ACHPN cheat sheet

Medicare hospice Conditions of Participation require an interdisciplinary group (IDG) that includes a physician, an RN, a social worker, and a chaplain or spiritual counselor; the IDG reviews and updates each patient's plan of care at least every 15 days.

Hospice volunteer services must be documented, and volunteer hours must equal at least 5% of total patient care hours under the Medicare hospice benefit.

Four Medicare hospice levels of care: routine home care; continuous home care for a crisis (at least 8 hours of care in a 24-hour period, more than half provided by an RN); general inpatient care for uncontrolled symptoms; and inpatient respite care limited to 5 consecutive days.

National Consensus Project palliative care domains: structure and processes of care; physical; psychological and psychiatric; social; spiritual, religious, and existential; cultural; care of the patient nearing end of life; ethical and legal aspects.

Total pain (Cicely Saunders) has four components - physical, psychological, social, and spiritual; refractory pain that resists opioid titration usually has a nonphysical driver that must be identified and treated.

Role mapping on the team: physician or NP for eligibility, certification, and complex symptom management; RN for assessment and case management continuity; social worker for psychosocial, financial, legal, and caregiver resources; chaplain for spiritual and existential assessment.

A face-to-face encounter by a hospice physician or NP is required within the 30 days before the start of the third and later benefit periods, and the encounter must be related to the terminal condition.

Structured handoff tools (SBAR: Situation, Background, Assessment, Recommendation) reduce omission errors when care transfers between team members or settings.

SPIKES framework for serious news: Setting up the conversation, assessing the patient's Perception, obtaining an Invitation, giving Knowledge in small chunks, responding to Emotions, and summarizing a Strategy.

NURSE statements for responding to emotion before delivering more information: Naming, Understanding, Respecting, Supporting, and Exploring.

Ask-Tell-Ask: elicit what the patient already knows and wants to know, give a small amount of information, then check understanding before continuing.

The core domains of a goals-of-care conversation are code status, intubation and mechanical ventilation, hospitalization and ICU transfer, artificial nutrition and hydration, and preferred place of death.

Advance directive categories: living will (stated treatment preferences), durable power of attorney for health care (designates a surrogate), and portable clinician orders (POLST/MOLST) that translate goals into actionable orders for seriously ill patients.

POLST is intended for patients with serious illness or frailty, not for healthy adults, and it travels with the patient across care settings as a signed medical order.

Teach-back (asking the patient to restate the plan in their own words) is the standard check for comprehension; qualified medical interpreters must be used rather than family members.

Plain-language rule: limit a single conversation to about three key messages and confirm understanding, since average adult health literacy in the United States is below high-school reading level.

WHO three-step analgesic ladder: step 1 non-opioid with or without adjuvant; step 2 weak opioid for mild-moderate pain; step 3 strong opioid for moderate-severe pain; adjuvant analgesics may be added at any step.

Anchor equianalgesic conversions: morphine 10 mg parenteral = 30 mg oral; hydromorphone 1.5 mg parenteral = 7.5 mg oral; oxycodone 20 mg oral is roughly equal to morphine 30 mg oral; fentanyl 25 mcg/h transdermal is roughly equal to 60 mg oral morphine per 24 hours (published tables vary).

Breakthrough dose = approximately 10-20% of the total 24-hour scheduled opioid dose, offered as needed and reassessed at the drug's expected peak effect.

Opioid rotation rule: reduce the calculated equianalgesic dose by about 25-30% when switching drugs, because of incomplete cross-tolerance, then titrate to effect.

Renal failure: morphine's active metabolites accumulate and cause myoclonus and sedation; prefer fentanyl, hydromorphone, or methadone. Meperidine is avoided because normeperidine accumulation lowers the seizure threshold.

Every scheduled opioid requires a bowel regimen (stimulant with or without an osmotic agent); methylnaltrexone or naloxegol are options for refractory opioid-induced constipation.

Adjuvant selection: gabapentinoids, duloxetine, or nortriptyline for neuropathic pain; dexamethasone for bone pain, capsular liver pain, or nerve compression; NSAIDs for somatic and inflammatory pain; ketamine for refractory pain.

Assessment: 0-10 numeric rating scale for adults, Wong-Baker FACES for children, and observational tools such as PAINAD (breathing, vocalization, facial expression, body language, consolability) or FLACC for nonverbal patients.

