Hospice Flashcards
1
Q
Dame Cecily Saunders
A
Founder of the modern hospice movement
2
Q
What year was the first hospice founded in the United States?
A
In 1974, Florence Wald, two pediatricians, and a chaplain founded the first hospice in the US Connecticut Hospice in Branford, CT.
3
Q
Of the following, which may indicate a poor prognosis for the hospice patient with a diagnosis of
end-stage cardiac disease?
a. Infection
b. Edema
c. Bleeding
d. Unexplained syncope
A
D
4
Q
. When a hospice patient is facing increasing weakness, with increased fatigue and decreased
mobility, which of the following is an important aspect of supporting the patient’s care needs?
a. Prioritizing energy use
b. Honoring the wishes of family members
c. Remaining as mobile as possible
d. Seeing as many visitors as possible
A
a - Prioritizing energy use is an important aspect of supporting the hospice patient who is experiencing progressive weakness and fatigue. Helping the patient to identify which activities are most important to physical, emotional and spiritual needs empowers the patient to spend limited energy on those aspects that matter most to them
5
Q
Gertrude is an 84-year-old with end stage ovarian cancer. Her condition has been deteriorating for the
past several days, and she has been sleeping much more than usual. Her daughter states that she has
not been eating or drinking much, and thinks she is more confused, since she’s been talking about
“packing her bags for her trip” every time she wakes up.
196. Of the following, what would be the most appropriate intervention?
a. Find out if Gertrude would like to take a final trip somewhere.
b. Instruct Gertrude’s daughter to give her a sedative when she starts talking like this.
c. Discuss the dying process with Gertrude’s daughter.
d. Increase Gertrude’s pain medication
A
c - Since language about some aspect of traveling is very common during nearing death awareness, signs and symptoms of the dying process should be discussed with Gertrude’s daughter. This will allow her to understand where her mother is in her disease trajectory, and begin to prepare for her mother’s death.
6
Q
Sam is a 78-year-old with colon cancer with metastasis to the liver. Though his physical status
has been stable, he has been increasingly withdrawn. During your weekly visit, he states, “I’m
not waiting around for the end to come. I can take matters into my own hands.” Of the
following, what is the most appropriate initial response?
a. Ask Sam’s family not to leave him alone.
b. Request a psychiatric evaluation.
c. Explore Sam’s feelings and provide support.
d. Request an increase in his anti-depressant dosage.
A
c - The most appropriate initial response is to explore Sam’s feelings and provide support. Since Sam is verbalizing a suggestion of suicidal ideation, it is imperative that appropriate members of the IDT, such as the hospice social worker, are involved as soon as possible to provide expertise and appropriate interventions. Sam’s safety and prevention from self-harm are of the highest priority, and interventions must be individualized to ensure that this occurs
7
Q
Tom is an 82-year-old with end-stage cardiac disease who has just celebrated his 60th wedding
anniversary with his wife, Margaret. Tom has been experiencing increasing dyspnea, which is
partially relieved when he is sitting up in a chair. He has been repeatedly offered a hospital bed,
so he can elevate the head of his bed, but refuses. He states, “I’ve slept in the same bed with
Margaret for the past 60 years, and I can’t imagine not getting to do that.” Of the following,
which is the most appropriate response?
a. Assure him she’ll just be in the next room.
b. Request a medication to help him sleep.
c. Remind him that his breathing status is the priority.
d. Collaborate with the pt/family/IDT for alternative options
A
d - Collaboration with the patient/family/Interdisciplinary Team (IDT) to explore alternative options is the most appropriate response. Tom’s feelings must be valued, supported and honored with alternatives provided that will optimize his comfort in the context of his choices.
8
Q
Steve is a 76-year-old with end stage lung cancer, who is from a very large Greek family. When
you arrive for your visit, his wife greets you at the door in tears, stating that she has just made
another big meal for him, and he keeps refusing to eat. Of the following, which is the most
appropriate initial response?
a. Assess Steve for the cause of his anorexia.
b. Instruct his wife to make smaller meals.
c. Evaluate the types of food she is preparing.
d. Instruct his wife to serve cold foods.
A
. a - Since there can be a number of causes for anorexia in this patient population, Steve should first be assessed to determine what may be impacting his appetite. Physical causes may include conditions such as thrush, mucositis, medication side-effects and electrolyte imbalances. Patients typically have a decreased appetite with a decline in condition, which can be very difficult for family members who feel that one of the most loving things they can do is to prepare and provide food. Education for both the patient and family members is important, so the patient can be given permission to eat according to his wishes and family members can be given alternative methods to provide support.
9
Q
Amy is a 49-year-old with end-stage breast cancer who is in the dying process at home. She has
not eaten for several days, and has been taking only sips of fluid. Her urine output is decreasing
and her mucous membranes are dry. Her husband wants to know why an intravenous infusion
has not been started to keep her from getting dehydrated. Of the following, which is the most
appropriate response?
a. It’s too difficult to manage an IV infusion at home.
b. She would need a central line placed in the hospital.
c. Artificial fluids of any type are against hospice policy.
d. Dehydration is a normal part of the dying process
A
d - Amy’s husband should be provided education regarding the benefit of dehydration as a normal part of the body’s adjustment during the dying process, which serves to increase the patient’s comfort level as organ systems are shutting down. Though the patient should be permitted to eat or drink anything she wishes, decreased intake is a naturally occurring mechanism the body uses to prevent fluid overload during a time when major organs begin to fail. Frequent mouth care should be provided to maintain oral moisture for comfort. When possible, it’s best to discuss the patient’s wishes for artificial nutrition/hydration early in the course of her disease. Having advanced directives in place that indicate a patient’s wishes limits the burdens of decision-making on the patient’s family and/or designated caregivers
10
Q
Thelma is an 80-year-old with end-stage colon cancer with metastasis to the liver. She has been
in the dying process for the past 24 hours, and her daughter has called, concerned because
Thelma is running a temperature. Upon visiting, you find Thelma to be non-responsive, but
resting peacefully, with an axillary temperature of 100°F. What is the next most appropriate
intervention?
a. Notify the doctor and draw blood cultures
b. Recommend using cool compresses
c. Order a cooling blanket
d. None of the above
A
b - Fever is very common during the dying process, due to the dehydration that most patients experience. Cool compresses, and a cool environment are some helpful non-invasive interventions. If the patient appears to be uncomfortable due to the fever, acetaminophen via the appropriate route of administration for the patient’s level of consciousness can be requested if not contraindicated
11
Q
Of the following, which can be a common cause for agitation during the active phase of dying?
a. Unresolved emotional/spiritual issues
b. Allergic reactions
c. Tri-cyclic antidepressants
d. Nausea
A
. a - Unresolved emotional and spiritual issues can be a common cause for agitation during the active phase of dying. Working with the patient prior to this phase of the disease process toward achieving resolution and/or closure of unresolved emotional and spiritual issues can be a key factor in helping the patient to die a peaceful death. During the dying process, even if the patient is unable to respond, hearing often remains intact. Family input regarding the possible source of spiritual or emotional distress can be very helpful in developing a care plan to help the patient achieve resolution and enhance a peaceful dying process
12
Q
What is the most important factor in treating terminal agitation?
a. Titrating sedatives to effect
b. Determining the cause
c. Providing family support
d. Initiating continuous care nursing
A
b - Since there can be many causes for terminal agitation, attempting to determine the cause is the most important factor in treating this distressing symptom. Since determining the cause can be difficult, the treatment approach may need to be a trial of various interventions to see what the patient responds best to
13
Q
If a patient begins to exhibit new-onset confusion, which of the following would NOT be a
potential etiology?
a. Benzodiazepines
b. Hypercalcemia
c. Pain
d. None of the above
A
d - Since any of the options could be a potential etiology for new-onset confusion, none are exempt. Confusion can be caused by many sources, including medications, metabolic abnormalities, pain and disease progression which encompasses many physical, psychosocial and spiritual factors.
14
Q
During IDT, two nursing colleagues start a discussion about a particular patient’s
“hallucinations”. One states that she believes the patient when she states that she is seeing
deceased relatives and conversing with them. The other states that she does not support this
theory, but thinks that there is a metabolic or pharmacologic reason for her visions. Of the
following, which approach would be in the patient’s best interest?
a. Ignore the patient’s conversation.
b. Honor the patient’s experience.
c. Suggest that labwork be ordered.
d. Ask the hospice chaplain to intervene
A
. b - Hospice professionals have differing views regarding the topic of visions of deceased loved ones that patients often have as they are entering the dying process. It is always correct to honor and validate the patient’s experience, regardless of individual feelings. If a metabolic or pharmacologic component is suspected as a contributing factor, further assessment may take place, according to the patient/family’s wishes
15
Q
James is a 59-year-old patient with a history of a non-operable, malignant brain tumor who has
been on hospice for the past few months but has new onset of significant neurological and
motor deficits on his right side based upon your assessment. He remains alert and responsive
and expresses his desire to stay at home. His wife is concerned and states “I cannot take care of
him if he is paralyzed”. What is the best response for the nurse in this situation?
a. “He will not be paralyzed forever”.
b. “We can transfer him to a nursing home immediately”.
c. “Let’s arrange a meeting with your family and the hospice team to discuss care options”.
d. “We will continue to provide the help and support that you need 24 hours a day”.
A
. c - The best response in this situation is to coordinate a family meeting to discuss care options. There may be opportunity for children and other family members along with hospice staff to provide additional services and support to both the patient and the wife. Since the patient wishes to remain at home, transfer to a nursing home is not a reasonable response. Likewise, telling the wife that this deficit/paralysis is only temporary is not within a nurse scope of practice. Similarly, giving them the impression that hospice will be there 24 hours a day for routine care needs is not reasonable.
16
Q
Harold is a 75-year-old hospice patient with end-stage Parkinson’s disease who is being cared for
at home by his 72-year-old wife. Harold is now bed bound and you are instructing his wife on
potential complications of immobility and how to prevent them. You should include which of the
following in your education to her?
a. Massage of reddened skin areas.
b. Frequent changes to upright position.
c. Schedule of passive repositioning.
d. Limited bathing/skin care due to risk of friction injury.
