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const fs = require('fs');

// ─── Helper Functions ─────────────────────────────────────────────────────────

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// ─── DOCUMENT BUILD ───────────────────────────────────────────────────────────

const children = [

  // ─── COVER ────────────────────────────────────────────────────────────────
  new Paragraph({
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  new Paragraph({
    children: [new TextRun({ text: 'ONCOLOGY ICU', bold: true, size: 56, color: '2E74B5' })],
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    ['Institution', ''],
    ['Unit', 'Oncology ICU'],
    ['Revision Date', 'June 2026'],
    ['Version', '1.0'],
    ['Approved By', ''],
  ]),
  pageBreak(),

  // ─── SECTION 0: HOW TO USE ─────────────────────────────────────────────────
  h1('HOW TO USE THIS DOCUMENT'),
  body('This guide provides a systematic, organ-by-system framework for conducting daily ICU rounds on oncology patients. It combines the standard ICU "FAST-HUGS" philosophy with oncology-specific overlays: chemotherapy toxicity monitoring, immunosuppression assessment, cancer-specific metabolic emergencies, and goals-of-care documentation.'),
  body(''),
  boldPara('Round Structure Recommendation:'),
  bullet('Bedside team: Attending physician, fellow/resident, bedside nurse, pharmacist, dietitian, social worker (as available)'),
  bullet('Duration: 8–15 minutes per patient (prioritize unstable patients first)'),
  bullet('Sequence: Review overnight events → Examination → System review → Plan → Goals'),
  bullet('Document each decision with rationale; update orders in real time'),
  divider(),

  // ─── SECTION 1: PATIENT SNAPSHOT ──────────────────────────────────────────
  h1('SECTION 1 — PATIENT SNAPSHOT'),
  body('Complete at the start of each round. This orients the entire team to oncologic and ICU context.'),
  new Paragraph({ spacing: { after: 80 }, children: [] }),
  infoTable([
    ['Patient Name / ID', ''],
    ['Age / Sex', ''],
    ['Primary Malignancy', '(type, stage, histology)'],
    ['Date of Diagnosis', ''],
    ['Metastatic Sites', ''],
    ['Current Treatment Regimen', '(chemo / targeted / immunotherapy / radiation / SCT)'],
    ['Last Treatment Dose', '(drug, date, cycle number)'],
    ['Reason for ICU Admission', ''],
    ['ICU Day #', ''],
    ['Code Status / Goals of Care', ''],
    ['Primary Oncologist', ''],
    ['Next-of-Kin / Surrogate', ''],
  ]),
  new Paragraph({ spacing: { after: 120 }, children: [] }),
  divider(),

  // ─── SECTION 2: OVERNIGHT EVENTS ──────────────────────────────────────────
  h1('SECTION 2 — OVERNIGHT EVENTS & 24-HOUR SUMMARY'),
  checkboxTable([
    ['New clinical events', 'Deterioration, arrhythmia, new fever, bleeding, mental status change'],
    ['Interventions performed', 'Intubation, line placement, bronchoscopy, procedure, dialysis started'],
    ['Medications changed', 'New antibiotics, vasopressors added/weaned, analgesics adjusted'],
    ['Lab alerts acted on', 'Critical K+, lactate, culture positivity, coagulation abnormality'],
    ['Imaging / consults ordered', 'CT, echo, specialty consultation results'],
    ['Family communication', 'Updates given, concerns raised, meetings held'],
  ]),
  new Paragraph({ spacing: { after: 120 }, children: [] }),
  divider(),

  // ─── SECTION 3: VITAL SIGNS ────────────────────────────────────────────────
  h1('SECTION 3 — VITAL SIGNS & MONITORING TRENDS'),
  body('Trend at minimum over the last 24 hours. Flag any value outside oncology-specific targets.'),
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      tableRow([{ text: 'Respiratory Rate (/min)', width: 2200 }, { text: '', width: 2000 }, { text: 'Target 12–20; > 25 indicates respiratory distress; correlate with ABG', width: 5300 }]),
      tableRow([{ text: 'SpO2 (%)', width: 2200 }, { text: '', width: 2000 }, { text: 'Target ≥ 94% (88–92% if COPD); trend FiO2 requirement', width: 5300 }]),
      tableRow([{ text: 'GCS / RASS Score', width: 2200 }, { text: '', width: 2000 }, { text: 'RASS target −2 to 0 for most; document CAM-ICU if applicable', width: 5300 }]),
      tableRow([{ text: 'Urine Output (mL/hr)', width: 2200 }, { text: '', width: 2000 }, { text: 'Target ≥ 0.5 mL/kg/hr; critical in TLS, nephrotoxic chemo, contrast use', width: 5300 }]),
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  }),
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  divider(),

  // ─── SECTION 4: SYSTEM REVIEW ─────────────────────────────────────────────
  h1('SECTION 4 — SYSTEM-BY-SYSTEM REVIEW'),