Opioid-induced respiratory depression in a tolerant patient is managed with diluted, titrated naloxone (e.g., 0.04-0.1 mg IV increments) to restore ventilation without precipitating severe withdrawal or reversing analgesia.

Dyspnea: low-dose opioids are first-line, supported by a handheld fan and treatment of reversible causes; supplemental oxygen has clear benefit mainly when hypoxemia is documented (SpO2 below about 90%).

Nausea is treated by mechanism: haloperidol or olanzapine for chemical/metabolic causes, metoclopramide for gastric stasis, ondansetron for chemotherapy or radiation, scopolamine or octreotide for obstruction.

Constipation: stimulant laxative (senna) plus an osmotic agent (polyethylene glycol); bulk-forming agents are avoided when oral intake is poor or obstruction is suspected.

Delirium: nonpharmacologic measures first (orientation, glasses and hearing aids, bowel and bladder care, medication review); haloperidol 0.5-2 mg or olanzapine 2.5-5 mg for distressing symptoms, always alongside a search for reversible causes.

Terminal respiratory secretions: anticholinergics such as glycopyrrolate 0.2 mg subcutaneously every 4-6 hours or scopolamine; deep suctioning is avoided because it is uncomfortable and usually ineffective.

Hypercalcemia of malignancy: intravenous fluids plus a bisphosphonate such as zoledronic acid; calcitonin adds a faster but short-lived effect; monitor for confusion, constipation, and polyuria.

Depression near end of life: psychostimulants such as methylphenidate act within days, whereas SSRIs require 2-4 weeks, so stimulants are often chosen when prognosis is short.

Malignant bowel obstruction: octreotide plus dexamethasone with symptom control; prokinetics are avoided when obstruction is complete.

Seizures: benzodiazepines for acute control; levetiracetam or phenobarbital for prophylaxis; dexamethasone for vasogenic edema or raised intracranial pressure.

Use validated screening instruments rather than impression alone: PHQ-2/PHQ-9 for depression, GAD-7 for anxiety, and a distress thermometer for overall psychosocial distress.

FICA spiritual history: Faith or belief, Importance of those beliefs, spiritual Community, and how the patient wants these Addressed in care.

HOPE spiritual assessment: sources of Hope, Organized religion, Personal spirituality and practices, and Effects on medical care and end-of-life decisions.

Distinguish grief from depression: grief comes in waves with longing and preserved self-esteem; depression shows persistent anhedonia, worthlessness, and global hopelessness.

Cultural humility replaces static cultural competence: ask about language preference, who should receive information, decision-making role of family, ritual needs at death, and beliefs about food, hydration, and disclosure.

Dignity-conserving care (Chochinov) organizes assessment into illness-related concerns, a dignity-conserving repertoire (personal and interpersonal), and a social dignity inventory.

Caregiver assessment covers objective burden, subjective burden, financial strain, and physical capacity; the Zarit Burden Interview is a commonly used structured measure.

Patients from stigmatized or minority groups may carry mistrust from prior discrimination; confidentiality, chosen family, and explicit nonjudgmental language support engagement.

Trajectory signs: months - functional decline and falling palliative performance score; weeks - bedbound, minimal oral intake, withdrawal; days - mottling, Cheyne-Stokes respirations, oliguria, cool extremities; hours - terminal secretions and apneic pauses.

Discontinue non-beneficial interventions near death: routine labs and vitals, glucose monitoring, preventive medications such as statins, and long-term bisphosphonates; convert essential medications to subcutaneous or intravenous routes when swallowing fails.

Assemble a symptom kit for home or inpatient use: an opioid, a benzodiazepine, an antipsychotic, an anticholinergic, and acetaminophen, all available as needed.

Palliative sedation is intentional reduction of consciousness for refractory suffering and is distinguished from euthanasia by the intent (comfort), proportionality of dose, and the absence of intent to cause death.

Rule of double effect conditions: the act is morally good or indifferent, the bad effect is not intended, the bad effect is not the means to the good effect, and there is proportionate reason.

Opioid titration to relieve dyspnea or pain at end of life is not associated with shortened survival in the tolerant patient; fear of hastening death is not a reason to leave symptoms untreated.

After death: verify absence of heart sounds and respirations, record the time, notify the attending and family, remove tubes and lines as culturally appropriate, and honor rituals such as opening a window or allowing time with the body.

