Protein Calorie Malnutrition as a Hospice Diagnosis

Diagnostic Criteria for PCM as a Hospice Diagnosis

• Protein calorie malnutrition (PCM) is defined as a condition of decreased body stores of protein and energy fuel that can occur regardless of cause and is associated with diminished functional capacity related to metabolic stresses 1
• Severe PCM is characterized by weight loss of >10% within the past 6 months or >20% beyond 6 months 1
• For hospice eligibility, PCM should be accompanied by progressive decline despite nutritional interventions 2, significant functional impairment with reduced physical capacity 3, and evidence of disease burden/inflammation from an underlying terminal condition 1

Clinical Manifestations Supporting Hospice Eligibility

• Advanced PCM presents with sarcopenia (loss of muscle mass and strength) 4

Assessment Methods for PCM in Hospice Evaluation

• Weight and height measurements to calculate BMI, corrected for fluid retention when applicable, can be used to assess PCM 1
• Handgrip strength can be used as a functional measure of nutritional status 5
• Serum proteins (albumin, prealbumin) can reflect nutritional changes 1
• Total lymphocyte count can be used as an indicator of immune function 1
• Functional assessment using validated scales such as WHO or Karnofsky scale can be used to evaluate PCM 1

Special Considerations in Different Populations

• In liver disease, PCM is found in 65-90% of patients with end-stage liver disease 6, 7
• Weight loss should not be recommended in patients with decompensated end-stage liver disease due to risk of worsening PCM 7
• Accurate estimation of nutritional status is difficult due to fluid retention in liver disease 7

Hospice Eligibility Criteria Related to PCM

• PCM qualifies as a hospice diagnosis when it is accompanied by progressive functional decline 3 and evidence of irreversible disease progression 1
• The condition has significant impact on mortality and quality of life 2

Management Considerations in Hospice Care

• Focus on comfort and quality of life rather than aggressive nutritional repletion 3
• Oral nutritional supplements may be used for comfort if tolerated 8
• In terminal, demented, or dying patients, parenteral nutrition should only be given in accordance with other palliative treatments 3

Pitfalls and Caveats

• Fluid retention in conditions like liver or kidney disease may mask the severity of weight loss 5
• Ensure comprehensive assessment before determining PCM as the primary hospice diagnosis 1