  // 4A Respiratory
  h2('4A. RESPIRATORY SYSTEM'),
  checkboxTable([
    ['Airway status', 'Intubated / Extubated / Tracheostomy / Natural airway; secure? Plan for today?'],
    ['Ventilator settings', 'Mode (AC/VC, PRVC, SIMV, PSV, CPAP/PEEP); FiO2; PEEP; Vt (6 mL/kg IBW); RR; Plateau P < 30 cmH2O; Driving P < 15 cmH2O'],
    ['Weaning assessment', 'SBT candidate? SAT completed? RSBI < 105? Cuff leak present?'],
    ['ABG interpretation', 'pH; PaO2; PaCO2; HCO3; P/F ratio; Classify: hypoxic / hypercapnic / mixed'],
    ['Chest imaging', 'CXR compared to prior; consolidation / effusion / pneumothorax / new infiltrate'],
    ['Pleural drainage', 'Chest tube/pigtail: output, appearance, suction setting, leak check'],
    ['Oncology-specific respiratory', 'Radiation pneumonitis? Checkpoint inhibitor pneumonitis (ICI)? Bleomycin toxicity? Leukostasis? DAH? PCP pneumonia?'],
    ['NIV / HFNO trial', 'If on HFNO: flow (L/min), FiO2; assess tolerance and response'],
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  boldPara('Oncology Respiratory Notes:'),
  bullet('ICI pneumonitis: Grade 1 — observe; Grade 2 — hold ICI, start pred 1 mg/kg/day; Grade 3–4 — hold ICI, methylprednisolone 1–2 mg/kg/day IV, consider bronchoscopy/BAL'),
  bullet('Radiation pneumonitis: typically 1–6 months post-radiation; treat with corticosteroids'),
  bullet('Bleomycin pulmonary toxicity: cumulative dose > 400 units is higher risk; avoid high FiO2 if bleomycin was used'),
  bullet('PCP pneumonia (Pneumocystis jirovecii): suspect in lymphoma/leukemia, SCT, steroids > 20 mg/day > 1 month; treat with TMP-SMX 15–20 mg/kg/day IV + adjuvant prednisone if PaO2 < 70 mmHg'),
  bullet('Leukostasis: WBC > 100,000/µL in AML/CLL; emergency leukapheresis + hydroxyurea'),
  divider(),

  // 4B Cardiovascular
  h2('4B. CARDIOVASCULAR SYSTEM'),
  checkboxTable([
    ['Hemodynamics', 'MAP, CO/CI, SVR if Swan or PiCCO/PICCO available; passive leg raise response'],
    ['Vasopressors / inotropes', 'Norepinephrine (mcg/kg/min); Vasopressin (units/hr); Dopamine; Dobutamine; weaning plan?'],
    ['Fluid balance', '24 hr balance (in vs out); cumulative balance since admission; 4-hour trends'],
    ['Fluid responsiveness', 'Pulse pressure variation > 13% = likely responsive (if no arrhythmia, no sRV failure)'],
    ['Rhythm', 'Continuous telemetry; 12-lead ECG if new event; rate control if AF'],
    ['Cardiac monitoring', 'QTc interval (target < 500 ms); troponin if suspected cardiac toxicity'],
    ['DVT / PE', 'Prophylaxis: LMWH dose-adjusted for renal function; therapeutic anticoagulation if active VTE; IVC filter if anticoagulation contraindicated'],
    ['Oncology cardiac toxicity', 'Anthracycline cardiomyopathy (cumulative doxorubicin > 550 mg/m²)? Trastuzumab cardiotoxicity? TKI-related HTN? 5-FU vasospasm? ICI myocarditis?'],
    ['Pericardial effusion', 'Check for effusion in malignant pericarditis; tamponade signs (Beck triad)?'],
  ]),
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  boldPara('QTc Monitoring Targets (Oncology-Specific):'),
  bullet('Arsenic trioxide, crizotinib, vandetanib, osimertinib, vemurafenib: high QT-prolonging risk'),
  bullet('Stop or hold drug if QTc > 500 ms or increase > 60 ms from baseline'),
  bullet('Correct K+, Mg²+, Ca²+ before and during therapy'),
  divider(),