A
c - Providing education on a schedule for passive repositioning is of great importance with a patient who is bed-bound and immobile to prevent complications. Massage of reddened skin areas is not recommended as it may further impair tissue perfusion. Upright positions are not recommended due to increased pressure on sacral/buttock areas. Proper bathing and skin care/hygiene is also vitally important and allows for assessment, observation and application of lotions/emollients to maintain moisture
17
Q
Which description best outlines intimacy as it relates to relationships where one partner is
terminally ill?
a. Intimacy is no longer of importance in terminal illness.
b. Intimacy should be discouraged for patients with terminal illness.
c. Intimacy is a universal human need within significant relationships.
d. Intimacy deprives patients of energy that could be used elsewhere
A
c - Intimacy is a universal human need that is met through relationships and although it can be compromised by terminal illness, it should be encouraged if desired. Although patients may not be able to maintain their prior abilities or desires, the need for that intimate human connection remains and should be recognized as vital to significant
18
Q
The term used to describe the mental and physical fatigue along with generalized weakness
associated with terminal illness and often attributed to malnutrition:
a. Anorexia
b. Asthenia
c. Cachexia
d. Delirium
A
b - The correct term for this is Asthenia. Cachexia is a state of general ill health and malnutrition marked by weakness and emaciation. Anorexia is the lack or loss of appetite resulting in the inability to eat and resulting weight loss that is common in many illnesses. Delirium is an etiologically non-specific, global, cerebral dysfunction characterized by concurrent disturbances of level of consciousness, attention, thinking, perception, memory, psychomotor, behavior, emotion, and the sleep-wake cycle
19
Q
Themes of nearing death awareness include all of the following except:
a. Describing a place.
b. Needing reconciliation.
c. Non-symbolic dreams.
d. Preparing for travel.
A
. c - Themes of nearing death awareness include describing a place, needing reconciliation, talking to or being in the presence of someone who is not alive, knowledge or statements of when death will occur, choosing time of death, preparing for travel or change, being held back, and symbolic dreams.
20
Q
Differentiation between nearing death awareness and delirium can include which of the
following?
a. Pleasantness/comfort of reported experiences.
b. Frequency of reported experiences.
c. Timing of reported experiences.
d. None of the above.
A
296a - Clinicians often use the pleasantness/comfort of the reported experiences to differentiate between nearing death awareness and delirium
21
Q
Jenny is an 85-year-old nursing home resident who has been in fairly good health and has remained
mentally alert and responsive until very recently when she developed increased confusion,
disorientation, severe mood lability, hallucinations and delusions, along with fluctuations in her
mood/behaviors over the course of the day with worsening symptoms at night. You are called to
assess her for admission to hospice care given her change in status.
297. Based upon Jenny’s symptoms and your assessment, the most appropriate diagnosis describing
her condition would be:
a. Dementia
b. Actively dying
c. Delirium
d. Psychosis
A
c - Delirium is the correct diagnosis based upon her presenting symptoms. The key factors that differentiate delirium from dementia are the rate of onset, the presence of delusions and/or hallucinations, and fluctuations in mood/behavior over the course of the day with worsening symptoms at night. Dementia is a slow, progressive disorder with stable symptoms generally and limited delusions or hallucinations.
22
Q
What should be your recommendations regarding her hospice admission given her
condition/diagnosis?
a. Admit immediately and contact family due to likelihood of imminent death.
b. Investigate her chart and request additional tests to confirm your suspected diagnosis.
c. Tell the facility staff that she is not eligible for hospice and ask them to notify her family.
d. Request orders for anti-psychotic medications to control her symptoms prior to
admission.
A
b - The correct response given the patient’s presenting symptoms and suspected diagnosis of delirium would be to investigate her chart and request additional tests to confirm the suspected diagnosis. There are many potential causes of delirium including constipation hypovolemia, hypoglycemia, infection, medications, bladder distention/catheter issues, hypoxemia and pain.
23
Q
Which of the following statements most accurately reflects the relationship between delirium
and dementia?
a. Delirium is a pre-disposing factor for the development of dementia.
b. Dementia lowers the medical acuity threshold for the development of delirium.
c. Delirium and dementia are pre-disposing factors for the development of either diagnosis.
d. Delirium is a symptom of dementia.
A
b - Cognitive impairment and dem. entia are the leading pre-disposing factors for delirium. Those patients with dementia are vulnerable to delirium at lower levels of medical acuity than nondemented persons.
24
Q
Hallucinations are best defined as which of the following?
a. A misinterpretation of real external stimuli.
b. A decreased ability to focus, sustain or shift attention along with a change in cognition.
c. A tormented state of mind related to unresolved emotional or spiritual issues.
d. A subjective sensory perception in the absence of any relevant external stimuli.
A
. d - Hallucinations are defined as a subjective sensory perception in the absence of any relevant external stimuli. Illusion is a misinterpretation of real external stimuli. A decreased ability to focus, sustain or shift attention along with a change in cognition is a symptom of delirium. A tormented state of mind related to unresolved issues is terminal anguish.
25
When describing medication coverage under the Hospice Medicare/Medicaid benefit to a newly
admitted hospice patient and family, of the following, which statement is the most accurate
about what medications are covered by this benefit?
a. “None of your medications.”
b. “All of your medications will continue to be covered as they are now.”
c. “Medications related to your terminal illness.”
d. “Only pain medications.
c - “Medications related to your terminal illness” is the accurate statement. The nature of every hospice organization is unique, and though all Medicare-approved hospices are required to follow the same basic regulations of the Hospice Medicare and Medicaid benefit, and meet the same conditions of participation, they may have varying arrangements regarding the method by which medications are provided to or obtained by their hospice patients. To be eligible for enrollment in the Hospice Medicare/Medicaid benefit, an individual must be eligible for traditional Medicare Part A/Medicaid, have certification from their doctor and the hospice medical director that they have a terminal illness with a life expectancy of 6 months or less if the illness runs its normal course, sign a statement to elect the Hospice Medicare or Hospice Medicaid benefit, and receive care from a Medicare-approved hospice.
26
When describing how the Hospice Medicare/Medicaid benefit impacts payment for a hospital
stay for a patient who has been admitted to hospice, which of the following is the most accurate
statement?
a. “Charges for all hospitalizations are billed to the hospice.”
b. “Hospice patients must be discharged from the hospice prior to hospitalization.”
c. “The hospice is never billed for hospitalizations.”
d. “Charges for hospitalizations related to the hospice admitting diagnosis are billed to the
hospice.
d - “Charges for hospitalizations related to the hospice admission diagnosis are billed to the hospice” is correct. Patients who enroll in the Hospice Medicare/Medicaid benefit remain enrolled in traditional Medicare/Medicaid for all other aspects of care that are not related to the hospice admitting diagnosis
27
Jerry is a 49-year-old hospice patient who has health insurance through his employer. Of the
following, which is the most accurate statement about coverage for hospice services through his
insurance?
a. The coverage is the same as the Hospice Medicare/Medicaid benefit.
b. The hospice will cover anything the patient needs.
c. The coverage depends upon the hospice benefit provision of the health insurance policy.
d. Hospice is not covered by insurance and the patient will be billed for all hospice services
c - Coverage for hospice services depends upon the hospice benefit provision of the health insurance policy. Each policy is different, and not all have a hospice benefit provision. Those who have a hospice benefit, typically have limitations. If a patient is admitted with private insurance, the policy must be reviewed and care coordinated with the insurance case manager. Patients should never be denied access to hospice care due to the inability to pay.
28
Of the following, which are included in core services under hospice care which must be provided
by the agency, and not according to a contractual arrangement?
a. Nursing, counseling, medical social services
b. Nursing, home health aide services, chaplain services
c. Nursing, physical therapy, occupational therapy
d. Nursing, counseling, chaplain services
a - Nursing, counseling and medical social services are core services that must be provided by the hospice agency and not provided according to a contractual arrangement. This does not limit the requirement for a more comprehensive team. Other required services which may be provided by the agency, or hired according to contractual arrangement, include: therapy services (PT, OT, speech-language pathology), physician, volunteer, hospice aide and homemaker services, medical equipment and supplies, acute and respite inpatient care, medications related to the terminal illness, and bereavement services
29
Under the Hospice Medicare/Medicaid benefit, when a patient is in need of a hospital bed in the
home, who provides coverage for the equipment?
a. The patient/family
b. The durable medical equipment company
c. The hospice
d. Traditional Medicare
c - Durable medical equipment (DME), such as hospital beds, walkers, wheelchairs, etc. is paid for by the hospice. Although the hospice may provide the equipment, or sub-contract a DME provider and pay for it, the hospice is being paid a per diem rate by Medicare to provide such equipment and services. There are 4 levels of care under the Hospice Medicare benefit, which determines the per diem rate that the hospice receives: Level 1 – routine home care (can also be designated at this level even if a resident in a long-term care facility), Level 2 – continuous home care day (may occur in the home or long-term care facility), Level 3 – inpatient respite care, Level 4 – general inpatient care (may occur in a hospice house so designated to provide this level of care). In order for the patient’s care to be designated at the various levels, certain defining criteria must be met
30
Mabel is a 69-year-old with end-stage breast cancer whose only income is her social security
check, which barely meets her minimum bills. Her car requires major repairs which she cannot
afford, so she has no transportation to get to her appointments for palliative chemotherapy. Of
the following, which is the best option for the hospice team to support Mabel?
a. Collect money from team members for a taxi.
b. Offer to drive Mabel yourself.
c. Request that a hospice volunteer take her.
d. Collect money to pay for Mabel’s car repairs
c - Requesting that a hospice volunteer take Mabel is the best option, since patient transportation is a frequent need that hospice volunteers fill. Many hospice patients/families face socioeconomic challenges that impact their care, and the IDT is a wonderful collaborative resource to help access additional resources in the community which the hospice may not be able to provide
31
Bob is an 80-year-old with end-stage lung cancer who lives in a community that has been
plagued by drugs and violent crime. Of the following, which is the most practical method to
ensure the safety of staff members involved in Bob’s care?
a. Ask Bob to meet them at a safer site.
b. Request a police escort.
c. Assume no one will bother hospice staff.
d. Ask Bob’s family to provide assistance
. b - Though situations are highly variable, requesting a police escort when a patient’s home is in a dangerous neighborhood may be the most practical step to provide staff safety. Typically, law enforcement is more than happy to support hospice in this manner. Any situation which is deemed to be dangerous should be discussed with the IDT, to allow appropriate collaboration and support for all team members
32
Gloria is a 68-year-old with end-stage chronic obstructive pulmonary disease (COPD) who is a
chain smoker. She is on 4L oxygen per nasal cannula continuously, and frequently smokes in her
house with her oxygen on. Of the following, which potential for adaptation to Gloria’s
environment would be most helpful in improving her safety?
a. Moving her oxygen concentrator into the garage.
b. Providing a longer length of oxygen tubing.
c. Requesting Gloria’s input into alternative areas to smoke.
d. Asking Gloria to take the cannula off when she smokes.
