Admitting Diagnosis for Septic Shock Patient Choosing Palliative Care
The admitting diagnosis should be "septic shock" (or "severe sepsis" if using older terminology), as this accurately reflects the patient's acute medical condition and does not preclude the simultaneous provision of palliative care. The diagnosis should document the underlying infection source when known (e.g., "septic shock secondary to pneumonia").
Rationale for Diagnostic Accuracy
Document the actual medical condition regardless of treatment goals. The admitting diagnosis serves multiple critical functions beyond treatment planning:
- Accurate prognostication and communication - The Surviving Sepsis Campaign guidelines emphasize that goals of care discussions must incorporate accurate diagnosis and prognosis, which requires proper documentation of septic shock 1
- Resource allocation and care coordination - Proper diagnosis ensures appropriate staffing, monitoring capabilities, and specialist involvement even when pursuing comfort-focused care 2, 3, 4
- Quality metrics and institutional learning - Accurate diagnosis coding allows hospitals to track outcomes and improve sepsis care pathways 2
Integration of Palliative Care with Septic Shock Diagnosis
The diagnosis of septic shock and palliative care goals are not mutually exclusive. The Society of Critical Care Medicine explicitly recommends incorporating goals of care into treatment planning while maintaining diagnostic accuracy:
- Early goals of care discussions are mandatory - Guidelines recommend discussing goals of care and prognosis with patients and families as early as feasible, but no later than within 72 hours of ICU admission 1, 2, 3, 4
- Palliative principles guide treatment intensity, not diagnosis - The guidelines state to "incorporate goals of care into treatment and end-of-life care planning, utilizing palliative care principles where appropriate" (grade 1B recommendation) 1
Documentation Approach
Use dual documentation that captures both the medical diagnosis and care goals:
- Primary admitting diagnosis: Septic shock with source (e.g., "septic shock secondary to urosepsis")
- Secondary diagnosis or problem list: Document "palliative care" or "comfort measures only" as a separate entry
- Goals of care documentation: Clearly document the patient's wishes regarding treatment limitations in the admission note 2, 3, 4
Clinical Implications
This approach allows for appropriate symptom management while respecting patient autonomy:
- Palliative care in septic shock reduces resource utilization - Research demonstrates that palliative care for patients dying with septic shock is associated with shorter hospital length of stay (12.0 vs. 13.1 days) and lower total hospital costs, while presumably improving alignment with patient goals 5
- Treatment modifications based on goals - With septic shock diagnosis documented, the team can selectively apply comfort-focused interventions (pain control, dyspnea management, family support) while declining aggressive interventions (vasopressors, mechanical ventilation, dialysis) based on the patient's stated wishes 1
- Flexibility for evolving goals - Accurate diagnosis allows for treatment escalation if the patient's goals change, while maintaining the option for continued comfort-focused care 2, 3, 4
Common Pitfalls to Avoid
- Do not use vague diagnoses like "failure to thrive" or "comfort care" as the primary admitting diagnosis, as these obscure the actual medical condition and impair communication 2
- Do not delay goals of care discussions - Address these within 72 hours of admission even when the diagnosis is clear 1, 2, 3, 4
- Do not assume palliative care means no treatment - Many comfort-focused interventions for septic shock (antibiotics for symptom relief, judicious fluids for comfort, oxygen for dyspnea) may align with patient goals 2, 3, 4