  // 4C Neurology
  h2('4C. NEUROLOGICAL SYSTEM'),
  checkboxTable([
    ['Consciousness', 'GCS (E/V/M); orientation (person/place/time); baseline vs today'],
    ['Sedation', 'RASS score; agent used (propofol mcg/kg/min; dexmedetomidine mcg/kg/hr; midazolam mg/hr); SAT performed?'],
    ['Analgesia', 'Numeric pain scale (0–10) or CPOT; opioid dose; adjuncts; multimodal plan'],
    ['Delirium', 'CAM-ICU positive/negative; ICDSC score; hyperactive vs hypoactive; non-pharm measures: reorientation, sleep hygiene, mobility'],
    ['Seizures', 'New seizure activity? AED levels if on therapy; EEG if suspected subclinical'],
    ['Focal deficit', 'New focal weakness / aphasia / ataxia? → urgent CT head or MRI; rule out CNS metastasis, PRES, stroke'],
    ['PRES', 'Posterior reversible encephalopathy: cisplatin, bevacizumab, calcineurin inhibitors; BP control; hold offending agent'],
    ['CNS status', 'Known brain metastases? Dexamethasone dose and indication? Radiation to brain?'],
    ['ICP signs', 'Headache, papilledema, Cushings triad (HTN + bradycardia + irregular respirations)?'],
  ]),
  divider(),

  // 4D Renal
  h2('4D. RENAL SYSTEM & FLUID-ELECTROLYTE BALANCE'),
  checkboxTable([
    ['Renal function', 'Creatinine + eGFR (compare to baseline); BUN; BUN/Cr ratio'],
    ['Urine output', 'Hourly UO; oliguria = < 0.5 mL/kg/hr; anuria = < 100 mL/day'],
    ['Fluid balance', 'Cumulative in/out; weight trend; peripheral/pulmonary edema'],
    ['Electrolytes', 'Na, K, Ca (ionized), Mg, Phosphate; replace deficits; oncology: hypercalcemia of malignancy, TLS electrolytes'],
    ['Acid-base', 'ABG or VBG: pH, bicarb, anion gap, lactate; HAGMA → TLS, cisplatin nephrotoxicity?'],
    ['Nephrotoxin review', 'Cisplatin, ifosfamide, methotrexate (high-dose), contrast agents, aminoglycosides, vancomycin (AUC monitoring)'],
    ['Renal replacement therapy', 'CRRT: modality (CVVHDF), effluent rate (target 20–25 mL/kg/hr), anticoagulation, filter life; dose drug adjustments?'],
    ['Diuresis strategy', 'Forced diuresis if high-dose MTX, cisplatin; furosemide target UO ≥ 100 mL/hr in TLS'],
    ['Foley catheter', 'Necessary? Indication still valid? CAUTI risk; urine culture if new fever'],
  ]),
  new Paragraph({ spacing: { after: 60 }, children: [] }),
  boldPara('Tumor Lysis Syndrome (TLS) — Daily Assessment:'),
  infoTable([
    ['TLS Risk', 'High risk: ALL (esp. hyperleukocytosis), Burkitt lymphoma, DLBCL, AML (WBC > 100K)'],
    ['Cairo-Bishop Criteria (Lab TLS)', 'Uric acid ≥ 8 mg/dL; K+ ≥ 6 mEq/L; Phosphate ≥ 6.5 mg/dL; Ca²+ ≤ 7 mg/dL — 2 or more, within 3 days before to 7 days after chemo'],
    ['Clinical TLS', 'Lab TLS + creatinine ≥ 1.5x ULN, cardiac arrhythmia, or seizure'],
    ['Daily Labs (repeat q4–8h)', 'CBC, electrolytes, creatinine, Ca, phosphate, Mg, uric acid, LDH, urinalysis'],
    ['IV Fluids', 'NS or 1/2NS at 2–3x maintenance; target UO ≥ 100–150 mL/hr; avoid urinary alkalinization routinely'],
    ['Hyperuricemia Rx', 'Allopurinol 100 mg/m² q8h (prevention); Rasburicase 0.2 mg/kg IV (treatment; contraindicated in G6PD deficiency)'],
    ['Hyperkalemia Rx', 'Calcium gluconate; insulin/dextrose; sodium bicarbonate; kayexalate/patiromer; dialysis if severe'],
    ['Hypocalcemia Rx', 'ONLY treat if symptomatic (tetany, QTc prolongation) — calcium gluconate IV; avoid overcorrection (worsens Ca-Phos precipitation)'],
    ['Hyperphosphatemia Rx', 'Sevelamer; aluminum hydroxide; restrict dietary phosphate; dialysis'],
    ['Dialysis Indications', 'Refractory hyperkalemia, severe acidosis, volume overload, creatinine rapidly rising'],
  ]),
  divider(),

