In Hospice care

Were goals of care documented this visit?

Yes: Face to Face Advance Care Planning was done with:

Patient participated in family meeting.

Parent participated.

The following was/were discussed: Counseling/Coordination of Care, Prognosis Days to weeks

Patient and family education

More specifically we discussed comfort measures and hospice in the home

We discussed healthcare options for end-of-life care

We reviewed goals of care

We refined goals of care

We decided among options for treatment.

I spent a total time of 50 minutes doing Face to Face Advance Care Planning..

The following questions were asked: Understanding/perception of illness:

(how the patient/family describes illness/prognosis, their perspective on how it has impacted their life, their understanding of treatment options and plan)

Crystal and her mother have a good understanding of the cancer reoccurrence. Crystal has been offered high dose radiation and has decided against it due to side effects. She would like to focus on comfort going forward.

Communication preferences:

(Does the patient/family want to know all the information whether good or bad, are there certain people with whom they do no want their case discussed?)

Crystal wants to know all information and is ok with her mother being present during serious discussions.

Acceptable quality of life:

(what does the patient need to be able to do in order to make the medical care worth it to endure?)

Crystal does not want to continue with cancer treatments. She also understands that the weekly infusions of Cetuximab will not continue with hospice care. She would like to explore medication options for symptom management. We discussed famil Crystal biggest fear is choking during the night. She frequently wakes ups coughing and unable to ve secretions for her throat. We talked about transitioning to Skilled Nursing Facility or to.Hospice House.

 Etc

Past experiences with serious illness/hospice:

(Do the patient/family members has experiences with hospice, ICU, dialysis, dementia, CPR, ventilators, and has that given a perspective on what the patient/ family wants):

Patients goals have changed today. She no longer wishes for extreme lifesaving measure.

Hospice discussion was held: Family/patient was open to the idea of hospice.

Hospice criteria applicable to this patient: CANCER: Her Disease has a very poor prognosis

Progression from an earlier stage of disease to metastatic disease with either: A continued decline in spite of therapy

Patient declines further disease directed therapy

Advance Directives,MOST form, and Code Status

Goals of care were changed today

Code status was changed to: DNR/Comfort

Symptom Assessment and Management

Chronic Pain

Nociceptive

Secondary to throat cancer

Treatment plan: Recommend morphine 5 mg oral solution through PEG tube. Please give Ondansetron 8 mg oral solution 30 minutes prior to opioid medication

Dysphagia

Treatment plan: Recommend comfort feeding, spoon feeding small bites/sips as tolerated

Excessive Secretions

Treatment plan: Recommend dexamethasone 8 mg IV daily for Tumour edema (tracheal compression) (J Laryngol Otol. 2016 May; 130(Suppl 2): S198–S207.

doi: 10.1017/S0022215116000633)

Continue glycopyrrolate as ordered.

Patient will need home suctioning set up with hospice services.

Failure to Thrive

Likely due to Cancer, depression, anorexia, tube feeding dependent.

Fatigue

Secondary to: cancer

Treatment plan:

Nausea

Treatment plan: Continue ondansetron, consider 8 mg po q 8 hour to avoid nausea with opioid use.

Constipation

At risk for increase with opioid use. Recommend Miralax daily and senna syrup 17 mg q hs

Plan for Follow-up:

Palliative Care will continue to follow this patient.

These recommendations have been discussed with the primary team and supporting staff caring for this patient.

Uh, indeed a lot more than " love"..... That idea seems rather nebulous, .... Not practical for me atthistime.sorry

Hi Swimbody,

When I had to go into the Emergency Dept here, on the written Note orders of my surgeon, whatever day it wss..... It was only 4 Days after that Mask firing to begin my Second round of Radiotherapy .

Needless to say, that's not a good way to starts rigorous trestment. I wss Immediately admitted. My Volume so low they immediately pumped in a bolus of Lactated Ringers solution and antibiotics (sevrral)etc

Then in earnest began talking about my treatment options and palliative care. They discovered I wss open to the discussion.

Since this new cancer has now metastasized to my Voice Box , I cannot speak a word, so I have to write everything to the person.

The 2 doctors who took care of me, one who knows me from admissions last year --- are glad that I'm a clear thinking and very practical person. No silly ideas or emotions, lets just deal with Facts, please.

This wss their mental status report on me at the end of the long Physical findings report ::

:

Mental Status: She is alert and oriented to person, place, and time.

Psychiatric:

Mood and Affect: Mood normal.

Behavior: Behavior normal.

Thought Content: Thought content normal.

Judgment: Judgment normal.

Comments: Patient is nonverbal at baseline but is very good about writing down and conversing in this manner. Mood and affect are congruent with what would be expected for someone with terminal diagnosis