What are the primary recommendations for managing symptoms in a patient with gastrointestinal stromal cancer in hospice care?

Hospice Recertification SOAP Note for Gastrointestinal Stromal Cancer

Subjective

Primary Terminal Diagnosis: Gastrointestinal Stromal Tumor (GIST), metastatic/advanced stage with life expectancy ≤6 months 1

Current Symptom Burden Assessment:

• Pain: Assess intensity using 0-10 numerical rating scale; document location (abdominal, visceral), character, and current opioid regimen 2
• Gastrointestinal symptoms: Document presence/severity of nausea, vomiting, constipation, diarrhea, bowel obstruction symptoms, bleeding (hematemesis/melena), early satiety 1
• Functional status: Document Karnofsky Performance Status (KPS) or ECOG Performance Status; patients with KPS ≤60 or ECOG ≥3 are appropriate for hospice-only care 1
• Nutritional status: Assess oral intake (if <1500 kcal/day, document need for enteral support), weight loss trajectory, anorexia severity 1
• Dyspnea: If present, assess intensity and contributing factors (pleural effusion, ascites, pulmonary metastases) 1

Psychosocial/Spiritual Concerns: Document patient/family understanding of prognosis, advance care planning status, caregiver burden, psychological distress related to disease progression 1

Objective

Vital Signs: Document weight (trend analysis), blood pressure, heart rate, respiratory rate, oxygen saturation 1

Physical Examination Findings:

• Abdominal exam: Palpable mass, distension, ascites, tenderness, bowel sounds (assess for obstruction) 1
• Signs of bleeding: Pallor, tachycardia, orthostatic changes 1
• Functional assessment: Observe ambulation, self-care ability, level of assistance required 1

Laboratory Values (if recently available): Hemoglobin/hematocrit (chronic bleeding), electrolytes (if dehydration concern), albumin (nutritional status) 1

Assessment

Terminal Prognosis Indicators for GIST:

• Life expectancy weeks to months: Progressive metastatic disease unresponsive to tyrosine kinase inhibitors (imatinib/sunitinib), declining performance status, progressive weight loss, uncontrolled symptoms despite optimal management 1
• Hospice appropriateness criteria met: Life expectancy ≤6 months, metastatic solid tumor, moderate-to-severe distress from cancer/therapy, serious comorbid conditions 1

Current Symptom Control Status:

• Acceptable: Adequate pain/symptom control, reduced patient/family distress, acceptable sense of control, optimized quality of life 1
• Unacceptable: Requires intensified palliative care interventions, consultation with specialized palliative care services 1

Decline Documentation: Specify functional decline, symptom progression, or disease advancement since last certification period 1

Plan

Pain Management

For opioid-naive patients: Start morphine 2.5-10 mg PO every 4 hours as needed, or 1-3 mg IV every 1 hour as needed 1, 2

For patients on opioids: Titrate rapidly without arbitrary dose ceilings; transition to sustained-release formulations once dose requirements established 2

Mandatory constipation prophylaxis: Begin stimulant laxatives (senna or bisacodyl) immediately when starting opioids—do not wait for constipation to develop; combine with osmotic laxatives (polyethylene glycol, lactulose, or sorbitol) 2

Neuropathic pain component: Add gabapentin or pregabalin as adjuvant to opioid regimen 2

Gastrointestinal Symptom Management

Nausea/Vomiting:

• First-line: Haloperidol, metoclopramide, or prochlorperazine; use around-the-clock dosing for greatest benefit 1, 2
• If anxiety contributes: Add lorazepam 0.5-1 mg PO every 1 hour as needed 1
• If opioid-induced: Consider opioid rotation 1

Malignant Bowel Obstruction (if present):

• Do NOT use nasogastric tube unless patient specifically requests after other measures fail 1
• Start octreotide 150 mcg subcutaneously twice daily (up to 300 mcg twice daily) to reduce GI secretions 2
• Add corticosteroids (dexamethasone 4-8 mg three to four times daily) 1, 2
• Opioids for pain control and to reduce intestinal secretions 2
• Never use metoclopramide in complete bowel obstruction 2
• Consider palliative venting gastrostomy only if extensive peritoneal/gastric serosal disease absent 1

Bleeding:

• Early adjunctive iron support including parenteral iron 1
• If acute bleeding: Prompt endoscopic assessment with hemostatic interventions 1
• Consider palliative radiation therapy for chronic tumor-related bleeding 1

Diarrhea:

• Empirical trial: Rifaximin for 1 week, or bile acid sequestrant (colesevelam preferred over cholestyramine for tolerability) for 10 days, or pancreatic enzyme replacement therapy for 10 days 1
• Loperamide 4 mg initial dose, then 2 mg every 4 hours or after each unformed stool (maximum 16 mg daily) 1

Dyspnea (if present):

• Oxygen only if hypoxic and/or subjective relief reported 1
• Morphine 2.5-10 mg PO every 4 hours as needed 1
• Lorazepam 0.5-1 mg PO every 1 hour as needed if anxiety component 1
• Fans for symptomatic relief 1

Excessive Secretions:

• Scopolamine 0.4 mg subcutaneously every 4 hours as needed, or 1.5 mg patches (1-6 patches every 3 days) 1
• Alternatives: Atropine 1% ophthalmic solution 1-2 drops sublingual every 4 hours as needed, or glycopyrrolate 0.2-0.4 mg IV/subcutaneously every 4 hours as needed 1

Nutritional Support

Discontinue anticancer therapy: Strongly encourage discontinuation given weeks-to-months prognosis 1

Hydration/nutrition in dying phase: Withdrawal of IV or nasogastric tube feeding is ethically permissible and will not exacerbate symptoms; may improve some symptoms 1

Focus on comfort measures: Small amounts of liquids, mouth care 1

Interdisciplinary Care Plan

Team involvement: Coordinate care with nurses, social workers, chaplains, dietitians for comprehensive symptom management and psychosocial/spiritual support 1

Family education: Provide guidance regarding anticipated dying process, focus on comfort, foster patient participation in preparing loved ones 1

Advance care planning: Review and document advance directives, healthcare proxy, DNR status 1

Monitoring and Reassessment

Frequency: Reassess pain and symptoms at every visit using standardized scales 2

Acceptable outcomes: Adequate symptom control, reduction of patient/family distress, relief of caregiver burden, strengthened relationships, optimized quality of life 1

Unacceptable outcomes requiring intervention: Uncontrolled symptoms, inadequate pain control, excessive patient/family distress—intensify palliative care efforts immediately 1

Recertification justification: Document continued decline in functional status, progressive disease, ongoing need for hospice-level symptom management, life expectancy remains ≤6 months 1