Table 2.

Medicare hospice guidelines relevant to movement disorders and additional red flags to trigger end-of-life care and conversations

Condition	Triggers
General [85]	1. Terminal Illness with expected prognosis of 6 months or less 2. Rapid Decline over 3–6 months including: progression of disease signs, symptoms and testing; decline in PPS ≤ 40%; involuntary weight loss and/or albumin <2.5 g/dL
Dementia [85]	1. Stage 7C or beyond according to FAST Scale [96] AND 2. One or more in the past 12 months: a. Recurrent aspiration pneumonia, pyelonephritis, sepsis b. Multiple decubitus ulcers (stage 3 or 4) c. Recurrent fever d. Inability to maintain sufficient fluid and calorie intake in past 6 months (10% weight loss or albumin <2.5) e. Other significant condition that suggests limited prognosis
Chronic neurodegenerative disease (movement disorders, neuromuscular diseases) [85]	1. Critically Impaired Breathing including dyspnea at rest, oxygen supplementation at rest, VC < 30%, with goal of care to avoid artificial ventilation OR 2. Rapid Disease Progression (transition to wheelchair or bed-bound status, unintelligible speech, need for dysphagia diet and/or major assistance for ADLs) with one of the following in the past 12 months: a. Critical nutrition impairment (inability to maintain sufficient fluid/caloric intake, weight loss, dehydration, and goal of care to avoid artificial feeding strategies) OR b. Life threatening complications (recurrent aspiration pneumonia, pyelonephritis, sepsis, recurrent fever, or advanced pressure ulcers (Stage 3 or 4)
Movement Disorders:
PD [54, 97]	1. Weight loss or low body mass index 2. Reduction in dopaminergic therapies secondary to loss of efficacy or increased side effects 3. Dysphagia limiting ability to take antiparkinsonian medication, with goal of care to avoid PEG tube placement 4. Severe behavioral disturbances (e.g. agitation, delirium) 5. Advanced dementia (see above)
DLB [87, 88]	1. Severe fluctuations in consciousness 2. Advanced dementia.(see above)
HD [30, 93, 94]	1. Treatment-refractory, progressive motor symptoms (e.g. chorea, dystonia) 2. Severe neuropsychiatric disturbances (e.g. depression with suicidality) 3. Advanced dementia (see above)
PSP [54, 95]	1. Severe neuropsychiatric disturbances (e.g. depression, apathy) 2. Severe motor symptoms (e.g. dystonia)
MSA [54, 95]	1. Severe, treatment-refractory autonomic dysregulation 2. Arrhythmia 3. Stridor

Abbreviations: PPS = Palliative Performance Scale; FAST = Functional Assessment Staging; VC = vital capacity; ADLs = activities of daily living; PD = Parkinson’s disease; PEG = percutaneous endoscopic gastrostomy; DLB = Dementia with Lewy Bodies; HD = Huntington disease; PSP = Progressive Supranuclear Palsy; MSA = Multiple Systems Atrophy