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Hospice admission — advanced colon cancer with cardiac comorbidity

Solomon Maria Macejkovic · 75y · male · 2020-01-11

Admission to hospice (procedure)

Chart background

Active conditions

  • Received higher education (finding)
  • Body mass index 30+ - obesity (finding)
  • Prediabetes (finding)
  • Anemia (disorder)
  • Ischemic heart disease (disorder)
  • Abnormal findings diagnostic imaging heart+coronary circulat (finding)
  • Hyperlipidemia (disorder)
  • Polyp of colon (disorder)
  • Chronic sinusitis (disorder)
  • Limited social contact (finding)
  • Social isolation (finding)

Active medications

  • Clopidogrel 75 MG Oral Tablet
  • Simvastatin 20 MG Oral Tablet
  • 24 HR metoprolol succinate 100 MG Extended Release Oral Tablet
  • Nitroglycerin 0.4 MG/ACTUAT Mucosal Spray

After-visit summary

Visit summary

What we discussed
• Primary malignant neoplasm of colon — hospice admission
• Ischemic heart disease
• Fatigue, anemia, and anorexia
• Abdominal discomfort
• Caregiver support and care coordination

Next steps
• Initial patient assessment completed; individualized plan of care developed documenting his goals in his own words: home, porch, music, no hospitalization, no resuscitation attempts.
• Ongoing hospice care visits: nursing twice weekly to start, escalating with need; aide support offered and declined for now (his choice to revisit); chaplain and social worker available; 24/7 on-call line reviewed — call hospice first, not emergency services.
• Continue 24-hr metoprolol succinate 100 mg ER and nitroglycerin 0.4 mg spray as needed — both directly serve comfort.
• Continue clopidogrel 75 mg and simvastatin 20 mg for now; identified with the patient as first candidates for future deprescribing if pill burden grows, by shared decision.
• Energy budgeting: prioritize porch mornings and valued activities; liberalize diet to preference; wife to keep a simple daily comfort diary (pain, appetite, sleep) to guide visits.
• Monitor at each nursing visit; anticipatory guidance provided; escalate through the on-call line if pain sharpens or persists.
• Respite care benefit explained and available; caregiver education begun.
• Hospice assumes coordination of services; formal patient discharge processing at the close of the episode.

deterministic_extractive_v1 · not_clinically_reviewed

Clinical note

**Subjective:** Solomon Macejkovic is a 75-year-old man admitted today to home hospice care for primary malignant neoplasm of the colon. His illness declared itself through progressive anemia, which prompted the evaluation that found first a colon polyp and then the malignancy. A retired engineer, he reviewed prognosis frankly with his oncology team and has declined further disease-directed therapy, reasoning that additional treatment buys hospital time, not porch time. Comorbid ischemic heart disease with documented abnormal findings on diagnostic imaging of the heart and coronary circulation; he has exertional and stress-related chest tightness a couple of times weekly, reliably relieved within minutes by nitroglycerin spray. Current symptoms: intermittent dull, heavy lower abdominal discomfort that does not shout, prominent fatigue (his heavy coat), reduced appetite, and increased daytime napping. He denies uncontrolled pain today, dyspnea at rest, fever, vomiting, or new neurologic symptoms. Goals of care, stated clearly and with capacity: remain at home, mornings on the porch, his jazz records, his wife's cooking, quiet; no hospital transfers, no resuscitation attempts, no machines. Psychosocial: married 51 years; wife Margaret is his devoted primary caregiver; longstanding limited social contact and social isolation which he experiences as contentment rather than distress; nights are the caregiver's chief worry. Additional history: obesity (BMI 30+), prediabetes, hyperlipidemia, chronic sinusitis, prior colon polyp. Medications reconciled: clopidogrel 75 mg daily; simvastatin 20 mg nightly; 24-hr metoprolol succinate 100 mg extended-release daily; nitroglycerin 0.4 mg/actuation mucosal spray as needed for chest tightness. No known allergies.

