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A 78-year-old woman with end-stage chronic obstructive pulmonary disease is being discharged from the hospital to hospice after a prolonged admission for respiratory failure. She has moderate cognitive impairment and her daughter is her health care proxy. The patient has expressed in the past that she does not want to be on a ventilator again. The daughter is tearful and says, 'I know she wouldn't want this, but I'm not ready to let go.' Which action by the hospice medical director best supports the patient's autonomy while addressing the daughter's distress?
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1. A 78-year-old woman with end-stage chronic obstructive pulmonary disease is being discharged from the hospital to hospice after a prolonged admission for respiratory failure. She has moderate cognitive impairment and her daughter is her health care proxy. The patient has expressed in the past that she does not want to be on a ventilator again. The daughter is tearful and says, 'I know she wouldn't want this, but I'm not ready to let go.' Which action by the hospice medical director best supports the patient's autonomy while addressing the daughter's distress?
- Defer the goals-of-care discussion until the daughter is emotionally ready
- Explain that the patient's past statements are not legally binding and the daughter must decide
- Facilitate a family meeting to explore the daughter's fears and reaffirm the patient's values
- Recommend a trial of noninvasive ventilation to give the daughter more time
Answer: C
The best action is to facilitate a family meeting that explores the surrogate's emotional barriers while reaffirming the patient's expressed values, supporting both autonomy and family support. Deferring or recommending noninvasive ventilation may conflict with the patient's wishes. The daughter as proxy should follow the patient's known wishes, but her distress needs to be addressed.
2. A 68-year-old man with advanced heart failure is being recertified for hospice. He has a left ventricular assist device (LVAD) that was placed as destination therapy. He now has recurrent hospitalizations for driveline infections and frailty. The patient is alert and wants to continue aggressive antibiotic therapy but does not want to be hospitalized again. Which action is most appropriate for the hospice medical director?
- Transfer the patient to a higher level of care for IV antibiotics
- Deny recertification because the patient is receiving life-prolonging therapy
- Require the patient to deactivate the LVAD before recertification
- Recertify the patient and develop a plan for outpatient IV antibiotics and symptom management
Answer: D
Hospice can provide palliative care alongside therapies like antibiotics if the goals are comfort and quality of life. The patient's wish to avoid hospitalization can be honored with a home-based plan. Deactivation of the LVAD is not required for hospice eligibility, and denying recertification solely due to LVAD is inappropriate.
3. A 72-year-old woman with metastatic ovarian cancer is enrolled in hospice. She is from a culture where family members typically make medical decisions and do not disclose a poor prognosis to the patient. The patient's son, who is the primary caregiver, asks the medical director to withhold the terminal diagnosis from his mother. Which response best demonstrates cultural humility while preserving the patient's right to know?
- Agree to withhold the diagnosis to respect the family's cultural norms
- Insist on telling the patient the full prognosis, citing autonomy
- Explore the son's concerns and offer to discuss the diagnosis in a way that respects the patient's values and preferences
- Document the son's request and defer all discussions to him
Answer: C
The medical director should explore the family's perspective and seek a compromise that honors cultural values while assessing the patient's own preference for information. Blanket agreement or insistence on full disclosure may not serve the patient's best interest. The goal is to provide culturally sensitive care while respecting the patient's autonomy as much as possible.
4. A 65-year-old man with end-stage liver disease is enrolled in hospice. He is experiencing neuropathic pain from peripheral neuropathy. His current medications include gabapentin 1200 mg three times daily, hydromorphone 4 mg every 4 hours as needed, and lorazepam 1 mg every 6 hours as needed for anxiety. The patient has chronic kidney disease stage 4 (eGFR 25 mL/min). The family is concerned about increasing sedation. Which medication adjustment is most appropriate?
- Increase hydromorphone dose to control pain
- Reduce gabapentin dose and continue hydromorphone at current dose
- Switch hydromorphone to morphine for better pain control
- Add a tricyclic antidepressant for neuropathic pain
Answer: B
Gabapentin accumulates in renal impairment and can cause sedation; dose reduction is warranted. Hydromorphone is a safer opioid in renal failure compared to morphine, which has active metabolites. Adding a TCA may increase sedation risk. Increasing hydromorphone may worsen sedation without addressing the neuropathic component.
5. A 58-year-old woman with amyotrophic lateral sclerosis (ALS) is enrolled in hospice. She has significant dyspnea and anxiety. She is on noninvasive ventilation (NIV) at night and has a feeding tube. She is alert and wants to continue NIV. Her family is concerned that NIV is prolonging suffering. Which approach is most appropriate for the hospice medical director?
