What are the guidelines for recertification and management of a patient with squamous cell carcinoma of the lung in hospice care?

Hospice Recertification SOAP Note for Squamous Cell Carcinoma of the Lung

Subjective

Document the following specific elements:

• Current symptom burden with severity ratings (0-10 scale): dyspnea, pain, cough, hemoptysis, fatigue, anorexia, anxiety, depression 1, 2
• Functional decline indicators: inability to perform activities of daily living, bedbound status, weight loss >10% in past 6 months, decreased oral intake 1
• Disease progression evidence: new or worsening symptoms since last certification, increased oxygen requirements, new metastatic sites, progression on imaging if available 1
• Patient/family understanding of terminal prognosis and goals of care 2
• Current medications and their effectiveness for symptom control 2

Objective

Required clinical findings supporting terminal prognosis (≤6 months):

• Performance Status: ECOG 3-4 (bedbound >50% of day or completely bedbound) 1
• Vital signs: tachypnea, tachycardia, hypotension, oxygen saturation on current support 2
• Physical examination findings: cachexia, digital clubbing, respiratory distress, decreased breath sounds, pleural effusion, lymphadenopathy 3
• Recent laboratory values if available: albumin <2.5 g/dL, hypercalcemia, elevated LDH 1
• Imaging evidence of progression: increasing tumor burden, new metastases (brain, bone, liver), malignant pleural effusion 1, 3

Assessment

Terminal squamous cell carcinoma of the lung with life expectancy ≤6 months based on:

• Disease-specific prognostic factors: median survival for advanced squamous cell lung cancer with palliative care only is approximately 6 months or less 1
• Performance status decline: PS 3-4 indicates terminal phase with median survival <6 months 1
• Symptom progression despite optimal palliative interventions 1, 2
• Patient declined or is not candidate for disease-modifying therapy (chemotherapy, immunotherapy) due to poor performance status, comorbidities, or patient preference 1

Active symptom management needs:

• Dyspnea (specify severity)
• Pain (specify location and severity)
• Other symptoms requiring active management 2

Plan

Symptom Management Protocol

For dyspnea (primary symptom in lung cancer):

• Opioids as first-line: morphine 2.5-10 mg PO every 2 hours PRN or 1-3 mg IV every 2 hours PRN; if already on chronic opioids, increase dose by 25% 2
• Benzodiazepines for anxiety-associated dyspnea: lorazepam 0.5-1 mg PO every 4 hours PRN 2
• Anticholinergics for secretions: scopolamine 0.4 mg subcutaneous every 4 hours, scopolamine patches 1-3 patches every 3 days, or glycopyrrolate 0.2-0.4 mg IV/subcutaneous every 4 hours 2
• Non-pharmacologic interventions: upright positioning, fans, cooler room temperature, relaxation techniques 2
• Do not reduce opioid doses for decreased blood pressure, respiration rate, or level of consciousness when necessary for adequate dyspnea management 2

For pain:

• Aggressive opioid titration for moderate/severe pain 2
• NSAIDs and bisphosphonates for bone metastases if present 1, 4
• Palliative radiation for symptomatic bone metastases or hemoptysis if performance status permits 1
• Palliative sedation for refractory symptoms after consultation with palliative care specialists 2

For hemoptysis (specific to squamous cell carcinoma):

• Palliative radiation if performance status permits and bleeding is significant 1
• Tranexamic acid 1-1.5 g PO/IV three times daily for persistent bleeding 1

Psychosocial and Spiritual Support

• Psychologic interventions: psycho-education, deep breathing, progressive muscle relaxation, guided imagery, cognitive behavioral therapy 2
• Emotional support to help patient and family reshape goals based on changing reality 2
• Spiritual care addressing existential distress 2
• Facilitate completion of important personal matters and relationship closure 2
• Bereavement support for family extending up to one year after death 4

Care Coordination

• Hospice interdisciplinary team involvement: nursing, social work, chaplain, home health aide 4
• Durable medical equipment: hospital bed, oxygen concentrator, bedside commode as needed 2
• Anticipatory guidance for family regarding dying process 2
• 24/7 hospice nurse availability for crisis management 4

Recertification Justification

Patient meets hospice eligibility criteria with:

• Terminal squamous cell lung cancer with median survival <6 months based on performance status 3-4 and disease progression 1
• Decline or ineligibility for disease-modifying therapy 1
• Active symptom burden requiring hospice-level palliative interventions 1, 2
• Patient/family understanding and agreement with hospice goals of care 4, 2

Next recertification due in 60 days (or 90 days for subsequent recertifications after initial two 90-day periods) 4

Critical Pitfalls to Avoid

• Do not delay palliative interventions while awaiting disease progression documentation; early integration improves quality of life and potentially survival 1
• Do not withhold opioids for fear of respiratory depression when managing dyspnea 2
• Avoid describing hospice as "giving up"; reframe as optimizing quality of life and comfort 2
• Do not implement aggressive nutritional support that may increase suffering in advanced disease 2