  // 4E GI
  h2('4E. GASTROINTESTINAL SYSTEM & NUTRITION'),
  checkboxTable([
    ['Bowel function', 'Last bowel movement; ileus? Distension? Bowel sounds; NGT output if present'],
    ['Mucositis', 'Grade 1–4 (WHO scale); oral rinses; pain management; TPN if Grade 3–4 prevents enteral nutrition'],
    ['Nausea / Vomiting', 'Chemotherapy-induced (CINV): antiemetic regimen adequate? Ondansetron, dexamethasone, NK1 antagonist, lorazepam?'],
    ['GI bleeding', 'Hematemesis, melena, hematochezia; check Hgb trend; endoscopy indication?'],
    ['Stress ulcer prophylaxis', 'PPI or H2-blocker: indicated if ventilated > 48h, or coagulopathic; de-escalate when enteral feeds established'],
    ['Enteral nutrition (EN)', 'Route (NGT/PEG/NJT); formula; rate (mL/hr); GRV if checked; HOB ≥ 30–45°; goal calories met?'],
    ['Parenteral nutrition (PN)', 'TPN if EN not feasible (> 3 days NPO, severe mucositis, bowel obstruction); lipid-inclusive regimen; line dedicated?'],
    ['Caloric goals', 'Target: 25–30 kcal/kg/day; Protein: 1.5–2 g/kg/day (higher in catabolic/SCT patients)'],
    ['Blood glucose control', 'Target 140–180 mg/dL; insulin infusion protocol if > 180 mg/dL × 2 readings; avoid hypoglycemia < 70 mg/dL'],
    ['Liver function', 'Bilirubin, ALT, AST, ALP, GGT; veno-occlusive disease (VOD) in SCT patients? Assess for drug-induced hepatotoxicity'],
  ]),
  new Paragraph({ spacing: { after: 60 }, children: [] }),
  boldPara('Hepatic Veno-Occlusive Disease (VOD) / Sinusoidal Obstruction Syndrome (SOS):'),
  bullet('Post-SCT: weight gain, jaundice, right upper quadrant pain, hepatomegaly'),
  bullet('Baltimore criteria: bilirubin ≥ 2 mg/dL + 2 of: hepatomegaly, ascites, weight gain > 5%'),
  bullet('Treatment: defibrotide 6.25 mg/kg IV q6h x 21 days; supportive care; avoid hepatotoxins'),
  divider(),

  // 4F Hematology
  h2('4F. HEMATOLOGY & COAGULATION'),
  checkboxTable([
    ['CBC', 'Hgb (transfusion if < 7 g/dL or < 8 if symptomatic); Platelets (transfuse if < 10K, or < 20K if febrile, or < 50K if bleeding/procedure); WBC / ANC'],
    ['ANC (Absolute Neutrophil Count)', '< 500/µL = profound neutropenia; < 1000/µL = neutropenia; duration of neutropenia'],
    ['Coagulation panel', 'PT, INR, aPTT, fibrinogen, D-dimer; trend daily if DIC suspected'],
    ['DIC assessment', 'Low plts + elevated D-dimer + low fibrinogen + prolonged PT/aPTT = DIC; treat underlying cause; cryoprecipitate for fibrinogen < 100'],
    ['Transfusion record', 'pRBC, platelets, FFP, cryoprecipitate given; reaction? Type & screen current?'],
    ['Thromboprophylaxis', 'LMWH (enoxaparin 40 mg SC daily; adjust if CrCl < 30); mechanical (SCDs); contraindicated if plts < 50K'],
    ['HIT screening', 'New thrombocytopenia on heparin? 4T score; anti-PF4 antibody; switch to argatroban/bivalirudin if HIT confirmed'],
    ['Bleeding risk assessment', 'Active bleeding? Procedure planned? Anticoagulation hold required?'],
    ['G-CSF / GM-CSF', 'Indication (primary/secondary prophylaxis, active neutropenia); current dose; expected nadir timing'],
  ]),
  divider(),

  // 4G Infectious Disease
  h2('4G. INFECTION & ANTIMICROBIAL STEWARDSHIP'),
  checkboxTable([
    ['Fever evaluation', '> 38.3°C once or > 38.0°C × 1h: in neutropenic patient = emergency; send blood cultures (x2 peripheral + each lumen of CVC) within 30 min'],
    ['Active cultures', 'Blood (peripheral + central); urine (if Foley or symptoms); sputum / BAL; wound; stool (if diarrhea → C. diff)'],
    ['Empirical antibiotic regimen', 'Febrile neutropenia first-line: antipseudomonal beta-lactam (piperacillin-tazobactam 4.5g q6h, or cefepime 2g q8h, or meropenem 1g q8h)'],
    ['Vancomycin indication', 'MRSA suspected: line infection, skin/soft tissue, mucositis with gram-positive risk, hemodynamic instability, relapsed ALL/AML'],
    ['Antifungal coverage', 'Azole prophylaxis (fluconazole in standard risk); echinocandin (caspofungin) for invasive candida; voriconazole for aspergillosis (halo sign on CT)'],
    ['Antiviral coverage', 'Acyclovir for HSV/VZV reactivation; ganciclovir/valganciclovir for CMV (monitor CMV PCR in SCT); oseltamivir for influenza if positive'],
    ['Antibiotic day count', 'Day of antibiotics; de-escalate based on culture sensitivities; procalcitonin trend to guide cessation'],
    ['Source control', 'Remove infected lines; drain collections; debride wounds; consult surgery if indicated'],
    ['HAI bundle compliance', 'CVC: daily necessity review, dressing check, chlorhexidine bathing; VAP bundle: HOB 30–45°, oral decontamination; CAUTI: Foley necessity reviewed?'],
    ['Isolation precautions', 'Neutropenic precautions (protective environment: positive pressure room, HEPA filtration, masks); contact isolation if MRSA, VRE, C. diff, CPE'],
  ]),
  new Paragraph({ spacing: { after: 60 }, children: [] }),
  boldPara('Febrile Neutropenia — Time-to-Antibiotic Target: < 60 minutes from fever recognition'),
  bullet('Low-risk (MASCC score ≥ 21, expected neutropenia < 7 days): oral fluoroquinolone; consider outpatient'),
  bullet('High-risk (MASCC < 21, ANC < 100, expected nadir > 7 days, mucositis, hemodynamic instability): IV antibiotics, admit ICU if unstable'),
  bullet('Do NOT delay antibiotics to await culture results in neutropenic fever'),
  bullet('Add antifungal empirically if fever persists > 72–96h despite broad-spectrum antibiotics'),
  divider(),

