What is the recommended management and documentation for a hospice patient with a severe shoulder infection, extreme swelling and pain from the shoulder to fingers, and suspected DVT, when hospice refuses to cover diagnostic tests?

Management and Documentation of Severe Shoulder Infection in a Hospice Patient

For a hospice patient with severe shoulder infection, extreme swelling, and suspected DVT, when hospice refuses to cover diagnostic tests, you should document your clinical assessment, treatment plan, and the hospice's refusal of testing while continuing to provide appropriate empiric treatment based on clinical presentation.

Clinical Assessment and Documentation

• Document detailed physical findings including extent of swelling (shoulder to fingers), presence of erythema, warmth, and pain severity 1
• Record vital signs including heart rate, respiratory rate, and temperature to assess for systemic infection or sepsis 1
• Document risk factors for DVT and infection, including any indwelling catheters, immobility, or previous history 1
• Note the presence of any clinical signs suggesting sepsis such as decreased capillary refill, skin mottling, or altered mental status 1

Treatment Approach

• Initiate empiric antibiotic therapy immediately based on the clinical presentation of severe infection with extensive swelling, redness, and warmth 1
• Consider parenteral antibiotics with broad-spectrum coverage appropriate for skin/soft tissue and possible bone involvement 1
• Document your clinical suspicion for DVT based on the pattern of swelling, pain, and other clinical features 1
• When diagnostic testing is unavailable, treatment decisions must be based on clinical presentation and risk assessment 1

Documentation of Hospice Limitations

• Clearly document the communication with hospice, including date, time, name of contact person, and specific services declined 1
• Record that you explained to hospice the clinical necessity of the diagnostic tests and potential consequences of not performing them 1
• Document your clinical reasoning for suspecting both infection and possible DVT 1
• Note that treatment decisions are being made empirically due to inability to obtain confirmatory testing 1

Management Without Diagnostic Testing

• For suspected DVT without confirmatory testing, consider empiric anticoagulation if bleeding risk is low and clinical suspicion is high 1
• Document your assessment of the risk-benefit ratio of empiric anticoagulation in this hospice patient 2
• For severe infection, document the choice of antibiotics, dose, route, and expected duration 1
• Consider elevation of the affected limb and other supportive measures for symptom management 1

Ethical and Legal Considerations

• Document that you discussed with the patient/family the clinical situation, treatment options, and limitations imposed by hospice coverage 1
• Record the patient's or surrogate's informed consent for the treatment plan despite diagnostic limitations 1
• Document your efforts to provide appropriate care within the constraints of the hospice program 1
• Consider documenting a request for hospice to reconsider coverage of essential diagnostic tests 1

Follow-up Plan

• Document a clear plan for reassessment, including frequency of visits and specific clinical parameters to monitor 1
• Record criteria that would trigger escalation of care or reconsideration of the hospice plan 1
• Note arrangements for communication with the hospice team regarding the patient's progress 1
• Document contingency plans if the patient's condition deteriorates despite empiric treatment 1

Documentation Template

• "Patient presents with severe shoulder infection extending to fingers with [specific symptoms]. Hospice contacted regarding need for diagnostic testing for suspected DVT but declined coverage. After discussion with patient/family, empiric treatment initiated with [specific antibiotics] and [anticoagulation if appropriate]. Will monitor for [specific parameters] and reassess in [timeframe]." 1