. c - Requesting Gloria’s input into alternative areas to smoke, separated from her oxygen flow, would be the most helpful. She must have input into the solution to increase the likelihood of success. Once she has chosen an alternative smoking area, ensuring that there are not barriers to her use of it (ie, mobility limitations, safety concerns such as steps, rugs, etc) will be very important. Continued reinforcement of safety, and the risk for facial burns and fire while smoking with oxygen needs to occur. All other options noted do not remove oxygen gas from the smoking environment
33
When visiting your patient, you note that her pain is poorly controlled. When asked if she has
been taking her pain medication as scheduled, she begins to cry, and states that she ran out
several days ago and suspects that someone in her family has been taking it. Of the following,
what is the most appropriate response that will ensure that your patient has access to her
medication for adequate pain control?
a. Admit her to a hospice house.
b. Ask her to obtain a security box for her medications.
c. Convert her to a fentanyl patch.
d. Start her on an intravenous infusion
b - Use of a security box for medications is a common intervention when diversion is suspected. The patient, or a trusted family member or friend, should be the only parties in the home with access to the key or combination. Ongoing medication monitoring is essential to ensure that the patient’s comfort needs are being met and regulations regarding controlled substances are being adhered to. Limitation on distributed amounts of medication is another common intervention, and may be beneficial depending on the patient’s situation and pharmacy access. Collaboration with the IDT is critical, to provide additional options, and support for both the patient and her family.
34
At the time of death, which of the following is the most appropriate manner for handling
Schedule II medications?
a. Disposal in the home with a witness present.
b. Leave the medication for the family to dispose of.
c. Return the medication to the pharmacy.
d. Send all medications with the patient’s body
b - Due to new FDA regulations (September 2015), hospice staff are no longer allowed to waste/destroy any of the patient’s medications at the time of death but are instead required to instruct the family on safe methods of disposal or drop off locations for all medication forms (liquids, gels, patches, tablets, capsules).
35
Carla is a 77-year-old with end-stage ovarian cancer who has been very active in her church for
the past 40 years. She lives alone in an apartment she just moved into, needing something on
the ground floor. She has been having increasing difficulty in preparing meals, and her
nutritional status is suffering as a result. Of the following, what community resource may be
most helpful for Carla?
a. American Cancer Society
b. Her church
c. Her neighbors
d. Home meal deliveries
. b - Carla’s church would be an excellent community resource for Carla. Since she has been involved there for so many years, she most likely has many strong relationships. Often, churches support their members with meals, visits, and sometimes even caregiving, depending upon the congregation.
36
Al is a retired hospital administrator who has owned a successful business for the past 10 years.
He has end-stage pulmonary fibrosis, and has been having increased weakness, and difficulty
with concentration. He had planned to finalize all of his business matters, but has grown too
weak to complete them. This is creating great anxiety for him, since his wife has not been
involved in the business, and will be left to deal with everything after he dies. Of the following,
which would be the most appropriate option to support Al?
a. Request an anti-anxiety agent.
b. Collaborate with the hospice social worker.
c. Ask a hospice volunteer with business skills to help him.
d. Tell Al to focus on managing his dyspnea
. b - Collaboration with the hospice social worker is the best option, to provide additional support for Al, as well as input into potential resources that may be helpful to him. Helping Al to prioritize completion of tasks which are realistic for him would be helpful, as well as considering what other parties in his support network may be helpful for both he and his wife in dealing with his business needs. Resolution of this issue to Al’s satisfaction will be an important aspect of helping him to die a peaceful death.
37
Rachel is a 45-year-old with end-stage breast cancer who states she used to have a very strong
faith, but has felt distant from God and has not attended church for many years. She states that
now, facing death, she would like to find a way to be closer to God before she dies. Of the
following, what may be most helpful for Rachel?
a. Give her a Bible
b. Request visitation from a local pastor
c. Collaborate with the hospice chaplain
d. Provide a list of local churches
c - Collaboration with the hospice chaplain would be the most helpful for Rachel, to provide her with access to expert support from a professional accustomed to spiritual counseling. Hospice staff members of other disciplines typically have varying levels of comfort when addressing spiritual issues, and may or may not also wish to provide spiritual support. Hospice care, by its very nature, often involves psychosocial and spiritual support by professionals who may be trained in other areas of expertise. Thus, the interdisciplinary approach is critical, to allow support and collaboration among all professionals to ensure optimal care to the patient and family.
38
Cultural traditions are often very strong in patient/family situations. When they seem to be
impacting the quality of a patient’s care in a negative manner, which of the following would be
the most appropriate response?
a. Educate the patient/family regarding hospice procedures.
b. Strive to better understand cultural practices/beliefs.
c. Work with one member of the family who seems agreeable to hospice care.
d. Try to work only with the patient to optimize care.
b - Striving to better understand a particular culture’s practices and beliefs is the foundation for ensuring that the patient and family receive optimal support and care. Integration of hospice principles and procedures according to the needs of the culture, instead of asking the culture to adapt to hospice is critical. Hospice staff must always remember that they are visitors in a patient’s and family’s home and lives for a very brief period, and must remain adaptable and respectful of the cultural needs and practices that exist there
39
Joan is a 76-year-old with end-stage colon cancer who has two adult daughters, Becky and Kay, who
have a turbulent relationship. Becky is the oldest, yet Joan has designated Kay as her health care
surrogate, and given her durable power of attorney. Joan has signed a DNR, which Kay supports, but
Becky disagrees with. She has stated that if Joan “goes into a coma”, she is going to hire an attorney
to have it reversed.
323. Of the following, what would be the most helpful support for Joan and her daughters?
a. Advise Becky that she has no legal rights.
b. Recommend that Kay hire her own lawyer.
c. Arrange a family meeting.
d. Recommend that Joan assign a meaningful role to Becky.
. c - Arranging a family meeting in collaboration with the IDT (especially the hospice social worker) would be the most helpful option to support Joan and her daughters. Many families have complex dynamics, which can be heightened during a time of crisis. A family meeting may be helpful to allow all parties to discuss their concerns with each other in a safe environment with the support of a third, objective party. Legally, in this situation, Kay will make final decisions for her mother’s care, if Joan is unable to make them for herself. However, if resolution of the emotional turmoil between the daughters is at all possible, it will help to increase Joan’s peacefulness as death approaches, and aid the daughters in their bereavement
40
When you are alone with Becky during one of your visits to her mother, she begins to cry and
states that “I made so many mistakes and she’s never forgiven me for them. I know she hates
me. That’s why she favors Kay so much.” Of the following, what would be the most helpful
response for Becky?
a. “We all make mistakes.”
b. “I’m sure your mother doesn’t feel that way.”
c. “Maybe you should talk to your mother about your feelings.”
d. “You should journal about it.”
. c - Suggesting that she talk to her mother about her feelings may help her to consider discussing them with her. Often, words and actions can be misinterpreted, and clarification can be a healing balm to relationships that have been unresolved for extended periods of time. Collaboration with the hospice social worker and chaplain is crucial to ensure that optimal support is being provided.
41
. Upon a recent visit to Joan, you note that she is more anxious than normal, and states that she
has been having increased pain. When performing your pain assessment, what would be an
important assessment question, in the context of Joan’s family situation?
a. “How many breakthrough doses have you taken in the past 24 hours?”
b. “How would you rate your pain on a scale of 0-10?”
c. “Where is your pain?”
d. “What makes your pain worse?
. d - Asking, “What makes your pain worse?” extends your assessment to contributing factors, which may include psychosocial or spiritual concerns. Joan most likely has unresolved emotional issues, if she has relationships in her life that are not optimal. Collaboration with the hospice counselor and chaplain to provide additional support in exploring these issues may increase Joan’s comfort - physical, emotionally, and spiritually.
42
Joan acknowledges her difficult feelings toward her daughter Becky and agrees to talk with her,
to try to improve their relationship before she dies. She requests that you attend their meeting
to support them both. Of the following, what is an effective tool of communication when
discussing difficult topics?
a. Using “I” statements
b. Using extremes like “never, or always”
c. Assigning blame
a - Using “I” statements is a very effective tool of communication when discussing difficult topics. This allows the person to express their own feelings, rather than projecting feelings onto others or assigning blame. Collaboration with the hospice counselor will be crucial, and having her present at the meeting would be optimal
43
When Joan’s daughter, Kay, learns that Joan and Becky are planning to meet, she requests to
attend, to “protect my mother’s rights.” Of the following, which is the most appropriate
response?
a. Provide the day and time of the meeting
b. Advise her to discuss her request with her mother
c. Advise her the meeting is between her mother and sister only
d. Ask her to call her siste
b - This decision ultimately belongs to Joan, and Kay should be advised to contact her mother about her request. Although it will most likely be most helpful for Joan and Becky to meet alone, hospice staff must be respectful of patient/family wishes and function in a supportive role.
44
Joan decides to meet with Becky alone, and the meeting goes well. They are able to discuss their
feelings openly, and resolve many of their disagreements. They reflect on good times in years
past, and Joan enjoys fond memories. Of the following, what would be a helpful tool for life
review for Joan?
a. Journals
b. Photo albums
c. Today’s newspaper
d. A current movie
. b - Photo albums are a wonderful tool for life review. Life review is often an essential part of helping a hospice patient make final emotional and spiritual preparation by cherishing loved ones, memories and life accomplishments
45
ed is a 72-year-old veteran who proudly displays his many service awards and medals around
his den. When you visit, he talks at length about his time in the military, but usually you do not
have the time you would like to stay and listen to his stories. Of the following, what would be a
helpful intervention to support Ted’s life review?
a. Ask him to write down his stories for you.
b. Tell him he’ll have to limit his stories to the time you have available.
c. Request a hospice volunteer who is a veteran to visit him.
d. Try to work on other paperwork during the visit so you can stay longer
. c - Requesting a hospice volunteer who is a veteran to visit with him is a wonderful option to support Ted’s life review. Veterans uniquely identify with each other, and the relationship would be life-enhancing for both
46
Martha states that she is committed to ensuring that Joe not be alone when he dies, and has
been maintaining a constant vigil. However, she is becoming exhausted, and states that she does
not have anyone else who can sit with him. Of the following, what would be the most
appropriate response?
a. “Joe may want to be alone when he dies.”
b. “Let me see if we can get some volunteers to help.”
c. “You have to take care of your health first.”
d. “Joe probably isn’t aware that anyone is there.”
b - Hospice volunteers can be a wonderful system of support for the dying patient and his family. They can provide a time of respite for exhausted family members, and enhance peace-of-mind, knowing that their loved one is not alone
47
Ed is an 89-year-old with end-stage lung cancer who is in the dying process. His two daughters,
Bobbie and Vicki, do not get along, and frequently have arguments over Ed’s bed about who
should get to spend time with him. Although Ed has not been verbally responsive for several
days, he becomes more restless and agitated when this is occurring. Of the following, which may
be most helpful in this situation?
a. Ask that they both remain out of the room.
b. Increase Ed’s medication.
c. Limit time that they spend with Ed.
d. Recommend that they agree upon a schedule for visiting
. d - Though many options may be possible, recommending that they agree upon a schedule for visitation would be the best option of those listed. It’s understandable that they both want to be with their father, but their disagreements are disrupting his comfort, and must be addressed. A third party, such as the hospice counselor, would be an excellent resource in helping them to work through difficult issues during such a difficult time.
