End-of-Life Care

Advance Care Planning

100

A 68-year-old man with a history of hypertension, hyperlipidemia, and tobacco abuse is evaluated in clinic for possible resection of a solitary lung nodule. He says he is amenable to surgery. When should an advance care planning discussion with this man take place?

What is NOW?

Advance care planning helps identify patients' values, goals, and preferences. It is important to facilitate ongoing discussions regarding patients' goals of care, especially in anticipation of new treatment plans or procedures.  

300

A 72-year-old man with a history of gastroesophageal reflux disease, morbid obesity, and nonalcoholic fatty liver disease is seen in clinic for evaluation of abdominal pain. He is diagnosed with biliary colic and elects to undergo cholecystectomy. When asked about his code status, the man tells you that he has never thought about it before but would be open to a discussion. What information would you want to outline in his advance directive?

What is Life-sustaining or life-prolonging interventions he wishes to avoid or receive?

500

Name the legal document, which must be (1) witnessed by someone who is neither a relative of the patient nor a health care provider and (2) notarized, records a patient’s choice of a designated proxy and authorizes one person to make the medical decisions on another’s behalf

What is Durable Power of Attorney for Healthcare, 

AKA Healthcare Proxy or HCPOA

700

Name the document expressing patient preferences for life-sustaining treatments and cardiopulmonary resuscitation (CPR) as well as for future medical care in general. Typically written to take effect in the setting of a terminal or profound illness/injury with limited chance for a recovery, these documents are often designed to limit heroic, invasive, and low-benefit interventions at the end of life

What is Living Will?

900

An 86-year-old woman is being treated for hyperactive delirium following emergency repair of an incarcerated femoral hernia. She is oriented only to person, not knowing where she is or who is with her. She is currently having visual hallucinations and cannot concentrate long enough to participate in a conversation. Who should make her medical decisions at this time?

A. The attending physician

B. The hospital's legal team

C. Her surrogate decision-maker

D. The palliative care team

E. The patient herself

What is C. Her surrogate decision maker?

End-of-life care for surgical patients

100

Measurement scale to assess functional decline in cancer patients

Palliative Performance Scale

300

You performed definitive surgery for a 25-year-old patient with stage 1 triple-negative BRCA2-positive breast cancer 2 years ago. She returns to your clinic today to ask your advice. She was found to have a locoregional recurrence as well as metastatic disease in her spine and both lungs about 3 months ago. She has been getting palliative chemoimmunotherapy from her medical oncologist since then. She was just discharged 2 weeks ago following a thoracentesis for malignant pleural effusion. She tells you she is very concerned because, over the past 4 to 5 weeks, she has lost her appetite, is requiring more assistance from her younger sister in the bathroom, and now “can hardly get out of the recliner.” She asks about her life expectancy and hospice, saying that her older brother had a good experience with hospice when he was dying of breast cancer. What is the most predictive factor regarding her life expectancy and hospice eligibility?

A. Her cancer’s BRCA2-positive and triple-negative status

B. Her recent malignant pleural effusion

C. Her medical oncologist’s estimate

D. Her recent rapid decline in function

E. Her disease progression on palliative chemoimmunotherapy

What is D. Her recent rapid decline in function?

The most important predictive factor in cancer prognosis is functional status, not disease, stage, or pathologic grade. Patients with most solid tumors (except some lung cancers) typically lose about 60% of functional ability in the last 3 months of life. The PPS is a good measure of how much a patient can do for themselves as well as their activity and energy level and is associated with time remaining in patients with solid tumors

500

71-year-old patient with rectal adenocarcinoma had an abdominoperineal resection and end colostomy 2 years ago. In the interim, she has developed widespread liver and lung metastases that have progressed despite chemotherapy. She is being seen in clinic for weight loss and fatigue. Since you saw her 4 months ago, she has lost 7% of her body weight and has gone from being able to cook and do light housekeeping to mainly sitting in a recliner and needing considerable assistance with her activities of daily living (ADLs) (her Palliative Performance Scale level has dropped from 90% to 50%). She has no nausea, vomiting, or abdominal pain, and her ostomy output has been soft, solid stool with regular gas. On physical exam, she is in no distress, she has generalized muscle atrophy, her abdomen is soft and non-distended, and the ostomy appears healthy. She reports that she does not have much appetite. Her family asks what you can do to improve her nutrition. What is most appropriate?

A. Discuss the risks and benefits of home TPN with the patient and family.

B. Prescribe megestrol as a trial and order imaging to determine her likely prognosis.

C. Deliver her poor prognosis, recommending a shift away from nutritional goals and toward comfort.

D. Prescribe an oral steroid, telling the patient and family that you hope it may improve her appetite and reverse her weight loss.

E. Place a PEG tube and start tube feedings.

What is C. Deliver her poor prognosis, recommending a shift away from nutritional goals and toward comfort.