Reportable deaths are those that are unexpected, accidental, suicidal, homicidal, or raise suspicion of abuse; these are referred to the medical examiner or coroner rather than signed out by the hospice physician.

Postmortem changes useful in documentation: livor mortis begins within about 1-2 hours, rigor mortis within about 2-4 hours starting at the face and neck, and algor mortis is the gradual cooling of the body.

Worden's four tasks of mourning: accept the reality of the loss, process the pain of grief, adjust to a world without the deceased, and find an enduring connection while moving forward.

Dual-process model (Stroebe and Schut): adaptation involves oscillation between loss-oriented grief work and restoration-oriented coping with daily life and new roles.

Prolonged grief disorder (DSM-5-TR): persistent, disabling longing or preoccupation with the deceased, plus associated symptoms, lasting at least 12 months after the death in adults and 6 months in children.

High-risk bereavement factors: sudden, violent, or stigmatized death; death of a child; prior psychiatric history or substance use; multiple recent losses; poor social support; and heavy caregiving strain.

Medicare hospice Conditions of Participation require bereavement counseling for the family for up to 1 year after the death, and bereavement services are a covered benefit even if the family declines them initially.

Disenfranchised grief (Doka) is grief that is not openly acknowledged or socially supported, such as after the death of a partner in a hidden relationship, a pet, or a person who died of a stigmatized cause.

Anticipatory grief before an expected death does not replace or reliably reduce later grief; the two can coexist and each warrants separate support.

Supportive presence, psychoeducation about normal grief, and meaning reconstruction help most bereaved people; targeted psychotherapy (complicated grief treatment, CBT) is indicated for prolonged grief disorder.

Four ethical principles: autonomy (respect for the patient's choices), beneficence (act for the patient's good), nonmaleficence (avoid harm), and justice (fair allocation of resources).

Elements of informed consent: decision-making capacity, adequate disclosure, comprehension, and voluntariness, documented in the record.

Medicare hospice eligibility: prognosis of 6 months or less if the illness follows its expected course; two initial 90-day benefit periods followed by unlimited 60-day periods, each requiring recertification.

The Medicare hospice benefit covers nursing, physician services, social work, chaplaincy, drugs and biologicals related to the terminal diagnosis, durable medical equipment, respite care, and bereavement; the patient waives Medicare coverage for curative treatment of the terminal condition.

A patient may revoke the hospice benefit at any time; revocation must be in writing and takes effect on the date it is made, after which the patient resumes standard Medicare coverage.

Surrogate decision-making hierarchy generally proceeds guardian, then health care agent, then spouse, then adult children, then parents, then siblings, with exact order set by state statute.

Capacity is a clinical determination requiring four abilities: understanding the information, appreciating the consequences, reasoning about options, and expressing a consistent choice; competence is a legal status decided by a court.

Voluntarily stopping eating and drinking (VSED) and proportionate palliative sedation are ethically and legally accepted in the United States; euthanasia and physician-assisted death are legal only in states that have enacted specific statutes.

HIPAA permits disclosure of protected health information for treatment, payment, and health care operations, and requires authorization for other uses; minimum necessary applies to each disclosure.

PDSA (Plan-Do-Study-Act) is a rapid-cycle improvement method: test a small change, study the result, then adopt, adapt, or abandon it before the next cycle.

Quality improvement versus research: QI aims to improve local practice and usually requires no IRB review; research aims at generalizable knowledge and requires IRB oversight and informed consent.

Root cause analysis is retrospective and used after a sentinel event; failure mode and effects analysis (FMEA) is prospective and used to identify risk before harm occurs.

Evidence hierarchy, from strongest to weakest: systematic reviews and meta-analyses, randomized controlled trials, cohort studies, case-control studies, case series, and expert opinion.

Teach-back and direct observation of skill (competency validation) are more reliable measures of learning than post-test scores alone in staff education.

Hospice and palliative care quality metrics include pain and dyspnea screening, timing of hospice enrollment, emergency department and hospital utilization, completion of advance directives, and bereaved family survey scores.

Just culture distinguishes human error (console), at-risk behavior (coach), and reckless behavior (punish), which supports nonpunitive reporting of adverse events.

Benchmarking against national measures (NHPCO, CMS hospice quality reporting, and specialty society metrics) converts internal performance data into actionable targets.

Research utilization requires appraising validity and applicability to the local population before adopting a finding into practice; single small studies are not sufficient grounds for a practice change.