48
Jackie is a 69-year-old, whose daughter, Rachel, has been her primary caregiver for the past 6
months. During Jackie’s death attendance, Rachel begins to cry, and states that she loved being
able to take care of her mom. Of the following, what may be most helpful to Rachel during this
time?
a. Ask her to participate in bathing/dressing Jackie’s body.
b. Provide her with literature about bereavement groups.
c. Ask her to take a break while you prepare Jackie’s body.
d. Call the hospice counselor for her
. a - Asking an appropriate family member to participate in preparing the patient’s body can be a very sacred and healing event. Primary caregivers who have occupied this role for any period of time may be especially appreciative of this final opportunity to provide tender care for their loved one’s body. While offering appropriate privacy for the family is important, hospice staff should be present during times of turning the patient’s body, etc, when unexpected sounds and drainage events may occur which can be distressing if anticipatory preparation is not provided
49
At time of death, which of the following is the highest priority?
a. Efficiency in visitation time.
b. Notifying the funeral home as soon as possible.
c. Adhering to patient/family beliefs and customs.
d. Prompt removal of the patient’s body
c - Of the options noted, adhering to patient/family beliefs and customs is the highest priority. Different cultures and religions may have specific practices regarding death and handling of the deceased person’s body. The role of the hospice staff is to provide optimal care and support, while respecting cultural and religious preferences
50
f the following, which is the optimal length of time for a visit for death attendance?
a. One hour
b. Two hours
c. Three hours
d. According to need
d - The length of a visit for death attendance is defined by the need present in the individual situation. It is critical to provide needed attention and resources to support the family at this difficult time. Care must be taken to gather appropriate IDT members, provide support for the family, and proper care and dignity for the patient’s body. Some families may be well-prepared for a patient’s death, while others may not be prepared at all. Sensitivity to the needs of the individual situation is critical. There’s only one chance to get this right
51
Emily’s father has just died. When you arrive at the home to attend his death, she states that
she has several siblings coming from out of town, who will not be arriving for several hours.
Since her father will be cremated, she would like to keep his body in the home until they arrive,
so they can say good-bye. Of the following, which is the most appropriate response?
a. “There is a specific time in which his body must be removed.”
b. “They should be able to see him at the funeral home.”
c. “We can make a video for them.”
d. “We’ll get him ready and wait for them.”
d - Often, the setting of the patient’s death is the last opportunity for family members to see the patient’s body prior to cremation, and sometimes burial. Therefore, care must be taken to bathe the body, dress it in a manner that the family chooses, and prepare the immediate environment as a peaceful setting in which the family can have privacy and time to say good-bye. In most cases, there is not a specific timeframe in which the patient’s body must be removed from the home, within reason. Collaboration with the IDT is critical to provide optimal support.
52
Two familiar approaches hospice MSW prepare families and patients for death
EMPOWER (effective manage of pain; overcoming worries to enable relief)
Trauma Informed care
53
5 principles of trauma informed care and hospice
(all that apply)
a. Safety
b. Discernment
c. Choice
d. Trustworthiness
e. Empowerment
al but B
54
What applies to pediatric hospices
A. Data on pediatric hospice is sparse
B. Typically preceded by extensive medical efforts
C. Differs from Adult in that concurrent curative care allowed
D. Dx differ from Adults: Congential/Disease/Accidents
E. Programs usually not tied to Medicare Funding
F. All of the above
F
55
True/False
"As a philosophy of care, hospice falls completely within the palliative model of care"
True
56
4 levels of hospice care
1. Routine
2. General Inpatient Care
3. Respite Care
4. Continuous Home care
57
top 3 locations of death for hospice patients
A. Hospital, Long Term Care, home
B. Home, Long Term Care, Inpatient hospice
B
58
T/F
A person's distress is exacerbated when they feel coerced, unsafe, or powerless to make their own decisions and choices
T
59
Lerner & Shelton's 10 step acute stress and trauma management protocol
1. Assess for danger/safety for self and others
2. consider the physical and perceptual mechanisms of psychological injury
3. assess the person's level of responsiveness/capacity/comprehension
4. assess medical needs
5. watch for others present who may also be traumatized
6. connect with individual by building rapport
7. allow person to tell their story
8. continue assessment with empathetic listening
9, normalize, validate, and education surrounding emotions, stress, and adaptive coping styles
10. bring the person to the present, describe future events and provide referrals if needed
60
T/F Medicare requires MSW at a minimum of 1 every 30 days.
F.
Only the RN has a minimum requirement—no other disciplines. However, we still have to show how the psychosocial needs/issues are being addressed. This often is about documenting RN/MSW consults related to those issues.
61
You are meeting with a new physician and her staff to discuss and review the hospice benefit for a potential patient within their practice. Your best explanation of the services available to the family would include which of the following?
a. Hospice is available 24 hours a day for any needs that the patient or family may have.
b. Hospice provides expert pain and symptom management through the collaboration of the healthcare team based upon patient/family needs.
c. Hospice will manage all of the patient’s care needs from the time of admission until death.
d. Hospice is only available to the family for a time period of 6 months.
b - Hospice provides expert pain and symptom management through nurses collaborating with the patient’s chosen physician, along with supportive social work, spiritual care, hospice aide and volunteer services based upon patient/family needs. The other options give the impression that hospice will be there 24 hours a day, and that the physician is no longer involved and services can only be provided for 6 months.
62
Examples of the core services required to be provided by the hospice agency itself include all of the following except:
a. Physician
b. Nursing
c. Therapies
d. Social work
c - Therapies such as physical, speech or occupational therapy are not part of the core services that must be provided by the hospice agency itself. These services may be contracted and provided on an as needed, individual basis for patients who require them
63
The National Hospice and Palliative Care Organization (NHPCO) formulated an updated staffing guideline in 2011 that reflects which of the following factors/characteristics?
a. Hospice location
b. Hospice length of stay
c. Hospice staffing model
d. All of the above
e. Both b and c only
e - Hospice length of stay, staffing model and organizational characteristics are the primary factors utilized in the updated NHPCO staffing guideline.
64
The Centers for Medicare and Medicaid Services allow for a hospice physician visit to determine eligibility of hospice patients prior to election and for the hospice to bill for those services. Which of the following situations would not reflect a patient who is eligible for such a visit?
a. A patient with a terminal diagnosis who has received hospice services through another agency.
b. A patient with a terminal diagnosis who received a pre-election evaluation 3 months ago.
c. A patient with an unknown prognosis who is currently receiving palliative care services.
d. All of the above.
d - All of the above situations would not allow for a pre-election eligibility visit/billing by hospice. CMS requires that the physician be a hospice physician, that the patient not have previously received a pre-election evaluation or hospice services, and that the patient be considered to be terminally ill with a 6 month or less prognosis.
65
The Health and Human Services Department of the Federal Government’s HIPAA regulation defines “Protected Health Information” (PHI) as which of the following?
a. Any information related to a healthcare provider’s or medical system’s records.
b. Information about the patient, their health condition or care that identifies or can be used to identify the patient.
c. All medical and billing records related to patient care or history.
d. Only that information which the patient deems as being private, or protected.
b - HHS states the following on what is protected health information under HIPAA: “Individually identifiable health information” is information, including demographic data, that relates to the individual’s past, present or future physical or mental health or condition, the provision of health care to the individual, or the past, present, or future payment for the provision of health care to the individual, and that identifies the individual or for which there is a reasonable basis to believe it can be used to identify the individual. Individually identifiable health information includes many common identifiers (e.g., name, address, birth date, Social Security Number).
66
The Quality Assessment and Performance Improvement (QAPI) component of the Hospice Conditions of Participation (CoPs) requires that hospice providers do which of the following?
a. Initiate performance improvement projects and demonstrate measurable improvements.
b. Evaluate performance and make changes when requested by CMS or the board.
c. Conduct a thorough surveillance of hospice operations including assessment of the impact of medical, psychosocial and spiritual care provided.
d. All of the above.
e. Both a and c only
e - Both a and c are correct QAPI requirements of the CoPs. Ongoing performance evaluation and improvement is an expectation of the QAPI process and not at the request of CMS or the board.
67
CMS regulations require a face-to-face visit for which of the following patient types?
a. A new Medicare admission to hospice with no prior hospice care.
b. A Medicaid patient being recertified at the completion of the first 90-day benefit period.
c. A Medicare patient whose family is reluctant to admit their family member.
d. A Medicaid patient being recertified prior to the start of the 3rd benefit period.
d - CMS requires that all Medicare and Medicaid patients receive a face-to-face visit by a Hospice Medical Director or designee (NP) to ensure ongoing eligibility prior to the start of the 3rd benefit period (prior to 180 days of hospice care- or the end of the 2nd benefit period). These visits must be in person, completed within a detailed timeframe and include a complete assessment of patient’s current status, disease progression, and anticipated prognosis with accurate, complete documentation of the above. Patients who previously received hospice care and have passed the 2nd benefit period with a hospice provider, must also receive a face-to-face visit prior to admission or readmission to a hospice.
68
The National Consensus Project for Quality Palliative Care - Clinical Practice Guidelines for Quality Palliative Care (3rd edition) identifies 8 domains of care. Which domain reflects the Physical Aspects of Care including emphasis on the assessment and treatment of physical symptoms with appropriate, validated tools?
a. Domain 2
b. Domain 6
c. Domain 4
d. Domain 8
a - Domain 2 reflects the Physical Domain and emphasizes the assessment and treatment of physical symptoms with appropriate, validated tools. Management of symptoms is multidimensional with pharmacological, interventional, behavioral, and complementary interventions. The utilization of explicit policies for the treatment of pain and symptom management, as well as safe prescribing of controlled medications is recommended.