  // 4H Oncology-Specific
  h2('4H. ONCOLOGY-SPECIFIC ASSESSMENTS'),

  h3('Chemotherapy Toxicity Review'),
  checkboxTable([
    ['Active agents / regimen', 'List all current and recent chemo/targeted/immunotherapy agents'],
    ['Cycle day / nadir timing', 'Expected nadir: Day 10–14 for most regimens; Day 7 for anthracycline-based'],
    ['Cardiotoxicity', 'Anthracyclines (cumulative dose?); trastuzumab (EF check q3 months?); 5-FU (ECG changes?); ICI myocarditis (troponin, echo)?'],
    ['Pulmonary toxicity', 'Bleomycin (cumulative dose); methotrexate pneumonitis; ICI pneumonitis (see 4A)'],
    ['Nephrotoxicity', 'Cisplatin (Mg wasting, tubular toxicity); high-dose MTX (leucovorin rescue, urinary alkalinization, MTX levels); ifosfamide (Fanconi syndrome)'],
    ['Neurotoxicity', 'Peripheral neuropathy (vinca alkaloids, taxanes, bortezomib); PRES (cisplatin, bevacizumab); encephalopathy (ifosfamide → treat with methylene blue)'],
    ['Gastrointestinal', 'Mucositis grade; diarrhea (ICI colitis vs. infection); hepatotoxicity; pancreatitis (L-asparaginase)'],
    ['Immune-related AEs (irAE)', 'Grade irAE in each organ: lung, gut, liver, endocrine, skin, neuro; hold ICI per grade; steroids per protocol'],
    ['Targeted therapy specific', 'VEGF-TKI: HTN, fistula, wound healing; ALK/EGFR inhibitor: interstitial lung disease; CDK4/6 inhibitor: myelosuppression; BCR-ABL: pleural effusion (dasatinib)'],
    ['CAR-T / SCT specific', 'CRS (cytokine release syndrome): Grade 1–4; tocilizumab 8 mg/kg IV if Grade 2+; ICANS (immune effector cell–associated neurotoxicity syndrome); GVHD grading'],
  ]),

  h3('Metabolic Oncologic Emergencies'),
  infoTable([
    ['Hypercalcemia of Malignancy', 'Ca > 12 mg/dL: IV NS 200–300 mL/hr; zoledronic acid 4 mg IV (onset 24–48h); calcitonin 4 IU/kg q12h for rapid effect; denosumab if renal failure; dialysis if refractory'],
    ['SIADH', 'Hyponatremia (Na < 135) + concentrated urine + euvolemia; restrict free water < 1L/day; tolvaptan if severe; 3% NaCl if symptomatic (seizure)'],
    ['Adrenal Insufficiency', 'Suspect in long-term steroid use or bilateral adrenal metastases; random cortisol + ACTH stim test; hydrocortisone 50–100 mg q8h IV if crisis'],
    ['Tumor Lysis Syndrome', 'See Section 4D above for full protocol'],
    ['Spinal Cord Compression', 'Back pain + weakness + sensory level + bowel/bladder dysfunction; urgent MRI spine; dexamethasone 10 mg IV bolus then 4 mg q6h; radiation/surgery'],
    ['SVC Syndrome', 'Facial/arm swelling, plethora, JVD, dyspnea; CT chest with contrast; stent or radiation; anticoagulation if thrombotic component'],
    ['Leukostasis', 'WBC > 100K + respiratory/neuro symptoms; leukapheresis + hydroxyurea; avoid RBC transfusion (increases viscosity); urgent hematology consult'],
  ]),
  divider(),

