What should be included in a SOAP (Subjective, Objective, Assessment, Plan) note for a patient with liver cirrhosis being considered for hospice admission?

SOAP Note for Hospice Admission: Liver Cirrhosis

For patients with liver cirrhosis being admitted to hospice, documentation must establish a prognosis of 6 months or less with comfort-oriented goals, demonstrated through progressive functional decline, refractory complications, and evidence that curative treatments (including transplantation) are no longer appropriate or desired. 1

Subjective

Patient/Family Goals and Understanding:

• Document explicit patient/family statement of comfort-focused goals and willingness to forgo life-prolonging interventions 1
• Assess prognostic awareness—does the patient understand they have a life-limiting illness with estimated survival ≤6 months? 1
• Identify designated surrogate decision-maker and document medical power of attorney 1

Symptom Assessment Across Four Domains:

• Physical: Pain severity/location, dyspnea, nausea/vomiting, pruritus, fatigue, sleep disturbance 1
• Psychological: Depression, anxiety, confusion from hepatic encephalopathy 1
• Social: Caregiver burden, financial distress, housing stability 1
• Spiritual: Existential distress, spiritual concerns, cultural considerations 1

Functional Status:

• Document Palliative Performance Scale (PPS) score—hospice typically requires ≤50% 2
• Activities of daily living dependence (bathing, dressing, toileting, eating) 1
• Recent decline in functional capacity over past 3-6 months 1

Objective

Disease Severity Markers:

• MELD-Na score (document current value and trend over past 3-6 months) 1, 3
• Child-Pugh score (Class C strongly supports hospice eligibility) 1, 4
• CLIF-C ACLF score if applicable—scores >70 associated with ~90% 90-day mortality 1
• Number of organ failures (≥2 organ failures indicates NACSELD ACLF with 28-day survival as low as 3%) 1

Evidence of Progressive Decompensation:

• Refractory ascites unresponsive to maximum diuretic therapy (spironolactone 400mg + furosemide 160mg daily) requiring frequent large-volume paracentesis 5, 4
• Hepatorenal syndrome with rising creatinine despite pharmacotherapy 1
• Recurrent/refractory hepatic encephalopathy (Grade 3-4) despite lactulose and rifaximin 1, 4
• Recurrent variceal bleeding despite endoscopic and pharmacologic management 5
• Spontaneous bacterial peritonitis (especially recurrent episodes) 5

Complications Indicating Poor Prognosis:

• Recurrent infections (sepsis, aspiration pneumonia, urinary tract infections) 2
• Stage 3-4 pressure ulcers 2
• Progressive malnutrition with albumin <2.5 g/dL 4
• Hepatocellular carcinoma (especially if not transplant candidate) 6
• Portal vein thrombosis 6

Vital Signs and Physical Exam:

• Document cachexia, jaundice, asterixis, altered mental status 7
• Tense ascites, peripheral edema, muscle wasting 7
• Signs of hepatic encephalopathy (confusion, somnolence) 7

Recent Healthcare Utilization:

• Number of hospitalizations in past 6 months (≥2 supports poor prognosis) 1, 6
• ICU admissions, mechanical ventilation >48 hours, or hemodialysis 1
• Length of stay trends (increasing suggests worsening disease) 1

Assessment

Primary Diagnosis:

• End-stage liver disease secondary to [specify etiology: alcohol-associated, NASH, viral hepatitis, etc.] with decompensated cirrhosis 7

Hospice Eligibility Criteria Met:

• Prognosis ≤6 months based on: [list specific criteria from objective section] 1
• Patient/family goals aligned with comfort-focused care 1
• Not a liver transplant candidate due to: [medical contraindications, patient preference, or active substance use if alcohol-related] 1, 6

Prognostic Indicators Supporting Hospice:

• MELD-Na score [specify value] with upward trend 1, 3
• Child-Pugh Class C cirrhosis 1, 4
• Refractory complications despite maximal medical therapy 1
• Functional decline with PPS ≤50% 2
• Multiple recent hospitalizations indicating disease trajectory 1, 6

Active Symptom Burden:

• [List specific symptoms requiring palliative management] 1

Caregiver Assessment:

• Caregiver burden level and support needs 1

Plan

Hospice Enrollment:

• Immediate referral to hospice for patients with comfort-oriented goals and prognosis ≤6 months 1
• Ensure goals of care documentation transfers with patient to hospice agency 1
• Confirm advance directive and code status (DNR/DNI) documented 1

Symptom Management Priorities:

• Pain: Initiate/titrate opioids as needed; avoid NSAIDs (convert diuretic-sensitive to refractory ascites) 5, 8
• Dyspnea: Opioids for refractory dyspnea; oxygen for comfort 2
• Ascites: Continue diuretics if providing comfort; consider palliative paracentesis for symptomatic relief 5
• Hepatic encephalopathy: Continue lactulose/rifaximin if improving quality of life; discontinue if burdensome 4
• Nausea: Antiemetics as needed 7
• Pruritus: Antihistamines, cholestyramine as tolerated 7

Medication Reconciliation:

• Discontinue: Medications not contributing to comfort (statins, prophylactic antibiotics unless preventing distressing infections) 4
• Continue: Diuretics if managing symptomatic ascites (spironolactone/furosemide), lactulose if preventing distressing encephalopathy, rifaximin 8, 4
• Avoid: NSAIDs, nephrotoxic agents 5, 8

Caregiver Support:

• Hospice team to provide caregiver education on disease trajectory and symptom management 1
• Assess need for respite care services 1
• Screen for caregiver depression/burnout 1

Communication and Coordination:

• Document that goals of care discussion occurred at this sentinel event (hospice admission) 1
• Ensure hepatology follow-up information provided to hospice team for consultation as needed 3
• Confirm patient/family understanding of hospice services and what to expect 1

Quality Metrics Addressed:

• Palliative care/hospice offered to patient with prognosis <6 months ✓ 1
• Surrogate decision-maker identified and documented ✓ 1
• Goals of care discussion documented at sentinel event ✓ 1
• Code status and advance directive confirmed ✓ 1

Common Pitfalls to Avoid:

• Do not delay hospice referral until the final days of life—68.5% of palliative care and 62.7% of hospice referrals in cirrhosis occur within one week of death 6
• Do not assume transplant listing precludes hospice discussion—only 11% of hospice patients were listed for transplant, suggesting many appropriate candidates are missed 4
• Do not continue aggressive interventions (hemodialysis, mechanical ventilation, pacemaker placement) without documented goals of care discussion 1
• Do not overlook caregiver burden—failure to assess leads to poor adherence and readmissions 5