Clinical Documentation for Palliative Care Transition in Elderly Patient with Advanced Dementia and Suspected Osteomyelitis
Immediate Clinical Decision
Continue IV vancomycin and cefepime while awaiting lab results and palliative care consultation, but shift the treatment goal from cure to comfort-focused symptom management, recognizing that the patient's DNR/DNH status and advanced dementia fundamentally alter the risk-benefit calculus of aggressive diagnostic workup. 1, 2
Documentation Framework for Your Note
Clinical Context Section
Document the following elements clearly:
Patient demographics and baseline status: 85-year-old with advanced dementia, DNR/DNH status established by stepson (sole contact and healthcare decision-maker) 2, 3
Current clinical scenario: Suspected osteomyelitis based on persistent leukocytosis and recent surgical hardware, with normal ankle X-ray that does not exclude the diagnosis 1, 4
Diagnostic limitations: MRI (gold standard for osteomyelitis diagnosis) not readily available in current location; would require significant time and logistical burden 1, 5
Current treatment: Already receiving IV vancomycin and cefepime for extended period 1
Goals of Care Discussion
Document the transition from curative to comfort-focused care:
Stepson (healthcare proxy) has opted for palliative care services, do not hospitalize, comfort measures only 2, 3
This decision aligns with the patient's advanced dementia stage and established DNR/DNH status 2, 6
Recognition that aggressive diagnostic workup (MRI, potential bone biopsy) would require burdensome transfers and interventions inconsistent with comfort-focused goals 1, 2, 3
Antibiotic Management Rationale
Your note should justify continuing current antibiotics with modified goals:
Continue IV vancomycin and cefepime as they are already in place and may provide symptom relief by treating underlying infection 1
The goal shifts from "cure of osteomyelitis" to "management of infection-related symptoms (pain, fever, systemic illness)" 1, 2, 3
Duration of therapy should be guided by symptom resolution rather than complete eradication of infection 1
Recommend 2-3 weeks of therapy for moderate-to-severe infection, then reassess based on clinical response and comfort 1
If symptoms improve, consider transitioning to oral antibiotics with high bioavailability to avoid continued IV access burden 1
Diagnostic Workup Modification
Document why you are NOT pursuing aggressive imaging:
Normal X-ray does not exclude osteomyelitis (sensitivity only 54%, specificity 68% for early disease) 1, 4, 7
MRI is the gold standard (sensitivity 90-97%, specificity 85-93%) but requires transfer and is not readily available 1, 5, 7
In the context of advanced dementia, DNR/DNH status, and palliative care goals, the diagnostic yield of MRI would not change management since surgical debridement is not consistent with comfort measures 1, 2
Serial radiographs in 2-4 weeks could be considered if it would inform symptom management, but are not mandatory given goals of care 1, 7
Lab Monitoring Plan
Waiting for pending labs is reasonable:
Review inflammatory markers (WBC, ESR, CRP) to assess infection severity and guide symptom management 1
Monitor renal function given vancomycin use, especially in elderly patient 8, 9
Adjust antibiotic dosing based on renal function per standard protocols 8, 9
These labs inform symptom burden and antibiotic safety, not definitive diagnosis 1
Symptom Management Focus
Document specific comfort measures:
Pain assessment and management (recognizing that pain assessment in advanced dementia requires behavioral observation tools) 2, 3
Nutritional support consistent with patient preferences and comfort 2, 6, 3
Avoid burdensome interventions: no transfers for imaging, no surgical debridement, no aggressive IV fluid resuscitation 2, 6, 3
Palliative Care Consultation
Document the referral rationale:
Assistance with symptom management in advanced dementia 2, 3
Support for family/stepson in navigating end-of-life decisions 2, 6, 3
Clarification of treatment goals and advance care planning 2, 6, 3
Critical Pitfalls to Avoid in Documentation
Do not document "awaiting MRI" as if it is planned - this creates expectation of transfer and aggressive workup inconsistent with stated goals 1, 2
Do not use language suggesting "inadequate workup" - instead frame as "workup appropriate to goals of care" 2, 3
Do not imply that antibiotics are being given to "cure" osteomyelitis - frame as symptom management 1, 2
Clearly document that stepson understands the implications of comfort measures, including that infection may not be eradicated 2, 6, 3
Specific Antibiotic Considerations
Vancomycin dosing in elderly with renal impairment:
Adjust dose based on creatinine clearance (likely reduced in 85-year-old) 8
Monitor trough levels if continuing therapy beyond 2 weeks 8
Consider discontinuation if symptoms resolve, as prolonged therapy increases toxicity risk 8
Cefepime neurotoxicity risk:
Particularly concerning in elderly with renal impairment and dementia 9
Dose adjustment required based on creatinine clearance 9
Monitor for worsening confusion, myoclonus, seizures - though baseline dementia makes this challenging 9
Consider switching to alternative if neurotoxicity suspected 9
Recommended Note Structure
Assessment and Plan:
"85-year-old with advanced dementia (DNR/DNH) and suspected osteomyelitis (persistent leukocytosis, recent hardware, normal X-ray that does not exclude diagnosis). Stepson (healthcare proxy) has elected palliative care approach with comfort measures only, do not hospitalize. MRI not readily available and would require burdensome transfer inconsistent with goals of care. Will continue current IV vancomycin and cefepime with goal of symptom management rather than cure. Plan 2-3 weeks of therapy, reassess based on clinical response. Awaiting pending labs to guide dosing adjustments and assess infection severity. Palliative care consulted for symptom management support and family counseling. Will avoid burdensome diagnostic interventions and focus on comfort."
This documentation clearly justifies your clinical decisions while respecting the patient's goals of care and the family's wishes. 1, 2, 3