What is the assessment and management plan for a hospice patient with multifocal pneumonia, cognitive impairment, dysphagia, incontinence, and bed confinement?

Assessment and Management Plan for Hospice Patient with Multifocal Pneumonia and Multiple Comorbidities

For a hospice patient with multifocal pneumonia, cognitive impairment, dysphagia, incontinence, and bed confinement, the management plan should focus on aggressive symptom control while avoiding interventions that may cause distress without improving quality of life.

Assessment (ICD-10 Codes)

• J18.1 - Multifocal pneumonia
• R13.10 - Dysphagia, unspecified
• F03.90 - Unspecified dementia without behavioral disturbance
• R39.81 - Functional urinary incontinence
• R15.9 - Fecal incontinence, unspecified
• Z74.01 - Bed confinement status
• Z51.5 - Encounter for palliative care

Management Plan

Respiratory Symptom Management

1. Dyspnea Control

   • For opioid-naïve patients: Start morphine 2.5-10 mg PO q4h PRN or 1-3 mg IV q1h PRN 1
   • For patients already on chronic opioids: Consider increasing dose by 25% 1
   • Position patient upright or in most comfortable position 1
   • Use fans to reduce sensation of dyspnea 1
   • Provide oxygen only if hypoxic or reporting subjective relief (target SpO₂ 85-92%) 1
   • Avoid high-flow oxygen; use targeted approach based on saturation 1

2. Secretion Management

   • Scopolamine 0.4 mg subcutaneous q4h PRN or 1.5 mg patches (1-3 patches q3d) 1
   • Alternative options: atropine 1% ophthalmic solution 1-2 drops SL q4h PRN, or glycopyrrolate 0.2-0.4 mg IV/subcutaneous q4h PRN 1

3. Anxiety Management

   • For benzodiazepine-naïve patients: lorazepam 0.5-1 mg PO q1h PRN 1
   • Add benzodiazepines for dyspnea-associated anxiety 1

Dysphagia Management

1. Comfort Feeding

   • Offer small amounts of preferred foods/liquids for comfort only
   • Discuss with family the natural progression of dysphagia in end-stage illness and limited role of artificial nutrition/hydration 1
   • Avoid tube feeding as it does not improve mortality outcomes in patients with severe cognitive impairment and dysphagia 2
   • Provide oral care every 2-4 hours to maintain comfort

2. Aspiration Risk Management

   • Elevate head of bed during and after feeding
   • Thickened liquids only if they improve comfort (not for prolonging life)
   • Suction equipment at bedside for secretions as needed

Skin Care and Incontinence Management

1. Pressure Injury Prevention

   • Repositioning schedule every 2 hours
   • Pressure-redistributing mattress
   • Daily skin assessment
   • Protective barrier creams

2. Incontinence Care

   • Absorbent products changed promptly when soiled
   • Gentle cleansing and moisturizing after each episode
   • Consider indwelling catheter only if frequent changes cause distress

Pain Management

1. Regular Assessment

   • Use appropriate pain scales for cognitively impaired patients
   • Monitor for non-verbal signs of pain (facial grimacing, restlessness)

2. Medication Regimen

   • Around-the-clock acetaminophen (if no contraindications)
   • Scheduled opioids if persistent pain
   • Consider topical analgesics for localized pain

Cognitive Impairment Support

1. Environmental Modifications
   • Maintain familiar surroundings
   • Minimize unnecessary stimulation
   • Use simple, clear communication
   • Involve familiar caregivers

Family Support

1. Education and Guidance

   • Provide anticipatory guidance regarding dying process of respiratory failure 1
   • Encourage expression of fears about dying and address anxiety 1
   • Support family members experiencing distress 1
   • Discuss expected disease progression and comfort-focused goals

2. Practical Support

   • Teach comfort care techniques
   • Offer respite options 2
   • Provide 24/7 contact information for urgent concerns

Spiritual and Psychosocial Support

1. Spiritual Care

   • Offer chaplain or spiritual counselor visits
   • Honor religious/cultural practices important to patient/family

2. Psychosocial Support

   • Social worker involvement for family support
   • Bereavement counseling resources

Medication Review

1. Discontinue Unnecessary Medications

   • Stop preventative medications (statins, antihypertensives)
   • Maintain only comfort-focused medications

2. Simplify Regimen

   • Convert medications to routes that minimize distress
   • Focus on symptom control medications only

Documentation

1. Advance Care Planning
   • Ensure DNR/DNI status is clearly documented 1
   • Document patient values and preferences in accessible location 1
   • Review and document goals of care 1

Special Considerations

• Consider palliative sedation for intractable symptoms despite aggressive management 1
• Avoid interventions that cause more distress than relief 1
• Regular reassessment of symptom control and care plan effectiveness

This comprehensive plan addresses the complex needs of a hospice patient with multifocal pneumonia and multiple comorbidities while focusing on comfort and quality of life rather than disease-modifying interventions.