Ch. 4 Hospice and Palliative Care
According to the position statements published by the Oncology Nursing Society and the American Society of Clinical Oncology, palliative care should be considered early during the course of illness for any individual with metastatic cancer and/or a high symptom burden. Which on the following is considered as a main advantage of early palliative care consultation? A. decreased burden of care for the primary care team B. Cost savings for patients admitted with advanced cancer C. Chemotherapy administration is increased D. Extended disease-free survival
B. Cost Savings for patients admitted with advanced cancer Rationale: Cost savings is not something hat is usually focused on in cancer care. However, studies have shown that patients who have early appropriate referral to palliative care have increased acceptance of their disease trajectory and make decisions that often reflect in decreased costs both for inpatient and for outpatient care. Decreased burden of care to the primary team may occur tangentially because the palliative care team is addressing symptoms and improving quality of life, but the main improvement is in cost savings. Palliative care involvement rarely includes increased chemotherapy administration or extended disease survival, as those are not the focus of palliative care models.
In order for a patient to access Medicare hospice benefits, the patient must have an estimated life expectancy of less than: A. 3 months B. 4 months C. 6 months D. 12 months
C. 6 months Rationale: Although other insurance plans may have different parameters, Medicare maintains a parameter of 6 months life expectancy as a requirement for patients to access Medicare hospice benefits. Eligibility criteria should not be confused with length of service; patients can receive hospice care for a long as they meet eligibility criteria.
Certification of prognosis must be provided for hospice care by which one of the following combination of staff members? A. referring physician and social work supervisor B. Pastor and hospice medical director C. Referring physician and hospice medical director D. Hospice medical director and insurance adjuster
C. Referring physicians and hospice medical director Rationale: Two physicians must certify that the patient is terminally ill. This typically includes the referring provider and the hospice medical director. This is made after independent assessment of the patient and based on the best judgement of the two physicians.
Unfortunately, it is common for hospice care referrals to occur quite late in the trajectory of a patient's illness. The median number of days a patient lives while on hospice care, according to 2018 data by the National Hospice and Palliative Care Association, is which one of the following? A. 25 B. 30 C. 7 D. 17
D. 17 Rationale: Patients live on average 17 days after admission to hospice, with a large percentage (35%) of deaths occurring within 7 days of admission.
From the United Kingdom to the United States, the hospice movement began with pioneers such as Dr. Florence Wald and Dame Cicely Saunders leading the way for the care of the terminally ill. The roots of the modern hospice movement can be traced to which one of the following time periods? A. 1960's in England B. 1970's in Scotland C. 1980's in the United States D. 1960's in Connecticut
A. 1960's in England Rationale: The first modern hospice, St. Christopher, was founded in 1967 in England, and based on the work of Dame Cicely Saunders, whose work with terminally ill, starting in 1948, is credited as starting the modern hospice movement. The first hospice program in the United States was opened in 1974 in Bradford, Connecticut, and was founded by Dr. Florence Wald, Yale School of Nursing dean, and an early pioneer in the hospice movement in the US. The Medicare hospice benefit was approved by Congress in 1982 after demonstration projects demonstrated that interdisciplinary team care focusing on quality of life and addressing symptom burden of terminal illness improved outcomes and cost less than usual care. The Medicare benefit became permanent in 1986, which provided a stable source of payment for hospice care and resulted in a steady growth of hospice programs throughout the US
Physicians are often overly optimistic when anticipating life expectancy for patients with terminal of advanced disease, and usually overestimate survival time of their patients by a factor of which one of the following? A. 4 B. 3 C. 5 D. 2
A. 4 Rationale: Providers tend to be optimistic and usually estimate the patient's survival as four times longer than the patient actually survivors.
