Hospice Recertification SOAP Note for Alzheimer's Disease
Subjective
Document continued disease progression and terminal decline:
Functional status deterioration: Record complete bedbound status, requiring frequent interventions for all activities of daily living, as loss of basic daily functional abilities is the hallmark of the final stage of Alzheimer's disease 1.
Cognitive decline: Document profound cognitive impairment with diminished or absent response to voices, lapses into unconsciousness, and inability to recognize family members 1.
Nutritional decline: Note inability to swallow, refusal of food/fluids, or profound weight loss, as malnutrition is widespread in advanced dementia and contributes to terminal decline 2.
Medical complications: Document recurrent infections (pneumonia, urinary tract infections), aspiration events, or other complications that indicate irreversible deterioration 1, 2.
Caregiver observations: Record family reports of rapid day-to-day deterioration and increasing care burden, as this information is critical for establishing prognosis 1.
Objective
Physical examination findings indicating terminal phase:
Vital signs: Document changing body temperature (hot and clammy, or cold), diminished or no urine secretion 1.
Respiratory status: Note changing breathing patterns, gurgling or rattly breathing 1.
Skin assessment: Record pale or mottled skin, indicating poor perfusion 1.
Functional staging: Document FAST Stage 7C or beyond (profound weakness, inability to ambulate, incontinence of urine and stool), as patients at this stage have a mean survival time of 3.2 months 3.
Neurological status: Note profound weakness, complete dependence for all care, and minimal responsiveness 1.
Assessment
Establish continued hospice eligibility with 6-month prognosis:
Primary diagnosis: End-stage Alzheimer's disease with continued progression toward death, as all patients with AD experience inevitable decline over time despite treatment 1.
Prognostic indicators: Document that patient meets criteria for advanced dementia with medical complications, which predicts median survival of 4 months 3.
Functional decline: Note that patient has reached FAST Stage 7C with complete functional dependence, which is associated with very high mortality and short time until death 3.
Medical complications: List recurrent infections, aspiration pneumonia, weight loss >10% in 6 months, or other complications that shorten survival 3.
Goals of care: Confirm that comfort-focused care remains appropriate and aligned with patient's advance directives and family wishes 1.
Plan
Continue hospice services with focus on comfort and quality of life:
Symptom management: Maintain current medication regimen focused on comfort, avoiding futile care that may prolong the dying process 1.
Medication review: Continue cholinesterase inhibitors only if they provide symptomatic benefit without adverse effects; discontinue medications that no longer serve comfort goals 1.
Behavioral symptom control: Use atypical antipsychotics (risperidone 0.25-2 mg daily or olanzapine 2.5-10 mg daily) only for severe agitation, delusions, or hallucinations that compromise comfort 1, 4, 5.
Infection management: Discuss with family whether to treat infections with antibiotics or focus solely on comfort measures, as this decision should align with established goals of care 1.
Nutrition/hydration: Avoid tube feeding, as it does not improve outcomes in end-stage dementia and may prolong dying; provide comfort feeding only 1.
Family support: Maintain close alliance with primary caregiver, provide education about the dying process, and connect family with support resources including the Alzheimer's Association 1.
Advance care planning: Ensure DNR orders are in place and family understands what to expect as death approaches 1.
Hospice team coordination: Schedule regular interdisciplinary team meetings to reassess symptoms and adjust care plan as patient's condition changes 1.
Spiritual care: Offer chaplain or spiritual caregiver support for patient and family, particularly essential during end-of-life care 1.
Recertification justification: Patient continues to meet hospice eligibility criteria with documented progression of terminal illness, FAST Stage 7C, and expected survival of less than 6 months based on functional decline and medical complications 3.
Common pitfalls to avoid:
Do not attribute all symptoms to dementia progression without investigating acute reversible causes like pain, constipation, or medication side effects that worsen comfort 4, 2.
Do not use benzodiazepines for agitation due to risk of paradoxical agitation in approximately 10% of patients and cognitive impairment 5.
Do not initiate aggressive interventions like tube feeding or hospitalization for infections unless they align with comfort-focused goals of care 1.
Do not delay family involvement in end-of-life care; facilitate in-person or virtual visits to enable meaningful goodbye 1.