What are the best practices for documenting a patient on BiPAP (Bilevel Positive Airway Pressure) experiencing slowly fading cognition prior to death?

Documentation Guidelines for Fading Cognition in BiPAP Patients Prior to Death

For patients on BiPAP therapy experiencing cognitive decline prior to death, document progressive changes in mental status using standardized assessment tools such as the Glasgow Coma Scale (GCS) while noting specific changes in responsiveness, pupillary reflexes, and brainstem function.

Recommended Documentation Framework

Mental Status Assessment

• Use standardized scoring tools to objectively document cognitive decline:
  • Glasgow Coma Scale (GCS) score with breakdown of eye, verbal, and motor components 1
  • Richmond Agitation-Sedation Scale (RASS) to track level of consciousness 1
  • Document specific changes in alertness using AVPU scale (Alert, Voice responsive, Pain responsive, Unresponsive) 1

Neurological Examination Elements

• Pupillary reflexes: Document size, symmetry, and light reactivity
  • Note: Fixed and dilated pupils may indicate advanced brain injury but should be interpreted cautiously as they can occur in reversible conditions 1
• Brainstem reflexes: Document presence/absence of:
  • Corneal reflex
  • Oculovestibular reflex
  • Cough/gag reflex 1
• Motor responses: Document any spontaneous movements, posturing, or response to stimuli 1

BiPAP-Specific Documentation

• Record BiPAP settings (IPAP/EPAP) and patient's tolerance 2
• Document any mask issues or air leaks that may affect ventilation efficacy
• Note oxygen saturation trends and any desaturation events 2
• Document any signs of patient-ventilator asynchrony as cognition fades

Progression of Cognitive Decline

Document specific observations in this sequence as cognition fades:

1. Early changes:

   • Drowsiness (GCS 13-14) with preserved ability to follow commands
   • Fluctuating attention and orientation
   • Document specific content of any confusion or disorientation

2. Moderate decline:

   • Stupor (GCS 8-12) with diminished response to verbal stimuli
   • Need for repeated or painful stimuli to elicit response
   • Document specific stimuli required to generate response

3. Advanced decline:

   • Semi-coma state (GCS 5-7) with minimal responsiveness
   • Document any primitive reflexes that emerge
   • Note BIS values if monitored (typically 38.9 ± 18.0 in semi-coma) 3

4. Terminal phase:

   • Coma (GCS ≤4) with absence of response to stimuli
   • Document loss of brainstem reflexes in sequence
   • Note BIS values approaching zero if monitored (typically 0.14 ± 0.23 in coma) 3

Important Considerations

• Avoid attributing all cognitive changes to terminal decline: Document any potentially reversible causes of altered mental status (medication effects, hypoxemia, hypercapnia) 4

• Document timing of cognitive changes: Note whether changes are gradual or sudden, as this has implications for underlying etiology

• Include family observations: Document family reports of subtle changes in responsiveness or recognition that clinical staff may not observe

• Medication effects: Document any sedatives or analgesics administered that may contribute to cognitive changes 1

• BiPAP contraindications: As cognition fades, document ongoing assessment of airway protection ability, as severely depressed mental status may become a contraindication to continued BiPAP use 2

By following this structured documentation approach, healthcare providers can accurately track the progression of cognitive decline in BiPAP patients approaching end of life, ensuring appropriate clinical decision-making and family communication.