Advance Care Planning

Question 1

T/F
1. Many people believe that having a financial POA means a separate medical POA is unneeded.
2. Many clinicians and Pt’s have the feeling that having an AD means “don’t treat”.
3. Pt’s often fear that once they name a proxy in an AD they lose control of their own health care decision making.
4. Many people hope that having AD will save their family from the burden of making difficult decisions about their health care

Answer 1

All true
1. assess their understanding, have literature available that addresses discrepancies.
2. assess their understanding–means “treat me the way I want to be treated”.
3. assess understanding, educate circumstances AD become active
4. Encourage Pt to discuss with loved ones “when is enough enough?” and give permission to not prolong the dying process (if compatible with Pt wishes)

Question 2

Jane is a 70-year-old with end-stage pancreatic cancer who states that she would like more information about preparing advanced directives. She has two adult daughters. One thinks she should continue with as much intervention as possible, and the other feels that Jane should focus on enjoying the time she has left instead of dealing with treatments and side effects. Jane does not think she wants further treatment, and is concerned that her wishes will not be honored.
378. Of the following, which option will provide the best support for honoring Jane’s wishes?
a. Make no changes to present plan of care.
b. Sign a Do Not Resuscitate form (DNR) and create a living will.
c. Create a living will and designate an appropriate Power of Attorney for Healthcare (POAHC).
d. Sign a Do Not Resuscitate form (DNR).

Answer 2

c - Creating a living will and designating an appropriate Power of Attorney for Healthcare (POAHC) is the option which will provide the best support for honoring Jane’s wishes. The POAHC may be one of her daughters, but does not have to be a family member. What is most important is that Jane select an individual who will honor her wishes, even if others provide pressure to do things differently. Creating a living will and/or signing a DNR will allow Jane to voice her wishes if she becomes unable to speak for herself. However, in most states, if the legal representative she designates does not agree with these wishes, they can still be rescinded by this party if Jane can’t speak for herself. Therefore, it is of utmost importance that the designated POAHC be someone she trusts implicitly to act on her behalf.

Question 3

Ann is a 64-year-old with end-stage cardiac disease who has had frequent admissions to the hospital for congestive heart failure. She lives alone, and is competent to make her own decisions. She states that she is tired, does not want to go back to the hospital anymore, and wants to sign a Do Not Resuscitate order (DNR), even though her daughter does not agree with her. Of the following, which is the most appropriate response?
a. Tell her she’ll have to have her daughter’s permission.
b. Support her and provide a DNR form for her to sign.
c. Reinforce the need for hospital care.
d. Tell her it’s up to her doctor.

Answer 3

b - Supporting Ann’s decision and providing a DNR form for her to sign is the most appropriate response. Since she is competent to make her own decisions, she does not need her daughter’s permission, though it would most likely be beneficial for her to discuss this with her. Most states have an approved DNR form that all emergency personnel will honor, which usually requires the signature of a physician, as well as the patient’s signature. Often, if the patient’s physician is not agreeable, or not available, the hospice medical director will agree to sign the form. A patient has the right to refuse life-saving treatment, but if she is not conscious to speak for herself, a DNR form must be in place to ensure that her wishes are honored. Additional advance directives that would be beneficial are a living will, and a power of attorney for healthcare (POAHC).

Question 4

Your patient’s doctor has recommended another round of chemotherapy, but she states that she is tired of all the chemotherapy, and wants to know what you think. Of the following, which is NOT an important question that patients should ask when considering further treatment?
a. How will it impact my quality of life?
b. How will it impact my prognosis?
c. Who will pay for it?
d. None of the above

Answer 4

d - None of the above is correct, since these are all important questions that patients should ask when considering further treatment options. Hospice should advocate for patients to ask questions and make informed decisions, rather than just agreeing to every treatment option that is offered.

Question 5

ACP Advanced care planning
A. verbal instructions about health care preferences
B. process that helps individuals plan for future health care decisions
C. ACP appropriate only for adults with chronic or serious illness

Answer 5

B.

Question 6

What is one of the 5 domains of quality patient care for individuals with serious illness?
A. Clinician-patient based communication and advance care planning
B. Ensure Patients understand medical language
C. Protect individuals who lack decision making capacity

Answer 6

A.

Question 7

ACP Advanced Care Planning as Palliative Care is

Answer 7

important component of person centered care, essentially to whole person focus of PC
conversations to help everyone learn what matters most to this particular person at the particular time
ensures patients receive tx that is aligned with their beliefs, preferences, wishes
ACP decreases the use of use of excessive life sustaining tx, increase use of hospice/PC care, prevents hospitalizations

Question 8

What term is not used for advance directive?
A. Durable Power of Attorney
B. Health Care Proxy
C. Health care Power of Attorney
D. Organ Donation forms
E. Burial contracts
F. Living Wills

Answer 8

E. Burial Contract
Organ Donation Forms and LIving Wills are also types of AD.

Question 9

According to which federal Act of l991 are health care systems required to provide written material about advance care planning?

