Hospice General

Question 1

FAST score 1

Answer 1

No difficulty subjectively or objectively

Question 2

Caution in deprescribing anticoagulation in patients with

Answer 2

**mechanical mital valve
**left ventricular assist device
Mechanical aortic valve has some clotting potential but not as severe as in mitral valve

Question 3

CYP 450 3A4 inhibitors, examples

Answer 3

Ketoconazole
Erythromycin
Diltiazem ( cardizem)
Grapefruit juice

Question 4

Cyp350 3a4 inhibitors, affect on fentanyl

Answer 4

Reduce fentanyl metabolism, thus increase serum fentanyl level

Question 5

New agitation/eestlessness, assess for…

Answer 5

Urinary obstruction
Constipation
Pain
Withdrawals
Med side effects

Question 6

Medicare part A

Answer 6

-hospital insurance
-covers those age 65 and up, certain disabilities
-covers dialysis, hospice, hospital, rehab, SNF, rural health centers

Question 7

Medicare part B

Answer 7

• medical insurance for ages 66 and up, certain disabilities
  -Pay premium or copay for care
  -Covers professional services, ie: phhysician, NP, rehab, psychologist, psychiatrist.
  -Covers DME, home health, outpatient care

Question 8

Balanced budget act of 1997

Answer 8

-Removed some restrictions, allowed APRN to bill independently
-set ARPN reimbursement rate at 85% of physician rate

Question 9

Medicare modernization act (MMA) of 2003

Answer 9

among other things,
-NP able to serve as attending in palliative care for hospice and non hospice patients
-For hospice, NP cant certify terminal illness.
-Cant serve as hospice medical director or replace physician for IDT
-Cant bill unless serving as attending physician NP
-No NP can certify terminal illness or 6 month prognosis admission to hospice care
-CMS requires APRN to work in collaboration with a physician

Question 10

4 fundamental ethical principles in palliative care

Answer 10

Autonomy
beneficence
non maleficence
justice

Question 11

Additional ethical principles:

Answer 11

Honesty
trust
confidentiality
informed consent
principle of double effect

Question 12

Decision making capacity

Answer 12

-Pt can make and communicate a decision
-Pt able to articulate understanding of
>medical situation and prognosis
>recommended care
>alternatives
>risks, benefits, consequences
-Pt uses reasoning to make a choice
-Decisions are consistent with pts values and goals

Question 13

bioethical and legal expert consensus is there is no difference between deciding not to start a treatment and deciding to stop a treatment.

Answer 13

IE: just because it is started, doesnt obligate you to continue it

Question 14

bioethical and legal expert consensus is there is no difference between deciding not to start a treatment and deciding to stop a treatment.

Answer 14

IE: just because it is started, doesnt obligate you to continue it

Question 15

Palliative sedation

Answer 15

-intentional administration of sedatives to reduce a terminal patients consciousness to adequately controll refractory symptoms.
-Intent is to promote comfort and minimize distress

Question 16

multiple myeloma: CRAB

Answer 16

Calcium elevation
Renal insufficiency ( creatinine elevated)
Anemia ( often normocytic, normochromic)
Bone pain (Lytic lesions, usually central skeleton, pain worse with movement)

Question 17

Imodium
vs
Lomotil

Answer 17

Imodium ( loperamide hydrochloride)

Lomotil (diphenoxylate and atropine) – more side effects, on beers list

Question 18

code status

Answer 18

only 8.4% survival to hospital discharge

Your illness is in its last stages. i understand that your quality of life is most important to you right now. With this in mind we want to focus on therapies that help you meet your goals. Resuscitation is unlikely to do this. Do you agree?

Question 19

nociceptive pain

Answer 19

Activation of nociceptive (pain sensitive) structures)
-somatic pain
-visceral pain

Question 20

Somatic pain

Answer 20

• from cutaneous amd deep musculoskeletal tissues
  -ie: bone mets, incisional pain, myofacial or musculoskeletal inflammation or spasm

Question 21

Visceral pain

Answer 21

-infiltration, stretching, compression, distention of thoracic or abdomenal viscera
-ie: cirrhiosis, pancreatic cancer
-often “deep, knawing, squeezing or cramping” may be associated with n/v, diaphoresis.

