The End-of-Life Care Continuing Medical Education activity covers pain management, non-pain symptoms, and ethical frameworks in patients with chronic illness using WHO management guidelines. An overview of ethics and empathy training in this activity is an asset to any physician's toolkit.
By learning from 25 case-based questions, you will not only gain the knowledge to better care for your patients, but also earn 2 AMA PRA Category 1 Credits™ in the process.
Upon completion of this activity, participants should be able to
A 76-year-old female Italian immigrant and widow presents to her physician inquiring about hospice care. She has heart failure, mild hypertension, and sleep apnea. She has noted that over the last month, her legs are more swollen, and she is having difficulty walking to church and the grocery store. She still keeps an impeccable home, managing her house cleaning herself, but now is sitting down for a longer period of time after carrying the vacuum up and down the stairs. She is also able to maintain her daily rituals of reading and cooking. She no longer wishes to return to the hospital, and has not been admitted since her myocardial infarction 5 years ago, which preceded her diagnosis of heart failure. She wishes to remain full code. She uses CPAP at night for her sleep apnea but otherwise does not require oxygen. Her home medications include furosemide 10mg BID, atenolol 50mg daily, lisinopril 10mg daily, simvastatin 5mg daily, and aspirin 81mg daily. She also has nitroglycerin 0.4mg sl prn (which she has not used since her MI) and uses acetaminophen 325mg “once in a while for an ache.” Why would this patient not be admitted to hospice?
Answer: C. She has a >6-month prognosis.
Hospice is available for any patient who is terminally ill and chooses a palliative-care approach. Because of the close relationship that primary care physicians often have with their patients, they are in a unique position to provide end-of-life care, which includes recognizing the need for and recommending hospice care when appropriate. The hospice benefit covers all expenses related to the terminal illness, including medication, nursing care, and equipment. Hospice should be considered when a patient has New York Heart Association class IV heart failure, severe dementia, activity-limiting lung disease, or metastatic cancer. Timely referrals are beneficial to both patient and hospice because of the cost related to initiating services and the time required to form a therapeutic relationship. Prognostication for heart failure is more scrutinized and difficult under hospice guidelines. Her current NYHA class is 2, due to increased symptoms with activity. In addition, her medical management can still be adjusted, likely with good response. In order to be admitted to hospice, a patient must have a <6-month prognosis. Since she still is independent in all ADLs including thorough house cleaning without becoming dyspneic, it is not reasonable to say she has <6-month prognosis. To qualify for visiting nursing services, a patient must be homebound, but no such requirement exists for hospice. Additionally, patients may choose to be full code on hospice. Medicare does not require a 24-hour caregiver to be present in order for the patient to receive hospice services.
Weckmann, Michelle. The Role of the Family Physician in the Referral and Management of Hospice Patients. Am Fam Physician. 2008 Mar 15;77(6):807-812.
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The University of Nebraska Medical Center, Center for Continuing Education is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The University of Nebraska Medical Center, Center for Continuing Education designates this Internet Enduring Material for a maximum of 2 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Further End Of Life Care CME info found here.
This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the University of Nebraska Medical Center, Center for Continuing Education and Board Vitals.