69
The Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare and Medicaid Services (CMS) initiated which of the following surveys in 2015 to assess hospice quality?
a. HCAHPS
b. CAHPS
c. HIS
d. FEHC
b - CAHPS is the survey now required by AHRQ and Centers for Medicare & Medicaid Services (CMS) for hospices. The CAHPS Hospice Survey was designed to measure and assess the experiences of patients who died while receiving hospice care and their primary informal caregivers. The CMS began national implementation of this survey in January 2015 with a dry run; full participation was initiated in April 2015. The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey is the first national, standardized, publicly reported survey of patients' perspectives of hospital care. HCAHPS (pronounced "H-caps"), also known as the CAHPS Hospital Survey, is a survey instrument and data collection methodology for measuring patients' perceptions of their hospital experience. The HQRP requires hospices to submit data to CMS via the Hospice Item Set (HIS). This data can be used to calculate six National Quality Forum (NQF)-endorsed measures and one modified NQF measure. The Family Evaluation of Hospice Care (FEHC) is a post-death survey used prior to CAHPS survey requirements and is designed to yield actionable information that reflects the quality of hospice care delivery from the perspective of family caregivers. Hospices that utilize FEHC must be exempt from CMS-required CAHPS Hospice Survey. This is no longer routinely used as most hospices are required by CMS to utilize the CAHPS survey.
70
The National Hospice and Palliative Care Organization (NHPCO) has identified 10 components of quality care. Which of the following is not included as one of these components?
a. Organizational excellence.
b. Standards.
c. Workforce safety.
d. Compliance with laws and regulations.
c - Workforce safety is not one of the 10 components of quality care according to NHPCO. Workforce excellence, Clinical Excellence, Organizational Excellence, Compliance with laws and regulations, Standards, Inclusion and access, Stewardship and accountability, Performance measurement, Patient and family-centered care, and Ethical behavior and consumer rights are the 10 components.
71
When a patient asks why you are using a laptop computer in his home to document his care, which of the following is an appropriate response?
a. “Because the agency requires it.”
b. “Because it will provide the most updated information about your care.”
c. “Because the government is requiring it.”
d. “Because using paper has become too wasteful.”
b - With the advent of the electronic health record, many hospices have moved to using laptop computers for all patient care documentation. This has been a difficult transition for many, but this practice enhances patient care by allowing rapid updates to care in a central record that all parties involved may access. Regardless of how hospice nurses feel about the use of a computer in the patient’s home or care setting, it is important to provide positive messaging to patients and families about this beneficial practice
72
Upon admission to your hospice agency, each patient and family is provided with a patient and family notebook, with various pieces of information that are important to their care. Since information can quickly become outdated, what would be an excellent option for ensuring that educational information provided to patients and families is the most current?
a. Ask the patient and family for feedback
b. Ask previous families for feedback
c. Participate in an evaluation committee
d. Compare literature with other hospices
c - Participating in a committee which evaluates the educational material on a regular basis would be an excellent means of ensuring that the information provided is the most current. Often, educational materials contain information which may be generated from different departments within the agency, therefore representation from appropriate parties on such a committee would enhance optimal outcomes
73
You have recently started caring for a new patient who is a member of your church, and the patient permitted news of her hospice admission to be added to the weekly church announcements. At Bible study, a mutual friend asks how she is doing. Of the following, which is the most appropriate response?
a. Provide an update on your patient’s condition.
b. Ask her to talk to the pastor.
c. Kindly reinforce that you cannot share personal information.
d. Ask the group to pray for her.
c - HIPAA regulations protect patient privacy in all settings, so it would not be appropriate to share any information regarding your patient’s condition. In addition to the protection that this affords your patient, this also lets others know that if they or a loved one ever needs hospice care, their information will also remain confidential
74
Which of the following is NOT included as a key element of palliative care, according to the National Consensus Project for Quality Palliative Care?
a. Ability to pay: a payer source must be identified
b. Continuity of care across all settings
c. Effective communication
d. The family is defined by the patient
a - The need for identification of a payer source is not a key element of palliative care, according to the National Consensus Project for Quality Palliative Care. All other options are included as part of the defining 11 key elements: Patient population, patient and family-centered care, timing of palliative care, comprehensive care, interdisciplinary team, attention to the relief of suffering, communication skills, skill in the care of the dying and bereaved, continuity of care across settings, equitable access and quality improvement.
75
Of the following, which would NOT be an appropriate activity for a hospice volunteer to assist a patient with?
a. Shopping
b. Light housekeeping
c. Investment advice
d. Companionship
c - It would not be appropriate for a hospice volunteer to provide a patient with investment advice. Hospice volunteers are an integral part of the IDT, and provide many valuable services to patients and families, as well as within the offices of the hospice agency. Care by hospice volunteers should always take place within the collaborative relationship of the IDT, and according to expectations of professional behavior and boundaries similar to any paid employee of the hospice.
76
When evaluating a patient for the initial recertification period for continued eligibility for hospice care, which of the following is true?
a. Clear, detailed indications of disease progression must be documented.
b. Eligibility is based only on the hospice medical director’s opinion.
c. Eligibility is based on the patient’s continued ability to pay.
d. The patient must be discharged and readmitted.
a - When evaluating a patient for recertification for continued eligibility for hospice care, indications of disease progression over the previous certification period must be documented. All team members involved in the patient’s care are expected to provide input into the recertification decision. Under the hospice Medicare benefit, there are two 90 day benefit periods and unlimited 60 day periods, as long as the patient remains appropriate for hospice care.
77
Of the following, which is required in order for a patient to be eligible for admission to hospice care?
a. Payer source available
b. Do Not Resuscitate order in place
c. Terminally ill with less than 6-month prognosis
d. Caregiver available
c - In order to be eligible for admission to hospice care, the patient’s physician and medical director must agree and sign a statement which certifies that the patient is terminally ill with less than a 6-month prognosis if the disease runs its normal course.
78
If conflict arises among team members during the IDT meeting, which of the following is the most appropriate response?
a. Ignore the issue, even if negative outcomes may occur
b. Ask the team manager to intervene
c. Address the issue with each party separately and privately
d. Facilitate trust, communication and expression of feelings
d - Facilitating trust, communication, and expression of feelings is the most appropriate response. Promotion of a safe environment which is respectful of differing views helps to enhance team unity, creativity, and optimal outcomes for both the members of the team, and patient/family situations.
79
During the IDT meeting, who should be the team member who provides information for the team regarding patient and family status and updates to the plan of care?
a. The primary nurse and primary counselor only
b. The primary nurse and medical director only
c. The primary nurse and hospice aide only
d. All involved team members
d - Although one person may lead the discussion, all team members who are involved in the patient’s care should provide information regarding patient and family status and updates to the plan of care. Each team member’s input is valuable, as relationships with the patient and family may vary according to the role the team member plays in providing care.
80
Helen, a 70-year-old with end stage colon cancer, has been admitted to hospice. She states that she has discussed stopping her treatments with her physician in the past, but he has not been willing to agree to this option. She states that he reluctantly agreed to refer her to hospice, but wants her to return to the hospital for any acute needs. She asks how she might get him to agree to support her desire to stay at home without further intervention, except for comfort measures. Of the following, which is the most appropriate response?
a. Recommend that she change physicians
b. Ask the hospice medical director to assume care
c. Offer to accompany her to visit her physician
d. Ask her family to talk to her physician for her
c - Offering to accompany Virginia during a visit to her physician would be the most appropriate response. Such in-person collaboration and advocacy on the patient’s behalf can be a very powerful method of building rapport with community physicians and helping to increase their understanding of hospice care. Many physicians have difficulty discussing end-of-life issues with patients. Therefore, providing support and education for both parties would be highly beneficial
81
Virginia is a 69-year-old who has been referred for admission to hospice for a diagnosis of end-stage colon cancer. When visiting to assess her eligibility for admission, she is able to give you a verbal history of her disease progression, but has no documentation regarding confirmation of her cancer. Of the following, which would be the most appropriate next step in order to complete the admission process?
a. Document her statements in quotations
b. Contact the referring physician’s office for documentation
c. Ask the hospice medical director to examine her
d. Ask a family member to confirm the information
b - Contacting the referring physician’s office for documentation to confirm her cancer diagnosis and disease progression is the appropriate next step in order to complete the admission process. Ongoing collaboration with the referring physician’s office is an essential and required step in caring for the patients who have been entrusted to the care of hospice
82
If a patient, who is under the hospice Medicare benefit, is being transferred to another hospice agency, which of the following will impact reimbursement for the patient’s care?
a. Coordination of the hospice Medicare benefit
b. The deductible on the patient’s plan
c. Amounts of standard co-payments
d. Co-insurance ceiling limits
a - When a patient is receiving care under the hospice Medicare benefit, and is being transferred to a different hospice, coordination of the hospice Medicare benefit is critical to ensuring accurate reimbursement. A patient cannot be admitted to two hospices under the same benefit period.
83
Jay is a 65-year-old with end-stage multiple myeloma who was recently admitted to the hospital due to intractable pain. His pain has been stabilized with the use of a continuous fentanyl infusion via his implanted venous access port. He will be continuing the same therapy at home. Of the following, which is a critical matter of coordination to maintain Jay’s comfort during his transition to home?
a. Ensuring that his personal belongings come home with him
b. Ensuring that his wife and family are prepared for his arrival
c. Coordinating equipment exchange
d. Obtaining the same type of specialty mattress that the hospital used
c - Coordinating equipment exchange is a critical aspect of maintaining Jay’s comfort during this transition. Typically, the hospital does not send their infusion pumps home with the patient. Therefore, appropriate arrangements must be made to ensure that Jay’s fentanyl infusion continues in a manner that is safe and effective for his care and maintenance of comfort.
84
Of the following, which is required when initiating changes in level of care within the hospice Medicare benefit?
a. The hospice medical director’s order
b. The primary physician’s order
c. Pre-approval from Medicare
d. Documentation of financial need
b - When initiating changes in level of care within the hospice Medicare benefit, the primary physician’s order is required. In addition, a discussion must take place with the patient and family, as well as the IDT. The plan of care must be updated, and all items must be documented in the patient’s record.
85
If a patient is being transferred into continuous home care under the hospice Medicare benefit, which of the following statements is true?
a. Reimbursement is based on the number of days as defined in the benefit.
b. Reimbursement is based on specific criteria as defined in the benefit.
c. Patients can receive this level of care at any time for any need.
d. Care may be provided for less than 8 hours per day.
b - Reimbursement for continuous home care under the hospice Medicare benefit is based on specific criteria as defined in the benefit. This level of care is designated for brief period
of crisis as a supportive means to help the terminally ill patient stay at home. Care must be provided for at least 8 hours per day, and more than 50% of care must be provided by skilled nursing staff (RN or LPN/LVN).
86
If a patient is being transferred into inpatient respite care under the hospice Medicare benefit, which of the following statements is true?
a. Care is furnished for brief periods of crisis.
b. The hospice will not be reimbursed for more than 5 days consecutively.
c. Admitting diagnosis must be related to the terminal diagnosis.
d. Care must consist of more than 50% skilled nursing care.
b - Under the Hospice Medicare benefit, respite care will not be reimbursed for more than 5 days consecutively. Beyond that, reimbursement occurs at the routine home care rate.