**Objective:** Elderly man reclining comfortably at home, alert, fully oriented, articulate, participating in the entire admission conversation though he tires with prolonged effort and defers logistics to his wife. No acute distress; breathing unlabored at rest; no chest pain during the visit. Appears fatigued with reduced reserve; rises from the recliner slowly and ambulates short household distances. Skin intact on initial assessment. No numeric vital measurements recorded at this visit.

**Assessment and Plan:**

### Primary malignant neoplasm of colon — hospice admission
Advanced colonic malignancy; patient has capacity and elects comfort-focused home hospice care. Certification procedure completed by the attending physician and hospice physician; formal notifications sent to his primary physician and Medicare.
- Initial patient assessment completed; individualized plan of care developed documenting his goals in his own words: home, porch, music, no hospitalization, no resuscitation attempts.
- Ongoing hospice care visits: nursing twice weekly to start, escalating with need; aide support offered and declined for now (his choice to revisit); chaplain and social worker available; 24/7 on-call line reviewed — call hospice first, not emergency services.

### Ischemic heart disease
Recurrent brief chest tightness responsive to nitroglycerin; symptom control is the goal rather than risk modification.
- Continue 24-hr metoprolol succinate 100 mg ER and nitroglycerin 0.4 mg spray as needed — both directly serve comfort.
- Continue clopidogrel 75 mg and simvastatin 20 mg for now; identified with the patient as first candidates for future deprescribing if pill burden grows, by shared decision.

### Fatigue, anemia, and anorexia
Energy decline consistent with advanced malignancy, cardiac disease, and known anemia; no further laboratory surveillance planned as it would not change comfort-directed management.
- Energy budgeting: prioritize porch mornings and valued activities; liberalize diet to preference; wife to keep a simple daily comfort diary (pain, appetite, sleep) to guide visits.

### Abdominal discomfort
Intermittent dull lower abdominal heaviness, currently tolerable without scheduled analgesia.
- Monitor at each nursing visit; anticipatory guidance provided; escalate through the on-call line if pain sharpens or persists.

### Caregiver support and care coordination
Wife is sole caregiver and anxious about nights.
- Respite care benefit explained and available; caregiver education begun.
- Hospice assumes coordination of services; formal patient discharge processing at the close of the episode.

FHIR resources at this visit

Procedure 49DiagnosticReport 1

Transcript

NURSEKnock knock — Mr. Macejkovic? I am Ruth Delgado, the hospice admissions nurse; we spoke with your wife this morning. This is Dr. Patel, our team physician.

PTCome in, come in. Forgive me for not getting up — this recliner and I have reached an understanding.

FAMILYI am Margaret, his wife. Fifty-one years this spring. Sit down, please — there is fresh coffee if anyone wants it.

DRThank you, Margaret. Maybe after we talk. Mr. Macejkovic —

PTSolomon. If you are going to be in my living room, it is Solomon.

DRSolomon, then. I have read everything your doctors sent over, but paper never tells it right. Would you tell me how you got here, the way you would tell it?

PTThe short version. My blood kept coming up low — the anemia — and they went looking for the reason. First it was a polyp. Then it was the tumor in the colon. I am an engineer — was an engineer — so I asked them for the numbers, the honest ones. And when I ran those numbers myself, the answer was clear enough. More treatment buys me hospital time, not porch time.

FAMILYThe oncologist was kind about it. But Solomon had already decided by the time we reached the car.

DRAnd the heart as well — I see the ischemic heart disease in your history, and the imaging of your heart and coronary circulation showed abnormal findings.

PTThe heart has been complaining for years. I carry the little nitroglycerin spray for when my chest tightens up. Between the heart and the tumor, something is going to call time on me. I would just as soon be comfortable while they argue over which.

DRThat is about as clear-eyed as anyone has ever put it to me. So let me ask what actually matters: what does a good day look like now?

PTThe porch in the morning if it is not too cold. My records in the afternoon — I have shelves of jazz that Margaret pretends to tolerate. Her cooking. And quiet. I was never a crowd person, and these last years the circle got very small. That used to bother her more than it bothered me.

FAMILYIt did. He would go weeks without seeing a soul besides me. But he is content that way, and I have made my peace with it. Mostly.

DRThen we build the care around the porch, the records, and Margaret's cooking. Ruth, the medications?

