ABFM Palliative Care common mistakes
ABFM Palliative Care · Understand the traps and how to avoid them.
On prognosis questions, selecting a single-point survival estimate (for example, "about three months") instead of a range with explicit uncertainty, and treating the six-month hospice threshold as a prediction rather than an eligibility rule.
Exam habits favor a definite answer, and staging language trains candidates to give point estimates rather than probabilistic ranges.
What to do instead
Frame prognosis as median plus best-case and worst-case ranges, tie it to performance status and disease trajectory, and separate "would I be surprised if this patient died in 12 months?" from the statutory hospice eligibility criterion.
Rotating opioids using the equianalgesic table at the full calculated dose, for example converting morphine 30 mg PO to hydromorphone 6 mg PO and starting all 6 mg without reduction.
Candidates memorize the table but forget incomplete cross-tolerance and confuse oral-to-parenteral ratios.
What to do instead
Always reduce the equianalgesic dose by 25% to 50% (more in frail or renally impaired patients), then titrate to effect; recalculate oral-to-parenteral morphine at 3:1 and document the conversion.
Treating terminal agitation as anxiety and starting lorazepam in a dying patient with myoclonus and fluctuating attention, without screening for delirium.
Terminal delirium overlaps with anxiety and restlessness, and benzodiazepines feel intuitively calming.
What to do instead
Screen with the CAM or Nu-DESC, stop deliriogenic drugs, treat reversible causes, and use haloperidol first-line unless the patient has Parkinson disease or Lewy body dementia; reserve benzodiazepines for withdrawal or catatonia.
When a patient says, "I am going to beat this," immediately reviewing stage, prognosis, and treatment failure instead of first exploring the patient's understanding and emotion.
Clinicians have an informational reflex and are uncomfortable sitting with strong emotion.
What to do instead
Use NURSE statements (name, understand, respect, support, explore), then ask-tell-ask; elicit what the patient already knows and wants to know before giving prognostic data.
Using a bilingual family member, often an adult child, to interpret a goals-of-care or bad-news conversation instead of a trained medical interpreter.
It is convenient, preserves trust, and candidates underestimate how filtering and role reversal distort information.
What to do instead
Arrange a trained medical interpreter, avoid using minors, speak directly to the patient, document interpreter use, and confirm understanding with teach-back.
Continuing dialysis or other life-sustaining treatment because the family insists, even though a patient with decisional capacity has clearly refused it.
Candidates conflate family-centered care and beneficence with autonomy, and fear conflict.
What to do instead
Document capacity, honor the capacitated patient's refusal, use substituted judgment only when capacity is absent, and request ethics consultation when family and patient conflict.
Electing hospice for a nursing home resident with advanced dementia without documenting FAST stage 7c or a qualifying complication, or for heart failure without NYHA class IV or an ejection fraction below 20%.
Training is cancer-centric, and candidates apply cancer hospice criteria to non-cancer diagnoses.
What to do instead
Memorize non-cancer hospice eligibility: dementia FAST 7c or beyond, CHF NYHA IV with EF below 20%, COPD with FEV1 below 30%, and document the supporting functional decline.
Planning to continue intravenous chemotherapy with curative intent after the patient elects the Medicare hospice benefit.
Candidates are unfamiliar with hospice benefit rules and assume all usual care continues.
What to do instead
Know that hospice covers palliative care only; curative treatment requires forgoing or revoking hospice, while palliative chemotherapy, radiation, and transfusions may still be covered.
Waiting until curative options are exhausted before consulting pediatric palliative care, or telling parents that palliative care means stopping treatment.
The adult "either cure or comfort" model is mistakenly applied to children.
What to do instead
Explain that pediatric palliative care is concurrent from diagnosis, is compatible with disease-directed therapy, and that perinatal palliative care should be offered antenatally for lethal anomalies.
Diagnosing major depression two weeks after a death or routinely referring every bereaved caregiver to psychiatry.
Candidates do not distinguish normal grief from prolonged grief disorder and over-pathologize acute sadness.
What to do instead
Normalize waxing and waning grief, screen with the PG-13, and apply DSM-5-TR prolonged grief disorder timing: at least 12 months in adults and 6 months in children, with targeted support rather than universal referral.