- Acknowledge the patient's choice to continue NIV and address symptom management
- Recommend discontinuing NIV because it is life-prolonging
- Refer to ethics committee for conflict resolution
- Suggest reducing NIV settings to ease anxiety
Answer: A
The patient's autonomy should be respected; NIV can be used for comfort even in hospice. The medical director should support the patient's choice and optimize symptom management. Discontinuing NIV against the patient's wishes is unethical. An ethics consult is not necessary unless there is a true ethical dilemma.
6. A 74-year-old man with advanced dementia is in a long-term care facility and enrolled in hospice. He has had recurrent urinary tract infections and now has a fever and hypotension. The attending physician wants to transfer him to the hospital for IV antibiotics. The patient's health care proxy (daughter) requests that he remain in the facility and receive comfort measures only. Which action best supports the patient's care plan?
- Agree with the attending physician and arrange transfer
- Support the daughter's decision and ensure a comfort care plan is in place
- Consult the ethics committee to resolve the conflict
- Call a family meeting to discuss the benefits of hospitalization
Answer: B
The health care proxy has the legal authority to make decisions based on the patient's known wishes. In advanced dementia, recurrent infections are often terminal events; comfort-focused care is appropriate. The medical director should support the proxy's decision and coordinate with the attending physician to avoid unnecessary hospitalization.
7. A 62-year-old woman with end-stage chronic obstructive pulmonary disease is in a rural home hospice setting. She lives with her husband, who is her primary caregiver and has significant hearing loss. The patient develops sudden severe dyspnea and anxiety. The hospice nurse calls the medical director for guidance. The patient has a standing order for morphine 5 mg sublingual every 1 hour as needed for dyspnea. Which instruction is most appropriate?
- Recommend a higher dose of morphine, such as 10 mg, to ensure symptom relief
- Instruct the husband to give the morphine and call 911 if no improvement
- Administer morphine 5 mg sublingual now and reassess in 15 minutes
- Ask the nurse to arrange for immediate hospitalization
Answer: C
In a dyspnea crisis, the first step is to use the standing order for immediate symptom relief. The nurse can administer the medication and reassess. Increasing the dose without assessment is unsafe. Hospitalization may be unnecessary if symptoms can be controlled at home. The husband's hearing loss is not relevant to medication administration.
8. A 70-year-old man with terminal cancer is enrolled in hospice. He is on a continuous subcutaneous infusion of morphine for pain. The family reports that he is increasingly agitated and has myoclonus. The medical director suspects morphine toxicity due to renal impairment. Which action is most appropriate?
- Rotate to an equianalgesic dose of hydromorphone and reduce the rate
- Increase the morphine infusion to control pain
- Add a benzodiazepine to control agitation
- Discontinue opioids and rely on nonpharmacologic measures
Answer: A
Myoclonus and agitation in a patient on morphine, especially with renal impairment, suggest neurotoxicity from active metabolites. Opioid rotation to hydromorphone is appropriate. Increasing morphine or adding a benzodiazepine would worsen the problem. Discontinuing opioids may cause pain and withdrawal.
9. A 68-year-old woman with advanced heart failure is enrolled in hospice. She is experiencing dyspnea at rest despite optimal medical management. She is on furosemide, lisinopril, and metoprolol. The medical director considers adding an opioid for dyspnea. Which factor is most important to discuss with the patient and family?
- Opioids may cause respiratory depression
- Opioids are not effective for dyspnea in heart failure
- Opioids may cause constipation and sedation
- Opioids are contraindicated with lisinopril
Answer: C
Opioids are effective for dyspnea in palliative care. The main side effects to discuss are constipation and sedation, which can be managed. Respiratory depression is rare with appropriate dosing. Opioids are not contraindicated with lisinopril.
10. A 55-year-old man with end-stage liver disease is enrolled in hospice. He has ascites and jaundice. He is experiencing significant pruritus. Which non-pharmacologic intervention is most appropriate to recommend?
- Warm baths to soothe the skin
- Cool compresses and moisturizing lotion
- Exposure to sunlight to reduce bilirubin
- High-protein diet to improve liver function
Answer: B
Pruritus in liver disease can be managed with cool compresses, moisturizers, and avoiding heat. Warm baths may worsen itching. Sunlight and high-protein diet are not effective and may be harmful.
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