NURSERight here. Solomon, tell me if this matches the pillbox. Clopidogrel, 75 milligrams, once a day. Simvastatin, 20, at night. The long-acting metoprolol, 100 milligrams. And the nitroglycerin spray, 0.4 milligrams under the tongue when the chest acts up.

PTThat is the roster. Margaret loads the box every Sunday. I am the talent; she is management.

NURSEHow often do you need the spray?

PTA couple of times a week, maybe. If I take the stairs too quickly or get worked up about something. It settles in a few minutes.

DRGood to know. Here is my thinking on those medicines — tell me if it sits right with you. The metoprolol and the spray earn their keep: they keep chest pain off your porch, so they stay. The clopidogrel and the statin are more about preventing trouble years down the road. For today we keep everything exactly as it is — no changes while everything else is new — but over time, if swallowing a handful of pills becomes a chore, those are the ones we would retire first. We decide together, no surprises.

PTA sensible engineering review. Keep what functions, sunset what does not. Agreed.

FAMILYDoctor, may I ask — his appetite has gotten small, and he naps more than he used to. Is that the cancer, or the heart, or...?

DRMost likely both, plus the anemia that started this whole story. The honest answer is that his body is budgeting its energy very carefully now. We will not chase numbers anymore — no more blood draws unless they would change his comfort. Instead we treat what he feels: pain, breathlessness, chest tightness, worry. Solomon, any pain today?

PTThe belly gets dull and heavy sometimes, low down. Nothing that shouts. Tired is the main complaint. Tired is a heavy coat.

NURSEThen let us talk about how this all works, because I want you both to know the machinery. Today is the initial assessment — I will listen to his heart and lungs, check his skin, look at safety around the house. From that we write his individualized plan of care: his goals in his own words, and the schedule. I will visit a couple of times a week to begin. An aide can come to help with bathing —

PTNot yet. A man can still run his own shower.

NURSEThen the plan says not yet, and it is yours to change, not ours. There is also a chaplain, and a social worker, if either of you ever wants a longer conversation. And this number answers twenty-four hours a day. Chest pain at three in the morning — you call us first, not the ambulance.

FAMILYThat is the part I needed to hear. The nights are what frighten me.

DRYou will not be alone with the nights anymore, Margaret. And there is respite built into this benefit — if you ever need a few days to rest, we arrange his care so you can step away. Looking after the caregiver is part of the job.

FAMILYFifty-one years and I have never left him anywhere. But it helps to know it exists.

DRTwo pieces of housekeeping. For hospice, two physicians certify that the illness has reached the stage where comfort is the right medicine — his attending physician and I have completed that certification. And we send the formal notifications — his primary doctor, Medicare — so the paperwork routes through us now. You two are officially out of the phone-call business.

PTThe best news I have had all month. The phone calls were worse than the tumor.

DROne more question, and it is the important one. Solomon — if your heart stops, or your breathing, what do you want done?

PTNothing heroic. No machines, no pounding on my chest, no sirens in the driveway. When a system fails past repair, you let it power down with some dignity. Margaret knows. Now you know.

FAMILYI know. We have talked it through many times, at that kitchen table. I will hold the line.

DRThen it goes into the plan of care in your exact words, and everyone who comes through that door will know it too. Solomon, anything you want to ask me? Anything at all.

PTJust one thing. The porch, the records, a little of her pot roast — how long do I get?

DRI will not pretend to know the number, and I have learned not to guess. What I can promise is this: however much there is, we will spend all of it on porches and pot roast, and none of it in waiting rooms.

PTThat is the first honest schedule anyone has given me in two years. Ruth, come do your listening. Margaret, get these people their coffee — they passed the interview.

NURSETwist my arm. Then I will check you over head to toe, write up the plan, and you will see me again Thursday. And Margaret, I will show you how to keep a little diary of his comfort — pain, appetite, sleep — so every visit starts from what the week actually looked like.

FAMILYI can do that. I kept his books for fifty years; I can keep this one.

PTShe never missed a decimal. I am in careful hands, Doctor — mostly hers.

DRThe best kind. We will see ourselves through the checkup, and then, Margaret, that coffee.