Which one of the following statements below best describes the concept of palliative care? Palliative Care: A. Focuses on improving the quality of life for the patient B. Focuses on treating the cancer with the fewest number of and severe side effects C. Is delivered by a specialized physician rather than delivered by a healthcare team D. Provides care to the dying patient at end of life
A. Focuses on improving the quality of life for the patient Rationale: Palliative care is the concept that includes delivering ancillary therapy to treat side effects of treatment and the disease so the quality of life (QOL) is improved. It is defined as patient and family-centered care that optimizes (QOL) by anticipating, preventing, and treating suffering as well as addressing physical, psychosocial, and spiritual problems. Key components of palliative care include patient and family-centered care across the serious illness trajectory. Articulating goals of care and shared decision making are essential elements of the palliative care approach. B is incorrect because palliative care is not focused on the actual treatment of the cancer, but on the other issues surrounding it. C is not correct because palliative care is most commonly delivered by an interdisciplinary team of providers and ancillary staff. D is incorrect because palliative care can be instituted at the time of diagnosis , it is not reserved only for use during end of life care.
Terminal secretions- also commonly referred to as a "death rattle" -- occur when the dying patient is too weak to clear or swallow pharyngeal secretions. Which of the following is one of the least invasive ways to manage terminal secretions in dying patients. A. anti-cholinergic drugs B. elevation of the head of the bed C. suctioning D. cool wash cloths
B. Elevation of the head of the bed Rationale: Elevation of the head of the bed can often decrease the noise and distress by secretions pooling in the back of the oropharynx. These can also be alleviated by anticholinergic drugs and suctioning, but these interventions are more invasive. Cool wash cloths do not help terminal secretions.
The palliative care treatment team is comprised of interdisciplinary palliative team members. Initially, which one of the following sets of three team members should be included on the team? A. family, pastor, friends B. Pain management specialist, chaplain, social worker C. Pharmacist, physical therapist, occupational therapist D. Significant other, integrative practitioner, nurse
B. Pain management specialist, chaplain, social worker Rationale: Although many other people may become involved in the palliative care of a cancer patient, a pain management specialist, a chaplain, and a social workers are the most common staff included. Typical members of a palliative care team include a physician and/or nurse (with expertise in pain and symptom management), social worker, spiritual care provider, and other healthcare professionals as needed whose approach to care is to identify and meet the needs of patients and caregivers. Other people in the patient's life, including the providers mentationed in C, may also assist. D is incorrect as not all patients utilize integrative therapy.
The tool that was developed and adopted by the National Hospice and Palliative Care Organization in 2007 to assess the sociocultural needs of the patient is is called which one of the following? A. NCCN B. SWAT C. ECOG D. EQOL
B. SWAT Rationale: SWAT or the Social Work Assessment Tool is the tool most commonly used by social workers to evaluate the patient/family environment and assessment their sociocultural needs. Examples of what is assessed during a SWAT include safe and affordable housing, public safety, and access to local emergency and health services. NCCN stands for the National Comprehensive Cancer Network, ECOG is the abbreviation for the Eastern Cooperative Oncology Group and EQOL is the abbreviation for an evaluation of the quality of life of the patient.
Although rural communities may not have tertiary palliative care readily, available providers in these settings can connect to a variety of services via which one of the following? A. home health aids B. telehealth connectivity systems C. Social Work services D. the local emergency services
B. Telehealth connectivity systems Rationale: Telehealth connectivity allows providers in rural community settings access to extended services such as consultation with pain management, extensive case review by a palliative care team to provide recommendations, and coordination of care when a patient is able to get to a tertiary center. Social work, local emergency services, and home health may all play a role in rural palliative care, but telehealth is what connects these services together for the patient in a rural setting.
Mrs. L is an 83-year old female, who has been admitted into the hospice care, and based on her declining condition, the recommendation is to place her on artificial nutrition and hydration (ANH). Which of the following statements is false regarding the effects of ANH on a dying patient? A. May increase the risk of aspiration and its complications B. Artificial nutrition given via tube feedings is associated with increased infection, and fluid overload C. ANH is known to reduce the sensation of thirst or dry mouth D. According to a Cochrane review, no clinical difference on quality of life was found in artificial hydration versus a placebo
C. ANH is known to reduce the sensation of thirst or dry mouth Rationale: Artificial nutrition and hydration (ANH) is not known to reduce the sensation of thirst or dry mouth. According to the Hospice and Palliative Nurses Association, many patients experience the sensation of dry mouth but this symptoms is associated with other factors besides lack of fluids, and, as a result, the introduction of parenteral fluids is unlikely to alleviate thirst. On the other hand, answers A,B, and D are all factors and potential complications associated with the use of ANH. The use of of ANH may increase the likelihood of aspiration and ANH given through a feeding tube is associated with an increased change of infection and fluid overload. Finally, a Cochrane review has found that there is no clinical difference on quality of life was found in artificial hydration versus a placebo.