700

An 84-year-old man with moderate dementia and recently diagnosed metastatic pancreatic adenocarcinoma is admitted with a malignant bowel obstruction and carcinomatosis. He does not have decision-making capacity, but both of his adult children are with him. What initial approach is most likely to help in the decision-making process regarding surgery?

A. Explain the pathophysiology and operative risks to the children so that they can make an informed decision.

B. Explain substituted judgment using the “empty chair” motif to alleviate the children’s decisional guilt.

C. Attend to each of the children’s emotions with empathic statements to alleviate their psychological distress.

D. Explain the various potential findings and ways to surgically fix the bowel obstruction and likely clinical course with each.

E. Request an oncology consult to offer medical treatment options.

What is B. Explain substituted judgment using the “empty chair” motif to alleviate the children’s decisional guilt.

Surrogate decision-makers (in this case the children) universally experience psychosociospiritual distress and emotional conflicts, including regularly feeling a burden of decisional guilt, which can be alleviated (at least partially) by prefacing all decisional discussions with explanations of how substituted judgment keeps the patient and his values at the center and focus of care. The “empty chair” motif (“Imagine… if your loved one were sitting right here [point to an empty chair], … listening to our conversation. What would he or she say?”) is highly effective at having surrogates merely fill the role of their sick loved one’s voice, rather than feeling they must make a decision for them.

900

A 79-year-old woman is found to have unresectable, metastatic pancreatic cancer. She presents to the office mentioning that, while she understands her diagnosis, she is in frequent pain that limits her ability to take deep breaths. The pain is midepigastric and gnawing in nature, radiating occasionally to her ribs. She has a single-lung metastasis and multiple metastases throughout her peritoneal cavity, as well as foci that nearly replace her right liver. She now has biliary obstruction, cachexia, and a life expectancy of about 3 months. The most appropriate next step in management is

A. Heated intraperitoneal chemotherapy

B. Pulmonary metastasectomy 

C. Transdermal pain patches

D. Celiac plexus neurolysis

E. Voluntary active euthanasia 

What is D. Celiac plexus neurolysis

Palliative treatment for unresectable pancreatic cancer should focus on making the diagnosis, relieving the symptoms of obstructive jaundice and duodenal obstruction, and controlling pain. These treatments should be accomplished with nonsurgical means whenever possible.

Goals of Care

100

You are caring for a 73-year-old patient in the ICU. They were admitted 7 days ago following a ground level fall, in which they suffered a severe traumatic brain injury with a large subdural hematoma. This required surgical decompression. In the subsequent week, the patient has shown very little cognitive recovery. Their Glasgow Coma Scale (GCS) score remains 3T, and their only neurologic functions are cough and gag reflexes. Overnight, they appear to have developed a ventilator-associated pneumonia with septic shock requiring very high doses of vasopressors to maintain adequate perfusion. You are concerned about worsening renal function, because the creatinine has tripled in the past 24 hours and urine output is very marginal despite volume resuscitation. The patient’s spouse is at the bedside and asks you to do “everything” to save their life. What is the best response to the spouse’s statement?

A. Accept this statement as a care directive and provide all possible medical interventions, including dialysis, to allow for patient survival.

B. Declare this medical situation to be futile and inform the patient’s spouse that you will not be providing care beyond the current support package and will not offer dialysis.

C. Use this statement as an opportunity to explore the patient’s goals and wishes more fully and initiate a discussion about scope of treatment limitations.

D. Initiate testing for death using neurologic criteria.

C. Use this statement as an opportunity to explore the patient’s goals and wishes more fully and initiate a discussion about scope of treatment limitations.

300

A 92-year-old woman with mild cognitive impairment is hospitalized after a hip fracture. Her family is worried about her being in the hospital alone and particularly concerned that she not be asked to make medical decisions because she often forgets details of conversations and the names of people who attend to her care needs. She is frequently disoriented to time and situation. How would you best explain the concept of decision-making capacity to this patient’s family?

A. It is synonymous with competence.

B. It is permanent and nonfluctuating.

C. It is determined by a court of law.

D. It is a definitive state and cannot change with the situation.

E. It reflects a person’s ability to make particular health care decisions at a given time.

E. It reflects a person’s ability to make particular health care decisions at a given time.

Capacity is determined by a physician and reflects the patient’s ability to make particular health care decisions at a given time. Capacity is not permanent; rather, it may fluctuate depending on a patient’s situation. People may have the capacity to make a given decision (such as who they would like to designate as their surrogate decision-maker) but not another (such as whether to have surgery or not). Also, someone who is delirious may lack capacity at that time but may regain capacity after recovering. If a patient can communicate choices, understand relevant information, appreciate a situation and its consequences, and manipulate information rationally, the patient may be deemed capable of making their own medical decisions, regardless of age. Capacity is different from competence, which is a legal term determined by a judge.