87
Of the following, which would NOT be an appropriate patient care duty for the hospice aide to perform independently?
a. Bathing
b. Transferring
c. Meal preparation
d. Dressing changes
d - Dressing changes are not in the scope of permitted duties that may be performed independently by the hospice aide. Hospice aides must abide by specific state licensure regulations. According to the Medicare Conditions of Participation for Hospices, the hospice aide may only perform duties as outlined by the plan of care that has been developed for the patient by a registered nurse, and function under the supervision of a registered nurse. In order for the hospice aide to perform a dressing change, the aide would need to be trained and evaluated for competency for each specific patient’s dressing needs. Because an aide was trained with a specific dressing type for one patient does not equate to being allowed to perform that same dressing change on another patient.
88
According to Medicare guidelines, how often does a registered nurse need to make a visit to the patient’s home for the purpose of supervising the hospice aide?
a. Once every 30 days
b. Once every 7 days
c. Once every 14 days
d. Once every benefit period
c - According to the Medicare Conditions of Participations for Hospices, a registered nurse must make a visit to the patient’s home no less frequently than every 14 days for the purpose of supervising the care of the hospice aide. The hospice aide does not need to be present
89
When a patient becomes weak enough to require that a hospital bed be placed in the home, which of the following is the most important consideration when scheduling delivery of the bed?
a. Whether additional staff may be needed
b. Where the bed will be placed
c. Whether the bed will fit through the doors in the home
d. If the family has appropriate bedding
a - When scheduling delivery of a hospital bed, it may be necessary to coordinate the assistance of additional staff members to help with patient transfer if the patient is too weak to stand and transfer to the new bed. When the need arises for a hospital bed in the home, this is often due to a decline in the patient’s condition. Hospital beds typically are transported in collapsible units, therefore, door width should not be an issue.
90
Tim is trying to decide whether to stop his dialysis, and knows that he may experience respiratory problems if fluid builds up in his lungs. Despite education regarding palliative interventions that are available, he states that he would still like to go to the hospital if he requests to do so. If Tim is readmitted to the hospital, which of the following actions would provide optimal collaborative communication with the hospital staff?
a. Call and speak to the charge nurse
b. Visit and provide his current plan of care and medication list
c. Fax his current plan of care and medication list
d. Email his current plan of care and medication list
b - Visiting and providing the hospital staff with Tim’s current plan of care and medication list would provide optimal collaborative communication with the hospital staff. This would provide the opportunity to visit Tim to ensure that his care needs are being met, and also to ensure that his information is communicated effectively. Depending on hospital policies, the hospice plan of care and medication list may possibly be placed on the hospital chart.
91
As Tim’s condition changes, who should be notified?
a. The hospice medical director only
b. The patient’s attending physician
c. The hospice medical director and attending physician
d. The hospice medical director, attending physician and IDT
d - All healthcare partners involved in Tim’s care should be notified of significant changes in his condition. The hospice medical director and attending physician are considered part of
the interdisciplinary team (IDT). Even if changes to the patient’s status are focused on pain and symptom management needs, the patient’s attending physician should always be included in updates regarding the patient’s status, in order to optimize collaborative relationships.
92
Jimmy’s care is now supplemented with a hospice aide for a period of 3 hours every morning to provide personal care. You arrive to complete your supervisory visit and witness the aide being very rough with Jimmy during his care along with a new skin tear as a result. What is your obligation in this situation?
a. Provide re-education to the hospice aide on proper care, and inform her supervisor.
b. Provide re-education to the hospice aide on proper care and document in medical record and also via an incident report.
c. Inform the aide that you are going to make a complaint if she ever does this again.
d. Do nothing as these things happen sometimes.
b - The obligation in this situation is to provide education, since this is a supervisory visit, document the skin tear and aide performance as required in the EMR, and complete an incident report for the resulting skin tear. Doing nothing, or threatening to make a complaint are not fulfilling the RN obligations as the care manager. In addition, only providing the re-education and informing the supervisor does not meet the documentation requirements for incident reporting and patient safety.
93
Jimmy is now actively dying and his friends along with volunteers have been arranged to be with him 24/7 so that he does not die alone. At your afternoon visit today, you notice that Jimmy is in the same clothes and in the same position as when you left yesterday morning along with a heavily soiled brief. What is your best initial response to this situation?
a. Advise the caregiver that you will be reporting them to Adult Protective Services immediately.
b. Inquire of the caregiver the time of their arrival, the care provided, and the status of Jimmy during their stay.
c. Report this to your supervisor immediately for necessary action.
d. Advise the caregiver to leave immediately as they are clearly neglectful.
b - The obligation in this situation is to provide education, since this is a supervisory visit, document the skin tear and aide performance as required in the EMR, and complete an incident report for the resulting skin tear. Doing nothing, or threatening to make a complaint are not fulfilling the RN obligations as the care manager. In addition, only providing the re-education and informing the supervisor does not meet the documentation requirements for incident reporting and patient safety.
Practice Test for the Hospice and Palliative
94
Jimmy is now bedbound and declining rapidly. You anticipate his death in the next 72 hours given his current status. His friends have been staying with him previously off and on, but have limited availability during the next few days due to their work schedules. He had previously expressed his fears to you regarding dying alone but adamantly wishes to remain in his home. Your best response to this request is which of the following?
a. Inquire if there are family members who might be willing to stay with him.
b. Inquire of the IDT if there are volunteers available for a death vigil setting.
c. Arrange for continuous care to be initiated.
d. Arrange for paid caregivers 24/7 to be paid for by the hospice agency.
b - The best response here is to inquire of the IDT if there are volunteers available for a death vigil supportive visit. Given the circumstances of his family situation, inquiring regarding family members providing this type of care is not appropriate as an initial action. The situation does not meet continuous care requirements given the current information and most hospice agencies would not have a budget to pay for hired caregivers
95
Jimmy has now become weaker and is very SOB, requiring more assistance with his activities of daily living (ADLs). He insists that he wishes to remain in his home and be as independent as possible. What is the best option for the nurse to facilitate this request?
a. Instruct Jimmy to hire a paid, live-in caregiver.
b. Instruct Jimmy to ask his parents, siblings and friends to make a schedule.
c. Instruct Jimmy to think about moving to a facility that can care for him.
d. Instruct Jimmy that you will discuss with the IDT to coordinate additional support
d - The best option here to facilitate Jimmy’s request is to inform him that you will discuss with the IDT and coordinate additional support. Durable medical equipment can be arranged, assistance with ADLs can be facilitated with a hospice aide; volunteers could assist with light housekeeping and companionship. The social worker could identify outside resources such as Meals on Wheels, or other community resources for meal preparation, yardwork etc. The spiritual care advisor can identify area churches that might have assistance to offer.
96
Jimmy continues on your hospice program and has been able to write letters and record video messages for each of his children and feels a sense of closure regarding that aspect of his life although he still wishes he could see them. Given that Jimmy lives alone, the interdisciplinary team (IDT) has expressed concern regarding the lack of a DNR order or advance directives given their fear that he may call 911. What is the most appropriate method to discuss this matter and demonstrate patient advocacy?
a. Ask Jimmy if he has thought about advanced care planning and help him write an advanced directive.
b. Inquire if Jimmy has specific requests regarding his care at the end of life, and what the IDT can do to assist him in making sure these are followed.
c. Tell Jimmy that aggressive treatment at the end of life has been shown to increase suffering, and that he needs to have a document in place to prevent that.
d. Hand Jimmy a DNR form and ask him to sign it so that he will not be resuscitated against his wishes.
b - The most appropriate method here that demonstrates patient advocacy regarding a sensitive subject is to inquire if he has specific requests regarding his care at the end of life and what the IDT can do to support and assist him in ensuring these requests are followed. This is a key role of the IDT and paramount to the provision of quality hospice/palliative care.
97
Jimmy has continued to decline and is now enrolled on your hospice program but has been unable to physically see or communicate with his children. He requests that you come up with an idea so that they will “know that they had a Dad who loved them but didn’t always know how to show it”. Which of the following referrals within the interdisciplinary team (IDT) would be most helpful?
a. Medical director
b. Social worker
c. Grief support
d. Hospice aide
c - The most helpful member of the IDT in this scenario would be the grief support services worker who can be creative in developing potential memory making videos, tape recordings, special letters or other alternative methods of communication so that Jimmy can feel he accomplished his goal and work through his anticipatory grief. The other team members are less likely to be able to meet this need.
98
The communication efforts have been positive, although challenging at times, in regards to Jimmy’s parents and siblings. He now wishes to make the same efforts with his children and ex-wife. During your interdisciplinary team (IDT) meeting, the social worker states that she is strongly opposed to this given the ages of the children and Jimmy’s history of violence. She feels that they “should not be re-exposed to him as it could potentially damage them emotionally and psychologically”. What is your best response to this statement?
a. Argue with her that it is not her decision, and that patient advocacy and life closure forgo any other concerns she may have.
b. Survey the other IDT members to determine if others share the same viewpoint and if so develop a plan of how to proceed.
c. Advise her that she will have to be the one to tell the patient that his goal will not be recognized.
d. Tell her that you no longer need her help on the case and will take over to make sure this patient attains his goal of reuniting with his children.
b - The best response is to survey the other team members and then develop a plan of how to proceed based upon responses. It may be that more planning and attention to the needs of these children are necessary than what was needed for the parents/siblings. A child life specialist or other expert in children’s grief/loss may be consulted and involved in this process. The child’s mother certainly needs to be agreeable and involved as well. The creativity and compassion of the IDT is needed to resolve this conflict and do what is in the best interests of the patient as well as the children/family. The other options here are not effective methods of communication, teamwork, or ensuring the patient receives the best physical, emotional, social and spiritual care possible to facilitate effective life closure. It is the responsibility of each and every member of the hospice/palliative are IDT to respect and ensure the rights of dying patients and their families.
99
After obtaining Jimmy’s permission and last known contact information of Jimmy’s family, the social worker contacted Jimmy’s parents and siblings initially per his request. After speaking with the social worker, Jimmy’s parents and siblings have agreed to be willing to communicate with Jimmy. What would be the best method to facilitate that initial communication given the history?
a. Arranging an in-person, family meeting in Jimmy’s home.
b. Arranging an in-person, family meeting at his parent’s home.
c. Arranging individual meetings/contacts per each family member’s wishes.
d. Arranging for each family member to write a letter/email to Jimmy to which he can respond.
c - Given the history, and the fact that there are several family members involved, it is best to arrange for each family member to individually determine what their level of comfort is with the method of communication and provide support and assistance with arranging each of
those according to those individual choices. This is an example of using a “win-win” strategy for conflict resolution where the focus is on goals and attempting to meet the needs of both parties. A family meeting, whether at Jimmy’s house or his parents, is likely to be too overwhelming and could escalate the emotions without providing the individual closure that is likely needed for each person. Although, letters/emails might seem to be an effective option, for some individuals it may not be enough, or it may be too difficult to communicate effectively and written communication in emotionally charged situations is easily misunderstood.
