organ dysfunction and produces the following symptoms:
    • Significantly decreased urine output
    • Abrupt change in mental status
    • Decrease in platelet count
    • Difficulty breathing
    • Abnormal heart pumping function
    • Abdominal pain

    As sepsis worsens, blood flow to vital organs, such as the brain, heart and kidneys, becomes impaired. Sepsis can also cause blood clots to form in organs and throughout the extremities— arms, legs, fingers and toes—leading to varying degrees of organ failure and gangrene. Approximately 30 percent of patients diagnosed with severe sepsis do not survive.

  3. Septic shock, in which severe sepsis manifests with extreme, persistent hypotension. The mortality rate for septic shock is nearly 50 percent.

Risk Factors of Sepsis

  • Very young or old age
  • Chronic illness
  • Weakened immune system due to:
    • HIV
    • Cancer treatments
    • Transplant drugs
    • Diabetes
    • Major trauma
  • Invasive devices, including:
    • Intravenous catheters
    • Breathing tubes
    • VADs
  • Presence of drug-resistant bacteria

Laboratory, Testing and Exam Indicators of Sepsis

Systemic inflammatory response syndrome as manifested by:

  • Temperature <36 °C (96.8 °F) or >38 °C (100.4 °F)
  • Heart rate >90/min
  • Respiratory rate >20/min or PaCO2<32 mmHg (4.3 kPa)
  • WBC <4x109/L (<4000/mm³), >12x109/L (>12,000/mm³), or 10% bands
  • Other—standard cultures, X-rays and imaging for infection
  • Elevated lactic acid and C-reactive protein (CRP), Prothrombin time and partial thromboplastin time (PT and PTT), platelet count, and d-dimer
  • Endotoxin Limulous amoebocyte lysate (LAL) indicating gram negative bacteria in bloodstream
  • Procalcitonin (PCT), a blood protein indicative of bacterial infection
  • SeptiCyte—measures the products of sepsis-related genes to see if those genes are activated; highly sensitive and specific for infection-induced inflammation and organ dysfunction

Hospice Eligibility for Sepsis Patients

Patients are eligible for hospice care when a physician makes a clinical determination that life expectancy is six months or less if the condition or comorbid disease runs its expected course.

However, sepsis referrals to hospice most often occur under the category of acute causes of death. A request for patient evaluation usually arises late in a disease process that is rapid and progressive, and therefore requires immediate attention by admissions personnel.

VITAS provides these guidelines as a convenient tool. They do not take the place of a physician's professional judgment.