  // 4I Lines & Devices
  h2('4I. LINES, TUBES & DEVICES'),
  checkboxTable([
    ['CVC / PICC / Port', 'Type, site, days in situ; necessity review; insertion site inspection (erythema, discharge, tenderness); dressing change due?'],
    ['Arterial line', 'Site; waveform quality; zeroed; distal perfusion check; necessity review'],
    ['Endotracheal tube', 'ETT size, position (CXR cm at lip); cuff pressure 20–30 cmH2O; suction plan'],
    ['Tracheostomy', 'Type, size; stoma care; inner cannula change; cuff check'],
    ['Urinary catheter', 'Days in place; CAUTI prevention; consider removal if not clinically required'],
    ['Nasogastric / Nasoenteric tube', 'Position confirmed (CXR or pH); feeds running; mark tube at nostril'],
    ['Chest tube', 'Drainage character (mL/shift); air leak; suction vs. water seal; removal criteria met?'],
    ['Wound / Drains', 'Surgical drains: type, output, character; wound assessment'],
    ['ICP Monitor', 'If present: ICP readings; CPP target (50–70 mmHg); CSF drainage'],
    ['Renal replacement therapy (CRRT)', 'Access site; circuit pressure alarms; filter down time; anticoagulation (citrate/heparin); effluent targets'],
  ]),
  divider(),

  // 4J Skin & Mobility
  h2('4J. SKIN, MOBILITY & REHABILITATION'),
  checkboxTable([
    ['Pressure injury assessment', 'Braden scale; high-risk areas: sacrum, heels, occiput, elbows; turn q2h; specialty mattress if Braden ≤ 12'],
    ['Wound assessment', 'Surgical / radiation skin damage; chemotherapy extravasation site (assess for necrosis); GVHD skin manifestations'],
    ['Early mobilization', 'ICU mobility scale (0–8); PT/OT consult; passive range of motion at minimum; sedation interruption to allow activity'],
    ['VTE prevention (mechanical)', 'Sequential compression devices (SCDs) when pharmacologic prophylaxis contraindicated; check lower extremity perfusion'],
    ['Oral hygiene', 'Chlorhexidine rinse q12h (VAP bundle); mucositis care protocol; lip moisturizer'],
    ['Ophthalmologic care', 'Lubricating eye drops q4h in unconscious patients; eyelid taping if incomplete closure'],
  ]),
  divider(),

  // ─── SECTION 5: LAB REVIEW ────────────────────────────────────────────────
  h1('SECTION 5 — DAILY LABORATORY REVIEW'),
  body('Check and trend the following labs each morning. Flag any critical values immediately.'),
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      tableRow([
        { text: 'Lab Group', width: 2200, shade: '2E74B5' },
        { text: 'Tests', width: 3600, shade: '2E74B5' },
        { text: 'Oncology Action Threshold', width: 3700, shade: '2E74B5' },
      ], true),
      tableRow([{ text: 'CBC with differential', width: 2200 }, { text: 'WBC, ANC, Hgb, Hct, Platelets', width: 3600 }, { text: 'ANC < 500: neutropenic precautions + empiric ATB if febrile; Hgb < 7: transfuse; Plt < 10K: transfuse', width: 3700 }]),
      tableRow([{ text: 'Metabolic panel', width: 2200 }, { text: 'Na, K, Cl, CO2, BUN, Cr, Glucose', width: 3600 }, { text: 'K > 5.5 or < 3.0: treat; Cr rise > 0.3 mg/dL: AKI workup; Glucose > 180: insulin protocol', width: 3700 }]),
      tableRow([{ text: 'Liver function', width: 2200 }, { text: 'AST, ALT, ALP, GGT, bilirubin (total/direct), albumin', width: 3600 }, { text: 'ALT > 3x ULN: review hepatotoxic agents; bilirubin rising: VOD, biliary obstruction, hemolysis?', width: 3700 }]),
      tableRow([{ text: 'TLS panel', width: 2200 }, { text: 'Uric acid, LDH, phosphate, ionized Ca, Mg', width: 3600 }, { text: 'Uric acid > 8: rasburicase; Phosphate > 6.5: sevelamer; Ca < 7 (symptomatic): calcium gluconate', width: 3700 }]),
      tableRow([{ text: 'Coagulation', width: 2200 }, { text: 'PT, INR, aPTT, fibrinogen, D-dimer, thromboelastography (TEG) if available', width: 3600 }, { text: 'DIC: low fibrinogen < 100 → cryoprecipitate; INR > 2 with bleeding → FFP', width: 3700 }]),
      tableRow([{ text: 'Inflammatory / Infection', width: 2200 }, { text: 'CRP, procalcitonin, ferritin (CRS), ESR', width: 3600 }, { text: 'Ferritin > 10,000: HLH or CRS (CAR-T); PCT trend to guide antibiotic de-escalation', width: 3700 }]),
      tableRow([{ text: 'ABG / Lactate', width: 2200 }, { text: 'pH, PaO2, PaCO2, HCO3, SpO2, lactate', width: 3600 }, { text: 'Lactate > 2: sepsis workup; P/F < 300: moderate ARDS; P/F < 100: severe ARDS', width: 3700 }]),
      tableRow([{ text: 'Drug levels / Monitoring', width: 2200 }, { text: 'Vancomycin AUC/MIC (target AUC 400–600); MTX levels (with leucovorin rescue); cyclosporin / tacrolimus trough', width: 3600 }, { text: 'Adjust dosing accordingly; consult pharmacy', width: 3700 }]),
      tableRow([{ text: 'Endocrine', width: 2200 }, { text: 'Thyroid function (q1–4 weeks on ICI); morning cortisol; HbA1c (at admission)', width: 3600 }, { text: 'ICI hypothyroidism: levothyroxine; ICI adrenalitis: hydrocortisone replacement', width: 3700 }]),
    ],
  }),
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  divider(),