100
Jimmy is a 44-year-old man with advanced lung cancer who is currently on your palliative care program but is beginning to decline in status. He has a significant history of aggression, anger and violence towards his family members including his siblings, parents, and spouse. He is divorced, and has 3 children ages 12-16 who he has not seen in several years because of his history. He tells you that he really wants to be able to make amends with his family while he still can and maybe even make a few “good” memories that they will be able to share after he is gone.
390. What should be your next step in helping Jimmy accomplish this goal?
a. Inform the IDT of his goal and obtain their guidance/input into how to proceed.
b. Obtain the contact information from his previous medical records for his family members and give it to Jimmy.
c. Obtain the contact information of each family member from previous medical records and call each person yourself.
d. Inform Jimmy that you do not think making contact with his family is a good idea given his history.
a - The next step to help Jimmy accomplish this goal would be to gain input from the interdisciplinary team (IDT) regarding how best to proceed given his violent history. It would not be advisable to obtain/make contact with family members personally, or to share that information with the patient as of now. Telling Jimmy that his goal is not a good idea would likely be crushing to him and the IDT should discuss and outline what the best course of action should be to not only accomplish Jimmy’s goal, but to make for a meaningful, and healthy interaction/communication with his estranged family members. This is vitally important given that there are children involved as well. The social worker and chaplain will be essential to this process. Enhancing quality of life and relationships is the primary goal of hospice and palliative care.
101
After obtaining Jimmy’s permission and last known contact information of Jimmy’s family, the social worker contacted Jimmy’s parents and siblings initially per his request. After speaking with the social worker, Jimmy’s parents and siblings have agreed to be willing to communicate with Jimmy. What would be the best method to facilitate that initial communication given the history?
a. Arranging an in-person, family meeting in Jimmy’s home.
b. Arranging an in-person, family meeting at his parent’s home.
c. Arranging individual meetings/contacts per each family member’s wishes.
d. Arranging for each family member to write a letter/email to Jimmy to which he can respond.
c - Given the history, and the fact that there are several family members involved, it is best to arrange for each family member to individually determine what their level of comfort is with the method of communication and provide support and assistance with arranging each of
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those according to those individual choices. This is an example of using a “win-win” strategy for conflict resolution where the focus is on goals and attempting to meet the needs of both parties. A family meeting, whether at Jimmy’s house or his parents, is likely to be too overwhelming and could escalate the emotions without providing the individual closure that is likely needed for each person. Although, letters/emails might seem to be an effective option, for some individuals it may not be enough, or it may be too difficult to communicate effectively and written communication in emotionally charged situations is easily misunderstood.
102
Jimmy is a 44-year-old man with advanced lung cancer who is currently on your palliative care program but is beginning to decline in status. He has a significant history of aggression, anger and violence towards his family members including his siblings, parents, and spouse. He is divorced, and has 3 children ages 12-16 who he has not seen in several years because of his history. He tells you that he really wants to be able to make amends with his family while he still can and maybe even make a few “good” memories that they will be able to share after he is gone.
390. What should be your next step in helping Jimmy accomplish this goal?
a. Inform the IDT of his goal and obtain their guidance/input into how to proceed.
b. Obtain the contact information from his previous medical records for his family members and give it to Jimmy.
c. Obtain the contact information of each family member from previous medical records and call each person yourself.
d. Inform Jimmy that you do not think making contact with his family is a good idea given his history.
a - The next step to help Jimmy accomplish this goal would be to gain input from the interdisciplinary team (IDT) regarding how best to proceed given his violent history. It would not be advisable to obtain/make contact with family members personally, or to share that information with the patient as of now. Telling Jimmy that his goal is not a good idea would likely be crushing to him and the IDT should discuss and outline what the best course of action should be to not only accomplish Jimmy’s goal, but to make for a meaningful, and healthy interaction/communication with his estranged family members. This is vitally important given that there are children involved as well. The social worker and chaplain will be essential to this process. Enhancing quality of life and relationships is the primary goal of hospice and palliative
103
You have recently begun to visit Charles, an elderly, frail palliative care patient who lives in an assisted living facility. He is very hard of hearing and therefore has his television volume at the highest level during your visits. You have asked him to turn it down just for your visit, but he continues to refuse. His vision is excellent though and he enjoys reading and writing. What is your best action to take so that you can ensure that you complete an effective visit?
a. Turn the volume down for your visit, and then allow him to turn it back up when your visit is complete.
b. Ask the patient why he doesn’t have hearing aids when he is clearly very hard of hearing.
c. Tell the assisted living staff that he is being uncooperative and have them take charge to make him comply.
d. Communicate with him through a note pad with questions and allow him to write his responses.
d - The best action in this situation is not to force the patient to turn the volume down, or to insist upon him obtaining hearing aids or involve the facility staff. Since the patient has excellent vision and enjoys reading and writing, the best action is to perform the majority of your visit communication through this method. This allows you to engage the patient in a manner
104
After a few weeks of caring for Jorge on the farm, and with effective control of his symptoms; he decides that he wishes to travel home to Mexico where his family lives and remain there until his death. Which of the following would not be the best action to take to facilitate this transition for Jorge?
a. Coordinate with his attending physician, the IDT and patient’s family to ensure that he will be able to obtain medications, care etc. upon his arrival.
b. Have the patient sign revocation papers immediately since he will no longer be receiving care from your agency.
c. Discharge the patient upon his departure and provide necessary documentation for his travel and ongoing care as needed/requested.
d. Provide assistance with arranging travel as needed, utilizing translation services when necessary.
b - The action that you would not want to take in this scenario would be to have the patient sign revocation papers immediately. Part of hospice care is ensuring and advocating for patient’s wishes along with their self-determination for life closure. Jorge’s wish is to return home, and it is the responsibility of the interdisciplinary team to assist in whatever way possible to make that wish a reality.
105
Jorge is a 59-year-old, undocumented citizen from Mexico who is referred to your agency for hospice care. He has stage IV liver cancer, speaks no English and lives with other undocumented workers on a rural farm in your area. These workers share a single cell phone number and there is no other contact information other than the address of the farm. You are asked to contact Jorge and introduce hospice and schedule his admission visit.
387. What is the best action to take in contacting Jorge to schedule your visit?
a. Call the phone number and leave a message that you are with hospice with someone so that Jorge can return your call.
b. Drive to the farm and talk to the farm owner since you could not speak with anyone who spoke English on the phone.
c. Contact a translation service and make a joint call to the number using translator to ask to speak with Jorge.
d. Call the referral source and inform them that you do not have any Spanish speaking staff and cannot take the referral.
c - Hospice regulations require that agencies must be able to provide services and materials in the patient’s language. Therefore, the best action to take is to utilize a translation service to provide the translation for the initial call as well as future visits/phone calls etc. It is always best to use a third party as opposed to a family member, friend etc. to ensure that the message is being translated properly and completely. Options A and B are HIPAA violations as you do not have permission to release information about Jorge to his fellow workers or to the owner. It is not allowable under CMS regulations to refuse the referral based upon language as that is discriminatory.
106
Gayle’s condition rapidly deteriorates suddenly prior to her planned transfer/level of care change. You determine that she is now actively dying after what appears to be tumor rupture through the abdominal wall with significant wound drainage requiring hourly to bihourly dressing changes in addition to severe pain/agitation that is not under control as of yet. What is the best option to proceed with now in order to manage Gayle’s care and support her family?
a. Continuous care
b. Respite care
c. General inpatient care
d. None of the above.
a - Continuous care is now the best option to manage Gayle’s symptoms and support her family through this crisis. This level of care requires that least 8 hours of care be provided within a 24-hour period and that greater than 50% of all hours of care be provided by nurses. These hours can be supplemented with social worker, chaplain, hospice aid and volunteer visits. A physician order must be obtained to initiate continuous care and to discontinue
107
Gayle is a 74-year-old hospice patient with ovarian cancer who has been cared for in her home for the past several months. Her care needs have now exceeded what her children as caregivers can manage long term.
385. Which of the following represents the best option for a short-term change in her level of care?
a. Continuous care
b. Respite Care
c. General inpatient care
d. None of the above.
b - Respite care is the best short-term option for a level of care change. Hospice regulations allow for a 5-day respite stay every 30 days within a licensed nursing facility. This situation does not meet continuous care or GIP level of care requirements where it is required that symptoms require management that cannot be provided in home or respite settings. Other options not related to level of care would be for the family to hire additional caregivers, or to place patient in a nursing or assisted living facility under the routine home care level of care.
108
When meeting with the son, you learn that he feels his mother is “giving up” by not pursuing any treatment and that she should have any and all treatment available for her cancer. Your most appropriate initial response to this statement is which of the following?
a. Tell him that chemotherapy would kill his mother.
b. Tell him to discuss this with his mother as it is her choice.
c. Inquire as to what he feels would be gained through treatment.
d. Inquire as to what treatment he wishes his mother would pursue.
c - The best initial response is to attempt to identify what the son feels would be gained through his mother’s treatment. He has already stated that he feels she should have any and all treatment available so asking what treatment he wishes she would pursue has already been addressed. Telling him that chemotherapy would kill his mother or that he should discuss with her would not be appropriate as an initial response. The goal is to support the son and to help him identify what he feels would be the benefit of treatment, and once that is discovered, further discussion regarding the associated risks, quality of life impact etc. can be addressed individually and with the patient.
109
During your visit, you note that the patient’s eldest son seems to be distracted and anxious, often getting up and pacing in and out of the room. The patient tells you that he has a history of ADHD and that she is concerned he does not understand all of this and requests that you assist him. What would be the best approach to meeting the patient’s request to assist her son?
a. Meet with the son one-on-one prior to admitting the patient to assess his level of understanding.
b. Explain that the social worker can call him to arrange a visit to answer any questions he may have.
c. Offer to have the spiritual counselor meet with him later today to discuss any concerns.
d. Insist that the son return to the room and listen to the information related to hospice care.
a - Meeting with the son individually may decrease his distraction and anxiety and allow for him to ask questions in a non-threatening environment. While you may wish to utilize the interdisciplinary team members in the future, given this situation, the best approach is not to put this off onto another team member or to a later date. In addition, you would not insist that the son return to the room when he clearly is anxious and distracted as that could heighten his symptoms.