500

A 49-year-old patient with ALS had a PEG tube placed for artificial nutrition last year. He is now admitted with increasing hypoxia and breathlessness because of progression to his phrenic nerve roots. His spouse says that he now wants a tracheostomy so that he can be mechanically ventilated. You confirm this with the patient, who is using an eye-gaze speech-generating device. What is the most appropriate next step?

A. Agree to perform the tracheostomy to relieve his symptoms, exploring the point beyond which he would no longer find his life meaningful and recommend compassionate withdrawal of life support when he reaches that point.

B. Do not offer the tracheostomy, given that he would be ventilator-dependent for the rest of his life. Explain the progressive nature of his condition with the patient and family.

C. Recommend a multidisciplinary discussion about end-of-life care, including the cessation of artificial nutrition.

D. Manage the patient’s breathlessness and hypoxia with opioid medications and noninvasive positive pressure ventilation, but do not perform a tracheostomy.

A. Agree to perform the tracheostomy to relieve his symptoms, exploring the point beyond which he would no longer find his life meaningful and recommend compassionate withdrawal of life support when he reaches that point.

The patient and his spouse both agree, and tracheostomy would provide palliation while avoiding oral intubation, which is more uncomfortable. ALS is an incurable progressive motor neuron disorder that results in impaired verbal communication, dysphagia, and respiratory failure but does not typically result in cognitive decline. The main reason to perform any palliative surgery—including tracheostomy—is so that the patient may live better or live longer. Many patients with ALS find that as long as they can think and communicate with loved ones, their life has acceptable quality. Not offering a tracheostomy or recommending stopping artificial nutrition to a patient who has clearly grappled with these decisions is counter to their values regarding the treatment burden they are willing to accept. Decision-making about tracheostomy also provides an opportunity to reflect on what health states might not be acceptable for the patient and to outline them up front, along with “exit strategies” that will honor their dignity and prevent undue suffering.

700

A neurologist consults you to perform a tracheostomy and PEG tube placement in a 65-year-old patient who has ongoing dysphagia following a severe, large volume thrombotic stroke. Which is an appropriate approach?

A. Provide the family with all relevant statistics based on population-level outcomes and patient-specific parameters and empower the family to make their own decisions based on the available data.

B. Focus the discussion on the technical aspects of the procedure and potential complications since the patient’s neurologist would have already discussed indications and rationale.

C. Ask the family members what they think the patient would want in determining the appropriateness of these interventions to ensure that they are not imposing their own beliefs.

D. Talk with the patient’s other care team members including the neurologist, nurses, and social workers before engaging the family to understand the clinical scenario and anticipate the family’s preconceptions.

E. Wait to speak with the family until after social work or spiritual care has been consulted to attend to the families’ emotional needs.

D. Talk with the patient’s other care team members including the neurologist, nurses, and social workers before engaging the family to understand the clinical scenario and anticipate the family’s preconceptions.

900

A new patient is scheduled in clinic to discuss possible left hip replacement. She is a 79-year-old woman with a history of hypertension, chronic kidney disease (stage 3a), mild cognitive impairment, insomnia, depression, and osteoarthritis. She has a do-not-resuscitate order in place from a prior hospitalization. During your encounter, the woman says that she is hoping she can have surgery and go home the same day. She lives alone. What should you counsel the woman about during her visit?

A. Given her advanced age, she is at increased risk for delirium, physical deconditioning, and loss of independence during the perioperative period.

B. Given her advanced age, she should undergo surgery only if it will provide a definitive cure for her medical condition.

C. Despite her advanced age, her recovery time will likely be the same as that of a younger patient.

D. Because the woman already has a do-not-resuscitate (DNR) order in place, she does not need to readdress her goals of care.

E. Because the woman already has a DNR order in place, she does not need to name a surrogate decision maker.

A. Given her advanced age, she is at increased risk for delirium, physical deconditioning, and loss of independence during the perioperative period.

Palliative and Hospice Care

100

Describe palliative care

• Palliative care focuses on providing an added layer of support to patients and their families or caregivers when the patients are diagnosed with life-threatening illnesses.
• Palliative care has no time limits and should be continuous and synonymous with providing quality health care over the life span of patients.
• Palliative care focuses on management of pain and other symptoms related to all aspects of medical care (physical, spiritual, social, and psychological). Patients may still meet criteria for aggressive surgical interventions and operations if these pertain to goals of care related to this management.

300

Describe hospice care

• Hospice care generally refers to a philosophy of multidisciplinary care for patients at the end-of-life. Hospice care is best described as a holistic approach focusing on a patient and his or her support system (eg, family and caregivers) for providing improved quality of life (as opposed to quantity of life).
• The focus during hospice care is mainly on comfort with management of pain and other symptoms and assistance in the dying process, involving psychological, spiritual, and social closure. (In short, all hospice care is palliative care, but not all palliative care is hospice care.)