  // ─── SECTION 6: MEDICATION REVIEW ────────────────────────────────────────
  h1('SECTION 6 — DAILY MEDICATION RECONCILIATION'),
  checkboxTable([
    ['Renal dose adjustments', 'eGFR trend; dose-adjust: LMWH, antibiotics (vancomycin, piperacillin-taz, carbapenems), antivirals, electrolyte replacement'],
    ['Hepatic dose adjustments', 'Total bilirubin; dose-adjust: vincristine (hold if bili > 3), doxorubicin, paclitaxel, irinotecan; avoid NSAIDs'],
    ['Drug-drug interactions', 'Azole antifungals + TKIs (CYP3A4 inhibition); warfarin + antibiotics; QT-prolonging combinations'],
    ['Anticoagulation review', 'Type, dose, indication; therapeutic range; hold before procedures; reversal agents available?'],
    ['Antiemetics', 'Scheduled vs. PRN; 5-HT3 antagonist; dexamethasone; lorazepam; aprepitant; metoclopramide'],
    ['Corticosteroids', 'Indication (irAE, edema, CINV, adrenal insufficiency); dose; taper plan; PCP prophylaxis if > 20 mg/day > 4 weeks'],
    ['PPI / H2 blocker', 'Indication still valid? De-escalate if on enteral feeds without ventilation or coagulopathy'],
    ['Vasopressors', 'Type, rate, trend; escalating or weaning; assess response; avoid excessive fluid boluses'],
    ['Blood products', 'Irradiated / leukoreduced / CMV-negative products for SCT, lymphoma, immunosuppressed; consent?'],
    ['Insulin protocol', 'Active infusion protocol? POC glucose frequency; hypoglycemia management plan'],
    ['Formulary / Formulary substitutions', 'Brand-to-generic substitutions safe? Oncology drugs: confirm exact formulation (e.g., liposomal vs. conventional doxorubicin)'],
  ]),
  divider(),

  // ─── SECTION 7: GOALS OF CARE ─────────────────────────────────────────────
  h1('SECTION 7 — GOALS OF CARE & COMMUNICATION'),
  checkboxTable([
    ['Code status', 'Full code / DNR / DNI / DNR-DNI; documented and visible on chart; consistent with patient wishes'],
    ['Family meeting', 'Last meeting date; key messages communicated; interpreter needed?'],
    ['Prognosis discussion', 'Has oncologist provided updated prognosis? ICU team aligned with oncology on expected course?'],
    ['Comfort measures', 'Symptom burden addressed: pain, dyspnea, anxiety, nausea; palliative care consult placed?'],
    ['Futility review', 'If patient not responding to maximal ICU therapy: ethics consult; palliative care involvement; trial of therapy timeframe set?'],
    ['Advance directives', 'Living will / healthcare proxy documented; surrogate decision-maker identified'],
    ['Spiritual / Psychosocial support', 'Chaplaincy; social work consult; family visitation plan; cultural considerations'],
    ['Chemotherapy continuation', 'Can therapy be safely continued in ICU? Risk/benefit discussion with oncology; dose modification needed?'],
  ]),
  divider(),

  // ─── SECTION 8: DAILY PLAN ────────────────────────────────────────────────
  h1('SECTION 8 — DAILY PLAN & ORDERS'),
  body('Complete a structured problem list with plan for each active issue. Communicate clearly to the bedside nurse.'),
  infoTable([
    ['Problem #1', ''],
    ['Plan', ''],
    ['Problem #2', ''],
    ['Plan', ''],
    ['Problem #3', ''],
    ['Plan', ''],
    ['Problem #4', ''],
    ['Plan', ''],
    ['Labs to order today', ''],
    ['Imaging to order today', ''],
    ['Procedures today', ''],
    ['Consults requested', ''],
    ['Anticipated transfers / disposition', ''],
    ['Target for tomorrow', ''],
  ]),
  divider(),

