ABEM HPM cheat sheet

Palliative care is interdisciplinary care that improves quality of life for patients and families facing serious illness by addressing physical, psychosocial, and spiritual needs; it is offered with disease-directed therapy and is not prognosis-limited.

Hospice in the US is a Medicare benefit for patients with a prognosis of 6 months or less if the terminal illness runs its usual course, who elect comfort-focused care and forgo curative treatment for that terminal diagnosis.

The surprise question asks whether the clinician would be surprised if the patient died within 12 months; it has low sensitivity and should be combined with functional decline, weight loss, and utilization data.

The Palliative Performance Scale ranges from 0% to 100% across ambulation, activity, self-care, intake, and consciousness; scores of 50% or less are associated with substantially limited survival.

Goals-of-care discussions should first assess the patient's understanding and values, then identify acceptable functional states and tradeoffs, before recommending a treatment plan and documenting a surrogate decision-maker.

The core interdisciplinary team includes medicine, nursing, social work, chaplaincy, pharmacy, and bereavement support; coordination improves symptom control and reduces unwanted transitions.

Medication reconciliation at transitions should review indications, anticholinergic burden, renal and hepatic dosing, and deprescribing opportunities for preventive drugs with limited benefit near end of life.

Symptom screening with a validated tool such as the Edmonton Symptom Assessment System should occur at baseline and intervals; scores guide reassessment but do not replace clinical evaluation.

Pain assessment should characterize location, quality, radiation, timing, intensity, aggravating and relieving factors, functional impact, and the patient's meaning of pain.

Use a validated self-report scale when possible: 0-10 numeric rating scale in adults, Wong-Baker Faces in children, and PAINAD or Abbey Pain Scale for advanced dementia.

For nonverbal or critically ill adults, use behavioral tools such as CPOT or BPS; physiologic signs alone are not reliable pain measures.

In opioid-naive adults, start a short-acting opioid at a low dose and titrate to effect; the approximate oral-to-IV morphine ratio is 3:1, with wide interpatient variation.

A breakthrough pain dose is commonly 10%-20% of the total daily opioid dose, given as needed and reassessed; frequent breakthrough use prompts recalculation of the basal dose.

Opioid switching requires equianalgesic calculation and an empiric 25%-50% dose reduction for incomplete cross-tolerance, then titration based on response.

Constipation from opioids does not resolve with tolerance; prophylactic stimulant laxatives, with or without osmotic agents, are standard, and methylnaltrexone is an option for refractory cases.

Neuropathic pain may respond to gabapentinoids, duloxetine, or tricyclics; corticosteroids can relieve pain from bone metastases, malignant bowel obstruction, and raised intracranial pressure.

Avoid meperidine because of neurotoxic metabolites; use caution with methadone for QT prolongation and with transdermal fentanyl in fever or external heat exposure.

Dyspnea in advanced illness is treated with low-dose opioids when nonpharmacologic measures fail; supplemental oxygen is indicated for hypoxemia, not routinely for normoxemic breathlessness.

Nausea management is etiology-directed: metoclopramide for gastric stasis, haloperidol or olanzapine for chemical and metabolic causes, 5-HT3 antagonists for chemotherapy, and octreotide or anticholinergics for obstruction.

Constipation assessment includes opioid use, hydration, mobility, hypercalcemia, and spinal cord compression; bulk-forming agents are poorly tolerated with low fluid intake.

Delirium is identified with the Confusion Assessment Method and managed first by treating causes such as pain, constipation, urinary retention, medications, infection, and metabolic derangement.

Antipsychotics are used for distressing delirium with psychosis or agitation; benzodiazepines are avoided except in alcohol or benzodiazepine withdrawal.

Malignant bowel obstruction may be managed with octreotide, dexamethasone, antiemetics, and analgesics; surgery or stenting is considered for selected patients with favorable prognosis.

Anorexia-cachexia has limited drug benefit; megestrol or dexamethasone may stimulate appetite but carry thrombotic, adrenal, and metabolic risks, so goals and family expectations should be clarified.

Terminal secretions are managed with repositioning, oral care, and anticholinergics such as glycopyrrolate or scopolamine; evidence for medication benefit is limited.

Hiccups persisting in serious illness may respond to chlorpromazine, baclofen, metoclopramide, or gabapentin after reversible causes are addressed.

The SPIKES framework structures bad-news conversations: setting, perception, invitation, knowledge, emotions, and strategy or summary.

Ask-Tell-Ask elicits the patient's perspective, delivers information in small chunks, and checks understanding before proceeding.

NURSE statements respond to emotion by naming, understanding, respecting, supporting, and exploring the patient's experience.

Prognostic information can be framed as best case, worst case, and typical case, which helps patients and families plan across a range of outcomes.

Advance care planning should document a health care proxy, values, and treatment preferences; POLST or MOLST forms convert preferences into portable medical orders for seriously ill patients.