110
You are meeting with a frail, elderly patient and her family for the first time at the patient’s home to potentially complete an admission to hospice care. The patient has been recently diagnosed with end-stage pancreatic cancer and has declined all treatment according to your records.
382. Which of the following inquires would be the most effective method to assess the patient’s understanding of her illness?
a. “Can you share your complete medical history with me?”
b. “So there is no treatment available for your cancer?”
c. “What have the doctors told you about your illness?”
d. “What are your wishes regarding final arrangements?”
c - Asking the patient what the doctors have told her regarding her illness is the most effective method to assess understanding related to the illness and prognosis. Obtaining a complete medical history is part of the nursing assessment, but does not establish comprehension of the illness. Inquiring about treatment and/or final arrangements does not establish an understanding of the illness/prognosis either.
111
Jane anticipates that her daughters may not be agreeable with her plans to travel, but feels that seeing her sister is one of the most important things she needs to do before she dies. Of the following, which would provide the most appropriate support for Jane?
a. Reinforce her right to make her own decisions.
b. Facilitate a family meeting in collaboration with the hospice counselor.
c. Offer to talk to Jane’s daughters for her.
d. Agree not to let anyone else know about her plans.
b - Facilitating a family meeting in collaboration with the hospice counselor would provide the most appropriate support for Jane. Though she certainly has the right to make her own decisions, enjoying a harmonious relationship with her daughters in her final days is most likely important to her, as well. Providing a supportive setting for the family to meet will enhance the potential for Jane to garner more support for her plans to travel and optimize her activities for self-determined life closure.
112
During one of your visits to Jane, she states that she has decided to stop her treatments, and do the things she enjoys with the time she has left. She states that she wants to go see her sister once more, but she lives 1100 miles away. Of the following, which option would optimally support Jane’s quality of life?
a. Help to arrange the trip.
b. Encourage life review using family pictures.
c. Reinforce her limitations regarding her care needs.
d. Reinforce getting permission from her daughters
a - Helping to arrange the trip would optimally support Jane’s quality of life. Traveling can be quite a challenge for those who are ill, and coordination often must take place between agencies and care providers in other locations, as well as the airline, etc., to ensure that the patient’s needs are met.
113
After the volunteer has been scheduled, Margaret’s daughter calls to thank you, and states that she would like to take her mom for a weekend away to take a break. However, she is not sure how to arrange care for her father. Of the following, which may be the best option?
a. Continuous care nursing
b. Asking a neighbor to stay
c. Hiring an agency that provides caregiving
d. Respite care
d - Respite care would be the best option. Under the hospice Medicare benefit, patients/families are entitled to a certain number of respite days on a regular basis to provide the opportunity for the caregiver to take a break. This is usually arranged as a short-term stay at a nursing facility and paid through the hospice Medicare benefit. Patients must meet certain skilled criteria to be eligible for continuous care nursing (Level 2 care), and hiring an agency for 24-hour care can be cost-prohibitive for most families.
114
One month after Eric’s return home, you note that Margaret appears exhausted and has lost weight. When questioned, she states that she is too busy taking care of Eric to have time to eat, and is not sleeping well. Of the following, what may be helpful for Margaret?
a. Arranging a volunteer to visit on a regular basis.
b. Bringing Margaret prepared food when you visit.
c. Telling her she must take care of herself.
d. Preparing a meal when you visit.
a - Arranging for a volunteer to visit on a regular basis would be the most helpful option. This would give Margaret permission to do the things she needs to do for herself; whether that be to rest, go out for errands, fix meals, etc. The volunteer may also be able to assist with meal preparation. Though reinforcing that caregivers should care for themselves, they are often so involved in the patient’s care that they neglect to do so
115
Jim is a 72-year-old with end-stage pulmonary fibrosis. He was recently hospitalized, and has returned home today. He is much weaker than when he went into the hospital, and is having difficulty getting up to the bedside commode by himself. His wife, Betty, is a small, frail lady, and is very upset, stating that she doesn’t think she’ll be able to help him get up. Of the following, which may be helpful interventions to support Jim and Betty?
a. Arrange for placement for Jim at a nursing facility.
b. Provide a urinal and bedpan.
c. Assess what support options she may have available for help.
d. Schedule home health aides 3x per week.
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c - As Jim’s condition declines, Betty is going to need increasing levels of support, and it will best to assess her overall support network to see who may be available to help her with ongoing needs. If no one is available, discussion of placement may be an option, though patients and families are often not in favor of this. Providing a urinal and bedpan and scheduling home health aides are certainly aspects of support that will be helpful, but their situation requires more comprehensive anticipatory planning to provide her with adequate support.
116
You receive notification from your supervisor that you have a new patient who was admitted last evening. The patient is a 50-year-old man with lung cancer who is currently homeless. He lives under a freeway overpass with several other homeless friends and that is where he wishes to stay until his death. She advises you to complete the comprehensive visit within the required timeframe. You proceed to do the following:
a. Notify your supervisor that you cannot properly care for a homeless person and refuse the assignment.
b. Notify your social worker and request he/she locate proper housing for this patient immediately.
c. Notify your social worker and inquire if she is able to make the comprehensive visit with you.
d. Notify your supervisor that your schedule is too full and you cannot complete the comprehensive visit.
c - The best action in this scenario is to notify the social worker and inquire if he/she is able to accompany you to the comprehensive visit. Given the patient’s housing situation and uncertain elements it would be wise to have another person attend the visit with you. In addition, another person’s input to the situation and development of the plan of care is essential for situations/circumstances such as this. You cannot refuse to provide care or remove the person from their environment that they consider “home” against their wishes. Autonomy is a key component of hospice and palliative care and must be honored regardless of the situation.
117
You have helped Wilson and his girlfriend plan the wedding to be held in their home with the hospice chaplain as the minister and provided assistance with obtaining the marriage license, donated wedding dress, etc. to be held next month per their request. Wilson has now developed a significant infection that has resulted in a rapid decline in his status. He insists that he cannot die without marrying his girlfriend and is very distressed. What is your best action in this situation?
a. Advise Wilson that you will reschedule the wedding as soon as allowable.
b. Tell both Wilson and his girlfriend that nothing can be done to reschedule.
c. Arrange for a transfer of Wilson to the hospital to stabilize him and hold the ceremony there.
d. Administer anti-anxiety medications to calm Wilson’s distress and sedate him so he is not aware.
a - The best action in this scenario is to advise the patient that you will reschedule the wedding as soon as possible/allowable. This is clearly a very important life-closure goal and the hospice team needs to do everything possible to make it possible as the hallmark of patient/family centered hospice care is allowing the patient/family to decide what is important for them. Telling them that nothing can be done, transferring out of the home, and sedating are not appropriate actions.
118
Of the following, which is required when initiating changes in level of care within the hospice Medicare benefit?
a. The hospice medical director’s order
b. The primary physician’s order
c. Pre-approval from Medicare
d. Documentation of financial need
b - When initiating changes in level of care within the hospice Medicare benefit, the primary physician’s order is required. In addition, a discussion must take place with the patient and family, as well as the IDT. The plan of care must be updated, and all items must be documented in the patient’s record.
119
If a patient, who is under the hospice Medicare benefit, is being transferred to another hospice agency, which of the following will impact reimbursement for the patient’s care?
a. Coordination of the hospice Medicare benefit
b. The deductible on the patient’s plan
c. Amounts of standard co-payments
d. Co-insurance ceiling limits
a - When a patient is receiving care under the hospice Medicare benefit, and is being transferred to a different hospice, coordination of the hospice Medicare benefit is critical to
ensuring accurate reimbursement. A patient cannot be admitted to two hospices under the same benefit period.
120
Virginia is a 69-year-old who has been referred for admission to hospice for a diagnosis of end-stage colon cancer. When visiting to assess her eligibility for admission, she is able to give you a verbal history of her disease progression, but has no documentation regarding confirmation of her cancer. Of the following, which would be the most appropriate next step in order to complete the admission process?
a. Document her statements in quotations
b. Contact the referring physician’s office for documentation
c. Ask the hospice medical director to examine her
d. Ask a family member to confirm the information
b - Contacting the referring physician’s office for documentation to confirm her cancer diagnosis and disease progression is the appropriate next step in order to complete the admission process. Ongoing collaboration with the referring physician’s office is an essential and required step in caring for the patients who have been entrusted to the care of hospice
121
Helen, a 70-year-old with end stage colon cancer, has been admitted to hospice. She states that she has discussed stopping her treatments with her physician in the past, but he has not been willing to agree to this option. She states that he reluctantly agreed to refer her to hospice, but wants her to return to the hospital for any acute needs. She asks how she might get him to agree to support her desire to stay at home without further intervention, except for comfort measures. Of the following, which is the most appropriate response?
a. Recommend that she change physicians
b. Ask the hospice medical director to assume care
c. Offer to accompany her to visit her physician
d. Ask her family to talk to her physician for her
c - Offering to accompany Virginia during a visit to her physician would be the most appropriate response. Such in-person collaboration and advocacy on the patient’s behalf can be a very powerful method of building rapport with community physicians and helping to increase their understanding of hospice care. Many physicians have difficulty discussing end-of-life issues with patients. Therefore, providing support and education for both parties would be highly beneficial.
122
How often should the individualized plan of care for the patient/family be updated?
a. No less frequently than every 7 calendar days and with any status changes
b. When patient/family status changes occur
c. When the hospice medical director requests an update
d. No less frequently than every 15 calendar days and with any status changes
d - The individualized plan of care for the patient/family must be updated no less frequently than every 15 calendar days and when the patient/family status changes, according to the Hospice Medicare Conditions of Participation. The plan of care must be reviewed at each visit by each discipline as well and updated as needed.
123
Of the following, which would NOT be an appropriate activity for a hospice volunteer to assist a patient with?
a. Shopping
b. Light housekeeping
c. Investment advice
d. Companionship
c - It would not be appropriate for a hospice volunteer to provide a patient with investment advice. Hospice volunteers are an integral part of the IDT, and provide many valuable services to patients and families, as well as within the offices of the hospice agency. Care by hospice volunteers should always take place within the collaborative relationship of the IDT, and according to expectations of professional behavior and boundaries similar to any paid employee of the hospice.
124
The primary role of the RN Case Manager within the interdisciplinary team (IDT) is which of the following?
a. Ensure proper documentation of all IDT members at each visit.
b. Schedules all visits for IDT members.
c. Supervises and directs activities of IDT members.
d. Coordinates and oversees the IDT plan of care and its implementation
d - The primary role of the RN Case Manager is to coordinate and oversee the IDT plan of care and the implementation of that plan of care. The RN Case Manager is not responsible for documentation of other members, scheduling of visits, or the supervision of any IDT member other than the hospice aide.