Answer 9

Patient Self-Determination Act (PSDA)

Question 10

A. Actionable Medical Orders B. Advance Directives
Which applies to each below
1. Can be completed with patient or healthcare agent/surrogate decision maker
2. Appropriate for all adults
3. Appropriate for children under 18 with serious illness
4. Appropriate for individuals with a serious illness or advanced frailty expected to die within a year or two.
5. Individuals who receive LTC at home or facility
6. Can only be completed by Pt when they have decision making capacity

Answer 10

1. A
2. B
3. A
4. A, B
5. A, B

Question 11

When Pt lacks decision making capacity a healthcare agent or surrogate can make additional decisions on Pt’s behalf on the POLST except for:

Answer 11

They cannot opt for increased life sustaining treatments, (liked changing DNR to full code)
They can opt for comfort measures and transition to hospice if Pt’s condition has worsened

Question 12

CPR includes chest compressions and
a. medication to restart the heart
b. intubation
c. anything else needed to make CPR successful
d. all of the above

Answer 12

d.

Question 13

Who cannot facilitate ACP conversations and draft POLST?
a. ARNP
b. Chaplain
C. Social worker
e. PA
f. attending MD
g. residents
h. hospitalists

Answer 13

B

Question 14

Who cannot sign POLST?
a. ARNP
b. Social Worker
C. Attending MD

Answer 14

B

Question 15

Why is it important to be trained for ACP and POLST conversations?
a. Ensure person centered conversation
b Accurate information provided (CPR, etc)
c Pt provided safe place to reflect on what matters most to them and make decision when they are ready
d. All of the above

Answer 15

d

Question 16

FIRST thing to do if EMS was called in error or because of uncertainty at the end of life?
A. Present POLST
B. Call the health care agent
C. Let EMS know the Pt would never want CPR

Answer 16

A.
WIshes for DNR can only be honored outside the hospital if Pt has a POLST or state equivalent
Even if health are agent present and insisting no CPR< EMS must and transport to hospital without POLST

Question 17

Why is it important that patients with POLST completed also have an advance directive?

Answer 17

Because the designated health care agent may need to make additional health care decisions on behalf of the Pt when they lose decision making capacity.

Question 18

T/F
POLST makes an important distinction between the individual’s wishes should their heart or breathing suddenly stop (CPR/DNR) and their wishes should they experience complications such as difficulty breathing,eating, etc.

Answer 18

T

Question 19

Who can decide Pt has capacity (individual’s ability to make informed health care decisions) and name a health care agent?
A. Chaplain
B. Social Worker
C. RN
D. MD
E. BCD

Answer 19

E

Question 20

Can Patients who lack the capacity to make complex health decisions make decision who to appointment designated surrogate?

Answer 20

Yes, if assessed as capable to do so

Question 21

Why is it important to engage Pt’s in advance care planning, even though they have designated a surrogate?

Answer 21

1. Surrogate may not know Pt’s health care wishes and might make decisions that don’t align with what matters to Pt
2. Surrogate may not always act in Pt’s best interest
3. Surrogate can experience significant distress when they need to make decision without knowing what Pt wants

Question 22

How is competency established?

Answer 22

Competency is a legal term. Guardianship hearings, court determines capacity.

Question 23

Role of the Hospice/PC Social Worker when working with POLST
A. Ensure Pt understand medical information
B. Promote quality ACP conversations
C. Consider advance directive and POLST forms as a product of Quality ACP conversations and not an end in themselves
D. Support Pt to make decisions that align with their wishes
E. Advocate for certified interpreter when needed
F. Promote the development of written materials for patients and family information
G. Alert Md and/or IDT if Pt does not understand an aspect of their dx, tx plan….coordinate follow up
H. All the above

Answer 23

H.
in family meeting MSW may pose questions that promote clarity and encourage the Pt and their loved ones to ask questions if needed. This includes MSW roles of advocate and educator in practice

Question 24

Why is hospice/PC MSW representation on ethics committee important?

Answer 24

our background in client self determination, person in environment, social justice, etc.

Question 25

ACP is an integral component of quality patient care and should not be seen as only appropriate at the EOL.
T/F
Ideally ACP conversations should only be brought up later in a serious illness trajectory?