Decisional capacity requires understanding, appreciation, reasoning, and communication of choice; it is decision-specific, while competence is a legal status.

When capacity is absent, the surrogate decision-maker follows state hierarchy and should use substituted judgment or, when unknown, best interests.

Teach-back and professional interpreters improve comprehension; avoid using family members as interpreters for complex goals-of-care discussions when possible.

Code status alone is insufficient; discussions should address CPR, mechanical ventilation, hospitalization, artificial nutrition and hydration, and symptom-focused alternatives.

Spiritual screening tools include FICA (faith, importance, community, address in care) and HOPE (hope, organized religion, personal spirituality, effects on care).

Spiritual distress is associated with worse quality of life and may present as loss of meaning, despair, guilt, or conflict with religious beliefs; chaplain referral is appropriate.

Caregiver burden includes physical, emotional, financial, and social strain; validated tools such as the Zarit Burden Interview can guide support and respite planning.

Normal grief varies culturally; prolonged grief disorder involves persistent yearning or preoccupation with impairment, generally at least 12 months in adults and 6 months in children.

The Kleinman explanatory model asks what the patient calls the illness, its cause, why it started, how it affects life, and what treatment is expected.

Depression in serious illness is common and treatable; screen with PHQ-9 or clinical interview, distinguish from grief, and consider SSRIs, psychostimulants, or psychotherapy.

Cultural humility requires asking about language, decision-making roles, religious practices, and preferences for disclosure rather than assuming group norms.

Meaning-centered and dignity-therapy approaches can reduce existential distress by helping patients articulate values, legacy, and sources of meaning.

Active dying may be signaled by somnolence, reduced oral intake, dysphagia, mottled skin, cool extremities, irregular breathing, terminal secretions, and oliguria.

In the final days, discontinue nonbeneficial medications, laboratory tests, and monitoring; convert essential symptom medications to subcutaneous, sublingual, rectal, or transdermal routes.

Terminal secretions are not routinely harmful; repositioning, mouth care, and anticholinergics may reduce noise, but suctioning is often avoided unless distress is clear.

Terminal agitation requires assessment for pain, urinary retention, constipation, and delirium before antipsychotics or benzodiazepines are used for refractory distress.

Artificial nutrition and hydration are not routinely beneficial in the imminently dying; decisions should follow patient values and may reduce fluid overload, dyspnea, and secretions.

Palliative sedation may be used for refractory severe suffering; it requires informed consent, proportional titration, and documentation of the indication and goal.

Death pronouncement includes confirming unresponsiveness, absent breath and heart sounds, fixed pupils, and documenting the time and circumstances.

US Medicare hospice programs must provide bereavement support to the family for at least 13 months after death.

The four core principles are autonomy, beneficence, nonmaleficence, and justice; conflicts among them are common in end-of-life decisions.

Informed consent requires disclosure, understanding, decisional capacity, and voluntariness; consent for a surrogate uses substituted judgment or best interests.

Withholding and withdrawing life-sustaining treatment are generally considered ethically equivalent when consistent with the patient's values.

The double-effect principle permits an intervention intended to relieve suffering even if a foreseeable harmful effect such as respiratory depression may occur.

Medical aid in dying is legal only in specific jurisdictions with strict eligibility and safeguards; clinicians may decline participation and should know referral and conscientious objection rules.

Futility disputes may be addressed through ethics consultation, institutional policy, time-limited trials, and legal processes when consensus cannot be reached.

Capacity is a clinical determination; competence is a legal determination made by a court.

HIPAA permits disclosure for treatment, payment, and operations; minimum necessary standards apply, and abuse reporting may be required by state law.

Advance directives may name a surrogate and state preferences but are not physician orders; POLST-type forms are actionable orders that travel with the patient.

US Medicare hospice eligibility requires physician certification of a prognosis of 6 months or less, election of the hospice benefit, and waiver of curative treatment for the terminal diagnosis.

The Medicare hospice benefit has two 90-day periods followed by unlimited 60-day periods; recertification and face-to-face encounters are required at specified intervals.

Hospice levels of care are routine home care, continuous home care, general inpatient care, and inpatient respite care; each has distinct eligibility and payment rules.

The interdisciplinary group must review and update the hospice plan of care at least every 15 days and include physician, nursing, social work, and chaplain representation.

Palliative care billing may use advance care planning codes 99497 and 99498, prolonged service codes, and team conference codes when documentation supports time and medical necessity.

Hospice quality reporting includes the Hospice Item Set and CAHPS Hospice Survey; programs track pain, dyspnea, family experience, and care transitions.

Quality-improvement methods include PDSA cycles, root cause analysis, and run charts; useful metrics include symptom scores, ED visits, hospice length of stay, and live discharge rates.

Palliative care programs may be consultative, inpatient units, home-based, or clinic-based; staffing models must match acuity, setting, and reimbursement.

Compliance risks in hospice include unsupported eligibility, inadequate recertification documentation, inappropriate live discharges, and billing for noncovered services.