Question 22

NSAIDs
Mechanism of action

Answer 22

-Inhibit enzyme cyclooxygenase
-Decrease prostaglandin production that protects gastric mucosa and renal parenchyma.

Question 23

NSAID contraindications

Answer 23

Chronic heart failure
Cirrhosis
Gastric bleed/ PUD
Significant atherosclerotic disease/HTN
multiple myeloma
renal failure
corticosteroids

Question 24

morphine to methadone ratio

Answer 24

<60mg morphine: refer to opioid naiive dosing
60-199mg MME, pt <65 yo. 10:1
>200mg MME and/or >65 y.o. 20:1

Question 25

Inotropes

Answer 25

Change force of heart's contraction posisitve inotropes= more force (dobutamine, digoxin) negative inotropes= less force

Question 26

Intraparenchymal hemorrhages

Answer 26

are generally non traumatic usually in context of HTN or cerebral amyloid angioplasty ( seen in Alzheimer's)

Question 27

Dyspnea treatment

Answer 27

Treat underlying cause morphine and fentanyl most commonly used for terminal dyspnea

Question 28

Cachexia

Answer 28

-Weight loss associated with muscle, with or without loss of fat mass. -Chronic inflammation, metabolism, and neural hormonal factors play a part. -Rarely reversed by supplements or increased nutritional intake.

Question 29

Classification criteria for cancer related cachexia

Answer 29

-involuntary weight loss of > 5kg in 6 months -food intake < 1500kcal/day -C reactive protein >10mg/dL

Question 30

Anthropomorphic measures of cachexia

Answer 30

-MAC in men, <32cm in women, < 18cm

Question 31

sarcopenia

Answer 31

loss of muscle mass loss of strength loss of function

Question 32

secondary cachexia

Answer 32

other etiologies for weight loss -pain, n/v, anorexia, bowel obstruction, stomatitis, dysphagia, depression

Question 33

secondary cachexia

Answer 33

other etiologies for weight loss -pain, n/v, anorexia, bowel obstruction, stomatitis, dysphagia, depression

Question 34

pharmacologic treatment for anorexia/ cachexia

Answer 34

-Progestins (megastrol, medroxyprogesterone acetate) -corticosteroids -cannabis and cannabinoids -non specific agents (mirtazapine, olanzapine, melatonin)

Question 35

Laxative of choice in ESRD and de compensated cirrhosis

Answer 35

Lactulose

Question 36

FAST score 2

Answer 36

Complains of forgetting locations of objects Subjective work difficulties

Question 37

FAST score 3

Answer 37

Decreased functioning evident to coworkers Difficulty with traveling to new places Decreased organizational capacity

Question 38

FAST score 5

Answer 38

Requires assist with choosing appropriate clothing for weather, location, day

Question 39

FAST score 6

Answer 39

occasionally or frequently: A) improperly putting on clothing without help or cueing B Unable to bathe properly C) Unable to manage mechanics of toileting D) Urinary incontinence E) fecal incontinence

Question 40

FAST score 7A

Answer 40

Less than 6 intelligible words in a day or interview

Question 41

FAST score 7B

Answer 41

Single word in a day or extensive interview

Question 42

Fast Score 7C

Answer 42

Ambulatory ability lost

Question 43

FAST score7D

Answer 43

Cant sit up without assist

Question 44

FAST score 7E

Answer 44

Loss of ability to smile

Question 45

FAST score 7F

Answer 45

Unable to hold up head independently

Question 46

PPS 70%

Answer 46

Reduced ambulation cant do Normal work/some disease full self care normal or reduced intake full LOC

Question 47

PPS 80%

Answer 47

Full ambulation normal level of acitivity with some effort/some disease full self care normal or reduced intake full LOC

Question 48

PPS 90%

Answer 48

Full ambulation Normal level of acitivity/some disease Full self care Normal intake Full LOC

Question 49

PPS 60%