Answer 25

False

Before individual is ill, or early in illness trajectory

Question 26

Common challenges in the ACP process
a. Many health care providers lack training for these conversations
b. Many health care providers lack a framework for understanding the influences on people’s health, wishes, and plans related to EOL
C. Gap remains in meeting need of under represented groups
D. ACP discussions not universally normalized
E. ALl of the above

Answer 26

E.
Pt’s worry discussion brought up “something you are not telling me” “You are doing this because I am dying”, “How long do I have” “Why Now”

Question 27

The most effective method to approach patients in facilitating ACP conversation is
A. Beginner’s mind
B. Cultivate an attitude of openness and lack of preoccupations
C. Use a lot of jargon and medical terms when explaining disease trajectory
D. Anticipate family members may have different goals and they change over time. determine POC jointly
E. Reassure all that goals and forms can be changed over time.

Answer 27

All but C

Question 28

What is involved in helping Pt and family determine plan of care jointly?

Answer 28

Help resolve contradictory goals which are held simultaneously
Help assist in prioritization of these goals

Question 29

Ideal ACP process for the Patient

Answer 29

1. Begin before you are ill
2. reflect on your values, beliefs, preferences, focus on what gives your life meaning
3. determine who you would trust to speak for you
4. Talk with this person and others who would be impacted by your decisions
5. Consider recording thoughts and sharing with those impacted to minimize family conflict, prevent misunderstandings
   6 complete AD, distribute copies to all impacted
   7 discuss preferences with health team
   8l review and update AD regularly.

Question 30

difference between competency and capacity

Answer 30

Competency: Legal, determined by judge, permanent, global, binary–all or none.

Capacity: Clinical, determined by provider, can wax and wane, decision-specific, sliding scale based on decision’s quality

Question 31

PSDA Patient self determination act passed in l991 was a direct result of the
A. Balmer case
B. Pentzer case
C. Cruzan case

Answer 31

C. Cruzan–allows Patients to make advance directives and have them honored by providing clear and convincing evidence (Pt’s wishes prior to losing decision making capacity)
Pt’s maintain autonomy when they lose decision making capacity

Question 32

It is quite common for family members to disagree with each other about various aspects of a patient’s care. Sometimes, this occurs due to poor communication among various parties. Of the following, which may be the most helpful approach to engaging all family members in optimal communication?
a. Ask the patient to speak individually to each of them.
b. Remind family members that all decisions belong to the patient.
c. Collaborate with the hospice counselor for further support.
d. Ask the patient to write a letter to each family member involved.

Answer 32

c.

Question 33

Jane is a 70-year-old with end-stage pancreatic cancer who states that she would like more information about preparing advanced directives. She has two adult daughters. One thinks she should continue with as much intervention as possible, and the other feels that Jane should focus on enjoying the time she has left instead of dealing with treatments and side effects. Jane does not think she wants further treatment, and is concerned that her wishes will not be honored.
378. Of the following, which option will provide the best support for honoring Jane’s wishes?
a. Make no changes to present plan of care.
b. Sign a Do Not Resuscitate form (DNR) and create a living will.
c. Create a living will and designate an appropriate Power of Attorney for Healthcare (POAHC).
d. Sign a Do Not Resuscitate form (DNR).

Answer 33

c - Creating a living will and designating an appropriate Power of Attorney for Healthcare (POAHC) is the option which will provide the best support for honoring Jane’s wishes. The POAHC may be one of her daughters, but does not have to be a family member. What is most important is that Jane select an individual who will honor her wishes, even if others provide pressure to do things differently. Creating a living will and/or signing a DNR will allow Jane to voice her wishes if she becomes unable to speak for herself. However, in most states, if the legal representative she designates does not agree with these wishes, they can still be rescinded by this party if Jane can’t speak for herself. Therefore, it is of utmost importance that the designated POAHC be someone she trusts implicitly to act on her behalf.

Question 34

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.

Answer 34

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.

Question 35

Jimmy has decided to sign a DNR form and ensure it is with him at all times and that his neighbors and friends are aware to ensure his wishes are followed. What must the nurse do to ensure the validity of the DNR form?
a. Obtain the patient’s, a witness’s and her own signatures.
b. Obtain the patient’s, a witness’s, and the hospice medical director’s signatures.
c. Obtain a verbal order from the patient’s attending physician, along with patient, witness, attending physician and her own signatures.
d. Obtain the patient’s signature only.

Answer 35

c - In order for a DNR order to be valid, it requires a verbal order from a physician, along with that physician’s signature, the patient’s, a witness and the nurse. If one of these items is missing or incomplete, the order is not considered to be official or valid. In the U.S., CPR and advanced cardiac life support (ACLS) will not be performed if a valid written “DNR” order is present. Many US states do not recognize living wills or health care proxies in the prehospital setting and prehospital personnel in those areas may be required to initiate resuscitation measures unless a specific state sponsored form is appropriately filled out and cosigned by a physician. State laws vary but typically emergency medical services personnel who are presented with a valid DNR form, signed by your doctor, or who identify a standard DNR bracelet on you, must comply with the DNR order