Hospice Flashcards
Dame Cecily Saunders
Founder of the modern hospice movement
What year was the first hospice founded in the United States?
In 1974, Florence Wald, two pediatricians, and a chaplain founded the first hospice in the US Connecticut Hospice in Branford, CT.
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
D
. 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 - 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
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
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.
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has been stable, he has been increasingly withdrawn.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.
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
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
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.
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 - 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.
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
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
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
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
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 - 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
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
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
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
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.
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
. 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
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”.
. 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.
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.
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
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
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
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
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
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.
. 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.
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.
296a - Clinicians often use the pleasantness/comfort of the reported experiences to differentiate between nearing death awareness and delirium
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
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.
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.
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.
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.
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.
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.
. 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.
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.
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
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.
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
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
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
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
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
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.
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).
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.
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.
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.
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
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
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.
. 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.
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
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.
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
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
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
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.
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
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