500

Name the notable side effects of opioid therapy

(At least 3)

• Constipation
• Nausea
• Sedation or confusion
• Respiratory depression
• Pruritus
• Neurotoxicity
• Prolonged QT interval

700

What end-of-life condition are these the four essential features for? 

• Disturbance of consciousness
• Acute onset
• Change of cognition or perceptual disturbance
• Usually with underlying medical cause (eg, infection)

What is Delirium?

900

Name some medical and interventional options for malignant SBO. (at least 3)

Endoluminal stenting, Decompressive PEG

Opiates (continuous abdominal pain)

Glycopyrrolate (crampy abdominal pain)

Metoclopramide (Nausea without cramps in partial MBO)

Haloperidol, Dexamethasone (nausea and vomiting)

Octreotide (Copious emeses refractory to opioid, anticholinergic, and antiemetic regimen)

The Dying Process

100

Name the 3 components of declaring a patient dead

• Lack of verbal/tactile stimuli response
• No heart beat or respiration
• Fixed pupils

300

What concept describes how the intent of the treatment is ethical even if potential side effects shortens the life of the patient

The Doctrine of Double Effect

• This is often seen during active dying when morphine is given to relieve severe dyspnea or secretions and in doing so respiratory function is reduced.
• In reality, hospice and palliative approaches rarely need to invoke the doctrine as titration of medications is generally possible without significant side effects.

500

A 63-year-old woman with CHF and oxygen-dependent COPD underwent a laparoscopic reduction and gastropexy for an acutely incarcerated paraesophageal hernia. She has been intubated for 10 days and is receiving enteral nutrition via gastrostomy. Her kidney function is rapidly deteriorating, and her family agrees with your recommendation to shift the focus of her care to comfort and compassionately withdraw the life support. What is the best withdrawal approach and why?

A. Use opioids sparingly after telling the family about the respiratory depressive effects of these drugs, which can hasten the woman’s death.

B. De-escalate code status to DNR/comfort and use opioids only after extubation to see if the woman can respond.

C. De-escalate code status to DNR/comfort and extubate the woman, giving opioids but no benzodiazepines because the combination of the two can depress respiratory drive more than opioids alone.

D. De-escalate code status to DNR/comfort and administer continuous opioids and benzodiazepines, after confirming that the family understands the principle of double effect.

E. Request a palliative care consult to manage the compassionate withdrawal of life support because this is not why you went into surgery.

D. De-escalate code status to DNR/comfort and administer continuous opioids and benzodiazepines, after confirming that the family understands the principle of double effect.

700

Examples of active dying signs 

(at least 3)

• Functional decline, completely bedridden, and no performance of activities of daily living
• Decreased food or drink desires with associated decrease in urine output
• More sleepiness and/or alerted circadian rhythm
• Difficulty swallowing
• Difficulty clearing oropharyngeal secretions (“death rattle”)
• Vivid dreams and visions (eg, hallucinations of deceased family members and friends)
• Severe cachexia (eyes may remain open when asleep due to loss of retro-orbital fat pad)
• Heightened awareness of environment even though appears asleep (important to conversations with/around patient)
• Delirium
• Incontinence of feces and/or urine
• Fever
• Change in respiratory patterns (slower or faster breaths) or apnea
• Peripheral mottling and/or cooling of legs and/or arms
• Usually fewer pain complaints

900

A 65-year-old patient with cirrhosis was admitted for hepatic encephalopathy. He is not a transplant candidate due to unmodifiable cardiac disease. Lacking curative options, his family opted for him to be placed on comfort care, and he remains in the hospital given the assessment that death is imminent. You are called by the nurse because of concerns that he is not managing his secretions. On examination, his eyes are closed, and he is unarousable but breathing spontaneously with an RR of 10, which is unchanged from earlier. Clear saliva is pooling in his mouth, and gurgling with respirations is audible. He is not using accessory muscles to breathe, and his muscles of facial expression are relaxed. What is the best next step?

A. Reassure the family and other caregivers.

B. Start atropine.

C. Schedule frequent oropharyngeal suctioning.

D. Order a barium swallow x-ray study.

E. Start continuous pulse oximetry and obtain a chest x-ray to evaluate for aspiration pneumonia.

A. Reassure the family and other caregivers.

This patient is not spontaneously swallowing his oral secretions, resulting in audible respirations. This is a normal phenomenon due to loss of the swallowing reflex with worsening encephalopathy at the end of life, not increased secretions. In the absence of signs of distress (he has a normal RR, is not using accessory muscles for breathing, and does not exhibit facial grimacing), no intervention is typically required