What is the assessment and plan for a patient entering hospice care with acute respiratory failure secondary to pneumonia?

Assessment and Plan for Patient Entering Hospice with Acute Respiratory Failure Secondary to Pneumonia

For patients entering hospice with acute respiratory failure secondary to pneumonia, treatment should focus on symptom management with opioids, benzodiazepines, and oxygen therapy as needed, while providing emotional and spiritual support to both patient and family.

Assessment Components

Respiratory Assessment

• Evaluate dyspnea severity using visual/analog scales 1
• Assess for physical signs of respiratory distress in non-communicative patients 1
• Monitor oxygen saturation (target 88-92% for adults, >92% for children) 1
• Evaluate for excessive secretions requiring management 1

Symptom Burden Assessment

• Pain assessment (location, intensity, character)
• Anxiety and psychological distress evaluation
• Thirst and oral comfort needs
• Family/caregiver distress assessment

Management Plan

Dyspnea Management

1. Pharmacological Interventions:

   • Opioid therapy: If opioid-naïve, start morphine 2.5-10 mg PO q4h PRN or 1-3 mg IV q1h PRN 1, 2
   • Anxiety management: If benzodiazepine-naïve, start lorazepam 0.5-1 mg PO q1h PRN 1, 2
   • Titrate doses based on symptom response with regular reassessment

2. Oxygen Therapy:

   • Provide oxygen if patient is hypoxic and/or reports subjective relief 1
   • Target oxygen saturation 88-92% in adults 1
   • Avoid high-flow oxygen; use targeted approach based on saturation 1

3. Secretion Management:

   • For excessive secretions: scopolamine 0.4 mg SC q4h PRN, or 1.5 mg patches (1-6 patches q3d) 1
   • Alternative options: atropine 1% ophthalmic solution 1-2 drops SL q4h PRN, or glycopyrrolate 0.2-0.4 mg IV/SQ q4h PRN 1

Non-Pharmacological Interventions

• Position patient upright or in most comfortable position 2
• Use fans to reduce sensation of dyspnea 1
• Maintain cooler room temperature 2
• Consider music therapy, relaxation techniques, and massage 1

Emotional and Spiritual Support

• Provide anticipatory guidance to patient/family regarding dying process of respiratory failure 1, 2
• Encourage expression of fears about dying and address anxiety 1
• Support family members who may be experiencing distress 1
• Document patient values and preferences in accessible location in medical record 1

Advance Care Planning

• Review and document goals of care 1
• Ensure DNR/DNI status is clearly documented
• Discuss and document preferences regarding escalation of care
• Ensure POLST/MOLST forms are completed if applicable 1

Special Considerations

NIV in Palliative Care

• NIV may be considered for symptom palliation in select patients who refuse invasive ventilation 1
• Should be used only if it provides symptom relief without causing mask discomfort or unduly prolonging life 1
• Discontinue if causing more distress than relief 1

Monitoring and Reassessment

• Regular reassessment of symptom control
• Adjust medication dosing based on symptom response
• Consider palliative care specialist consultation for intractable symptoms 1, 2

Caregiver Support

• Provide education on expected changes as death approaches
• Offer emotional support to caregivers
• Consider respite options if needed

Pitfalls and Caveats

• Avoid withholding opioids due to concerns about respiratory depression; properly dosed opioids are appropriate for dyspnea management in end-of-life care 1
• Do not use high-flow oxygen empirically; target oxygen therapy based on saturation and subjective relief 1
• Avoid focusing solely on respiratory management while neglecting psychological, social, and spiritual needs 1
• Remember that NIV can sometimes increase patient distress and should be discontinued if not providing relief 1

By implementing this comprehensive approach to symptom management while providing emotional support, patients entering hospice with acute respiratory failure due to pneumonia can experience improved comfort and dignity at the end of life.