Unlike other areas of clinical practice, it may be appropriate in a hospice setting for team member to do which one of the following? A. Conduct a physical examination on the caregiver or family member B. Evaluate the patient once at the beginning of hospice assessment C. Assess patient and family member or suppose providers separately D. Talk to family members without knowledge of the patient
C. Assess patient and family member or suppose providers separately Rationale: While it may be appropriate to evaluate the needs of family members separately from the patient to get a clear picture of the needs of the whole person and milieu, it would not be appropriate to do such an evaluation without he knowledge of the patient. Nor would it be appropriate to only conduct one evaluation of the hospice patient or to do a physical examination of a family member of a hospice patient.
Both as a philosophy of care and as a regulated insurance benefit, hospice care is a model of high-quality, compassionate care. When a patient signs up for hospice care, they are agreeing to which one of the following? A. Chemotherapy if the doctor thinks it is an option B. Transferring care to a different oncologist C. Cessation of aggressive therapy D. Intubation for respiratory distress
C. Cessation of aggressive therapy Rationale: Patients must agree to cessation of aggressive therapy in order to enroll in hospice care. Accessing a second opinion, intubation for respiratory distress, and chemotherapy are not included in a hospice care plan.
Mr. S is an 80-year-old male, who has been admitted into hospice care with an advanced form of cancer. He has been in hospice care for less than 24 hours, but his health is rapidly declining , and after an evaluation from the hospice team, it is determined that his death is eminent. Which one of the following signs could the hospice team have considered as a sign of eminent death? A. rapid breathing B. restless movements C. Cheyne-Stoke breathing D. bounding pulse
C. Cheyne-Stoke breathing Rationale: Describing the quality of Cheyne-Stoke breathing to the patient's family can help them recognize this as one of the signs of impending death. Other clinical signs of impending death which families should be aware of include pulselessness of the radial artery, respiration with mandibular movement, decreased urine output, terminal secretions, nonreactive pupils, and a decreased response to visual stimuli. Rapid breathing, restless movements, and bounding pulse are less likely to be signs of eminent death, though restless movement may precede the more terminal phases.
According to the National Comprehensive Cancer Network (NCCN) Distress Screening tool, a patient who scored a "4" or below should be referred to which one of the following services or members of the healthcare team? A. psychiatrist B. Support Group C. Primary Oncologist D. Clergy Person
C. Primary Oncologist Rationale: If the score of the Distress Screening tool is lower than a 4, then the tool suggests that the primary oncologist and their staff can manage the distress. If the score is higher than a 4, the patient should be referred to specialty services such as psychiatrist, support group, clergy, or palliative care team.
Tertiary palliative care refers to which one of the following? A. care provided by rural palliative care team B. Basic palliative care principles carried out by a home health nurse C. Advance care planning in the terminal setting D. Care provided in a cancer center with Joint Commission Palliative care certification
D. Care provided in a cancer center with Joint Commission Palliative care certification Rationale: Tertiary care is the highest level of palliative care, usually carried out by a well-coordinated and developed team at a designed cancer center with a Joint Commission care certification, where guidelines, research, and organized care conferences are utilized to provide multifaceted services to the patient and family. Primary palliative care includes basic palliative care skills, advance care planning, symptoms assessment and management, communication among healthcare provider, patient, and family caregivers, as well as, support for the patient and family caregiver. Primary palliative care can be offered by all oncology healthcare healthcare providers as well as primary care providers to patients and family caregivers. Secondary palliative care is a bridge between primary and tertiary palliative care. Secondary palliative care is offered by the healthcare professional and organizations who provide specialty palliative care and consultation. Secondary palliative care is accessed in community or rural settings, where needs often exceed the skill of primary care providers and access to palliative care experts is scarce.
