What is the best approach to manage a patient with respiratory failure in a hospice setting?

GIP Hospice SOAP Note for Respiratory Failure

Subjective

Symptom Assessment:

• Document dyspnea severity using physical signs of respiratory distress (labored breathing, use of accessory muscles, tachypnea) in non-communicative patients 1, 2
• Record patient/family report of breathlessness intensity and associated anxiety 2
• Assess for excessive secretions causing respiratory distress 1
• Document fluid overload symptoms if present 1
• Note patient's expressed goals of care and understanding of prognosis 3

Caregiver Concerns:

• Document family distress level regarding respiratory symptoms 1
• Record caregiver burden and need for anticipatory guidance 1

Objective

Vital Signs & Physical Findings:

• Respiratory rate, oxygen saturation, work of breathing 2
• Presence of audible secretions, rales, or wheezing 1
• Signs of fluid overload (peripheral edema, jugular venous distension) 1
• Level of consciousness and ability to protect airway 1

Current Interventions:

• Document oxygen delivery method and flow rate 2
• List current opioid and benzodiazepine doses 1
• Note use of anticholinergics for secretion management 1

Assessment

GIP Level of Care Criteria Met:

• Acute respiratory failure requiring intensive symptom management beyond routine hospice care 1
• Estimated life expectancy: weeks to days 1, 2
• Symptoms not adequately controlled with routine home hospice interventions 1

Primary Problem:

• Acute respiratory failure with intractable dyspnea requiring aggressive palliative intervention 1, 2

Plan

Pharmacologic Management

Opioids (First-Line):

• If opioid-naive: Start morphine 2.5-10 mg PO every 2 hours PRN or 1-3 mg IV every 2 hours PRN 1, 2
• If already on chronic opioids: Increase current dose by 25% 1, 2
• For acute progressive dyspnea, use more aggressive titration with IV dosing every 15 minutes until relief 1, 2
• Titrate to effect, not to a predetermined maximum dose 1, 2

Benzodiazepines (Adjunctive):

• Add lorazepam 0.5-1 mg PO/IV every 4 hours PRN if dyspnea is associated with anxiety or air hunger 1, 2
• Particularly effective when combined with opioids in advanced COPD 1

Secretion Management:

• Scopolamine 0.4 mg subcutaneous every 4 hours PRN, OR 1.5 mg transdermal patches (1-3 patches every 3 days) 1, 2
• Alternative: Atropine 1% ophthalmic solution 1-2 drops sublingual every 4 hours PRN 1, 2
• Alternative: Glycopyrrolate 0.2-0.4 mg IV or subcutaneous every 4 hours PRN 1, 2

Fluid Management:

• Discontinue or decrease enteral/parenteral fluids if fluid overload is contributing 1, 2
• Consider low-dose diuretics for symptomatic fluid overload 1, 2

Non-Pharmacologic Interventions

Immediate Comfort Measures:

• Position patient upright or semi-recumbent 2
• Direct fan toward patient's face 1, 2
• Provide oxygen if hypoxic OR if patient reports subjective relief (not required for non-hypoxemic patients) 1, 2
• Maintain cool room temperature 2

Ventilatory Support Considerations:

• Noninvasive ventilation (BiPAP/CPAP) may be offered for symptom palliation in select patients who remain alert and can tolerate mask 1
• NIV can reduce dyspnea and morphine requirements, particularly in hypercapnic patients 1
• Discontinue if patient intolerance or increased distress 1
• Address patient/family preferences regarding time-limited trial versus comfort-focused care only 1, 2

Anticipatory Guidance & Family Support

Education:

• Provide anticipatory guidance to patient/family regarding natural dying process from respiratory failure 1, 2
• Explain that absence of hunger/thirst is normal in dying patients 1
• Reassure that opioids for dyspnea relief, when properly dosed, do not hasten death 1

Emotional & Spiritual Support:

• Provide ongoing emotional and spiritual support to patient and family 1, 2
• Involve family in comfort measures (mouth care, repositioning, hand-holding) 1
• Address fears about dying and suffocation 1

Monitoring & Reassessment

Continuous Assessment:

• Reassess dyspnea severity and distress every 15-30 minutes during acute crisis 2
• Monitor for excessive sedation while titrating medications 1
• Evaluate effectiveness of interventions and adjust accordingly 2, 3

Escalation Plan:

• If symptoms remain intractable despite aggressive titration, consider palliative sedation consultation 1
• Document goals of care and any changes based on patient/family preferences 3

Common Pitfalls to Avoid

• Do not undertitrate opioids due to unfounded fears of respiratory depression—properly dosed opioids are safe and effective for dyspnea 1, 2
• Do not rely solely on oxygen therapy in non-hypoxemic patients, as it provides no benefit 1, 2
• Do not use lemon-glycerin swabs for dry mouth, as they worsen xerostomia 1
• Do not delay aggressive symptom management—early intervention optimizes quality of life 2