Hospice Recertification SOAP Note for Senile Degeneration of Brain
Subjective
Document the following elements to support continued hospice eligibility:
- Functional decline: Record complete dependence in all activities of daily living (ADLs)—inability to dress, bathe, toilet, transfer, or feed without total assistance 1, 2.
- Cognitive status: Document inability to communicate meaningfully (speaking fewer than 6 words), inability to recognize family members, or loss of decisional capacity 1, 2.
- Nutritional compromise: Note weight loss, decreased oral intake, or difficulty swallowing despite assisted feeding 2.
- Family understanding: Record family/caregiver comprehension of disease progression and alignment with comfort-focused goals rather than life-prolonging interventions 1.
- Advance care planning: Document previously expressed values, wishes, and decisions about hospitalization avoidance or aggressive interventions 1, 2.
Objective
Key clinical findings that demonstrate terminal decline:
- Mobility: Document bedbound status or complete inability to ambulate independently 2.
- Vital signs and breathing: Record changing respiratory patterns (gurgling, rattly breathing, irregular respirations, or Cheyne-Stokes breathing) 2.
- Nutritional status: Measure weight loss trends and document inability to maintain adequate nutrition/hydration 1.
- Level of consciousness: Note decreased awareness, significant changes in alertness, or progressive obtundation 1.
- Comorbidities: Document cerebrovascular disease with infarcts, recurrent infections (aspiration pneumonia, urinary tract infections), or pressure ulcers 1, 3.
Assessment
Primary diagnosis: Senile degeneration of brain with advanced vascular cognitive impairment and cerebrovascular disease with infarcts.
Prognosis: Life expectancy less than 6 months based on progressive functional decline, complete ADL dependence, inability to communicate, nutritional compromise, and bedbound status 1, 2, 4.
Hospice appropriateness: Patient meets criteria for continued hospice care with documented irreversible decline in function, alignment of care with comfort-focused goals, and family understanding of terminal nature of illness 1, 2.
Plan
Symptom Management Priorities
Focus on comfort and quality of life rather than life prolongation 1, 2:
- Pain assessment and management: Use behavioral pain scales (since verbal communication is impaired) and treat with opioids as needed, adjusting for inability to report discomfort 2, 3.
- Respiratory distress and secretions: Manage with scopolamine 0.4 mg SC q4h prn, atropine 1% ophthalmic solution 1-2 drops SL q4h prn, or glycopyrrolate 0.2-0.4 mg IV/SC q4h prn 5.
- Behavioral symptoms: Address agitation, restlessness, or distress with environmental modifications first, then pharmacologic intervention (lorazepam 0.5-1 mg PO/SL prn, or low-dose antipsychotics if needed) 2, 5.
- Skin integrity: Implement pressure ulcer prevention and treatment protocols 1.
- Incontinence management: Provide dignity-preserving care with appropriate containment products 1.
Nutritional and Hydration Approach
Comfort feeding only 2:
- Hand-feed small amounts as tolerated, recognizing that decreased intake is part of the natural dying process 2.
- Provide fluids as tolerated; artificial hydration is not indicated in the terminal phase 2.
- Do not pursue tube feeding, as it does not improve outcomes in advanced dementia and contradicts comfort-focused goals 2.
Psychosocial and Spiritual Support
Address suffering across all domains 1:
- Provide ongoing support and education to family caregivers about disease progression and what to expect 1.
- Offer bereavement support resources and anticipatory grief counseling 1.
- Engage chaplaincy or spiritual care services based on patient/family values 5.
- Document family satisfaction with dignity, involvement in decision-making, and being informed about the dying process 1.
Care Coordination
Ensure interdisciplinary team involvement 5:
- Maintain regular communication between hospice team, primary care provider, and family 5.
- Avoid hospitalizations for acute events unless absolutely necessary for comfort 1, 2.
- Reassess symptom burden and adjust interventions at each visit 5.
Documentation for Recertification
Emphasize progressive decline 1, 2:
- Record rapid day-to-day deterioration and irreversible functional losses 2.
- Document that goals of care focus exclusively on comfort, quality of life, and symptom management 1, 2.
- Note family understanding that the disease is progressive and life-limiting 1.
This approach prioritizes dignity, comfort, and quality of life while avoiding interventions that would increase suffering without meaningful benefit 5, 6, 7.