  // ─── SECTION 9: BUNDLE COMPLIANCE ────────────────────────────────────────
  h1('SECTION 9 — ICU QUALITY BUNDLE COMPLIANCE (Daily Confirmation)'),
  body('The ABCDEF Bundle (Liberation Bundle) adapted for oncology ICU:'),
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        { text: 'Component', width: 2500, shade: '2E74B5' },
        { text: 'Today Done?', width: 1500, shade: '2E74B5' },
        { text: 'Notes', width: 5000, shade: '2E74B5' },
      ], true),
      tableRow([{ text: 'A', width: 500, shade: 'DEEAF1' }, { text: 'Assess / Manage Pain', width: 2500 }, { text: '☐ Yes  ☐ No', width: 1500 }, { text: 'CPOT or NRS ≤ 3 target; multimodal; opioid-sparing preferred', width: 5000 }]),
      tableRow([{ text: 'B', width: 500, shade: 'DEEAF1' }, { text: 'Both SAT & SBT', width: 2500 }, { text: '☐ Yes  ☐ No', width: 1500 }, { text: 'SAT: hold sedation, assess wake-up; SBT: PS 5/PEEP 5 for 30–120 min if SAT passed; document result', width: 5000 }]),
      tableRow([{ text: 'C', width: 500, shade: 'DEEAF1' }, { text: 'Choice of Analgesia/Sedation', width: 2500 }, { text: '☐ Yes  ☐ No', width: 1500 }, { text: 'Light sedation (RASS −1 to 0) preferred; avoid benzodiazepines; propofol or dexmedetomidine favored', width: 5000 }]),
      tableRow([{ text: 'D', width: 500, shade: 'DEEAF1' }, { text: 'Delirium Assess/Manage', width: 2500 }, { text: '☐ Yes  ☐ No', width: 1500 }, { text: 'CAM-ICU or ICDSC; non-pharm first; haloperidol 0.5–2 mg q6h if agitated; quetiapine if prolonged', width: 5000 }]),
      tableRow([{ text: 'E', width: 500, shade: 'DEEAF1' }, { text: 'Early Mobility/Exercise', width: 2500 }, { text: '☐ Yes  ☐ No', width: 1500 }, { text: 'ICU mobility scale; PROM if immobile; OOB to chair if feasible; PT/OT consult', width: 5000 }]),
      tableRow([{ text: 'F', width: 500, shade: 'DEEAF1' }, { text: 'Family Engagement', width: 2500 }, { text: '☐ Yes  ☐ No', width: 1500 }, { text: 'Family updated today; invited to rounds; care team meeting scheduled?', width: 5000 }]),
    ],
  }),
  new Paragraph({ spacing: { after: 120 }, children: [] }),

  boldPara('Additional Oncology ICU Quality Metrics:'),
  checkboxTable([
    ['Neutropenic protective isolation compliance', 'Positive pressure room; HEPA filtered; mask on entry; no fresh flowers/plants/raw produce'],
    ['Chemotherapy safe handling', 'PPE for handling hazardous drugs; closed system transfer; waste disposal per protocol'],
    ['CRS monitoring (CAR-T patients)', 'Fever + hypotension + hypoxia: Grade 1–4 CRS; tocilizumab 8 mg/kg IV (Grade 2+); ICU-level monitoring for Grade 3–4'],
    ['GVHD surveillance (SCT patients)', 'Skin (erythema, bullae); gut (diarrhea volume); liver (bilirubin); grading and treatment escalation per protocol'],
    ['Radiation recall monitoring', 'New skin inflammation at prior radiation site with chemotherapy rechallenge'],
    ['Second primary infection prophylaxis', 'Acyclovir/valacyclovir for HSV/VZV; fluconazole or voriconazole per protocol; PCP prophylaxis (TMP-SMX or dapsone/atovaquone)'],
  ]),
  divider(),

  // ─── SECTION 10: HANDOFF ──────────────────────────────────────────────────
  h1('SECTION 10 — END-OF-ROUND HANDOFF & COMMUNICATION'),
  infoTable([
    ['SBAR Summary Situation', '(Patient X is a __ year old with __ cancer, ICU day __, admitted for __)'],
    ['Background', '(Disease course, recent chemo, relevant comorbidities)'],
    ['Assessment', '(Current status: stable/improving/deteriorating; active problems)'],
    ['Recommendation', '(Today\'s plan; key actions; overnight watch items)'],
    ['Anticipated deterioration triggers', '(If X happens → do Y; notify attending if Z occurs)'],
    ['Upcoming procedures', '(Timing, consent status, NPO requirements, blood product availability)'],
    ['Family contact plan', '(Who to call; what they know; what is pending)'],
  ]),

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