Distress is a common psychosocial symptom, not only in patients, but also for the families, loved ones, and caregivers involved. More physical and emotional distress, as well as more prolonged caregiver grief, is experienced by patients who die in which one of the following manners? A. Dies unexpectedly B. Dies alone C. Dies at home D. Dies in the hospital
D. Dies in the hospital Rationale: Studies have demonstrated that patients who die in the hospital experience more physical and emotional prior to death as compared to patients who die at home. One third of all patients die at home. Dying at home is associated with greater caregiver, satisfaction, less aggressive care at the end of life, higher quality of death as assessed by family members, and lower overall caregiver burden. Persons receiving hospice care have an impending expected death and family members may experience more support both as they care for the patient and through bereavement care.
G.T. is a 48-year-old mother of two with metastatic breast cancer, which has metastasized to her pancreas. She has recently begin palliative care. She has been suffering from periods of extreme pain, to the point being debilitating. After consulting with the patient and the patient's family, her palliative care team has decided to place her on a regimen of pain medication. Which one of the following statements best illustrates a standard of palliative care? A. G.T.'s palliative care team respected her autonomy as a patient, as well as her family's wishes, and developed a treatment plan to aggressively treat her cancer. B. G.T.'s palliative care team dealt with her psychosocial and spiritual distress. C. G.T.'s palliative care team begin end-of-life care D. G.T.' s palliative team respected her autonomy as a patient, as well as her family's wishes, and initiated a plan to ease the pain caused by her cancer.
D. G.T.'s palliative team respected her autonomy as a patient, as well as her family's wishes, and initiated a plan to ease the pain caused by her cancer. Rationale: According to the NCCN's standards of palliative care in oncology, symptom burden from disease or treatment is anticipated, prevented, and skillfully managed. This standard is best exemplified in how the palliative care team treated G.T.'s symptoms of pain and is reflected in Answer D. Answer A is incorrect because developing a treatment plan for cancer is not a standard of palliative care, even though respecting the autonomy of the patient is a standard. Answer B is also incorrect. A standard of palliative care in oncology is treating psychosocial and spiritual distress with the same importance as a physical condition, but, in this example, the palliative care team was dealing with symptom of pain, making B an incorrect response. Answer C is also incorrect. End-of-life care is not a standard a palliative care identified by the NCCN.
The process of dying can be a traumatic and painful experience for any family dealing with illness and associated suffering of a loved one, even a loved one who is elderly or has been experiencing the trajectory of a long illness. Which one of of the following is responsible for assisting the family through the dying process and grieving period? A. It is the responsibility of extended family members only. B. It is the responsibility of the psychotherapist of the patient C. It is the responsibility of the RN who attends to the patient at home D. It is the responsibility of the whole interdisciplinary hospice team
D. It is the responsibility of the whole interdisciplinary hospice team Rationale: Grief benefits are offered to the family of hospice patients after the death of the patient so that they do not have to rely on only other family members, clergy or therapists. Grief counseling is a large part of hospice care, is the responsibility of the entire interdisciplinary team, and support groups should be offered to all family members whenever possible.
Shared Decision Making and goals of care are known to be essential elements of palliative care practice. Which one of the following is NOT an element of shared decision making or goals of care? A. The plans are based on the wishes and beliefs of both patients and caregivers. B. The plans are flexible, and the goals may change over the course of an illness C. Plans are elicited in an intentional and structured way. D. Plans are meant to map out advance care planning.
D. Plans are meant to map out advance care planning Rationale: The answer D is not an element of Shared Decision Making. Advance care planning if often confused with goals of care and Shared Decision Making but the element of advance care planning is not part of the goals of care. Answers A, B, and C, however, all go into the goals of care for palliative care team. In planning out goals of care, the plans are meant to be based upon the shared beliefs of patients, families, and caregivers; the plans are meant to be flexible and may change over the course of the illness, and are enacted in an intentional and structured way, so that the patient and palliative care team can plot out the best way for a patient to move through this phase of their disease course.
