Hospice & Palliative Care
This domain tests hospice philosophy, the Medicare hospice benefit, psychosocial assessment and intervention, grief and bereavement, interdisciplinary teamwork, and ethical/legal decision-making. Items often ask what the social worker should do first, what is covered, or how to handle family conflict.
Hospice eligibility and benefit structure
Medicare hospice requires a prognosis of 6 months or less if the illness runs its normal course. The benefit has two 90-day periods, then unlimited 60-day periods; a face-to-face encounter is required before the third period and each subsequent recertification. Election waives curative treatment for the terminal diagnosis and is revocable. Levels of care are routine home, continuous home, general inpatient, and inpatient respite (up to 5 days). Conditions of Participation (42 CFR 418) require an interdisciplinary group that meets every 15 days, an individualized plan of care, social work services, and bereavement support up to 1 year after death. Palliative care can coexist with curative treatment and is not prognosis-limited.
Psychosocial assessment and intervention
Assess illness understanding, goals, coping, mental health, caregiver burden, finances, safety, culture, spirituality, advance directives, and decision-making capacity. Interventions include psychoeducation, family meetings, crisis intervention, counseling, legacy work, caregiver support, advocacy, and coordination. Document goals-of-care discussions.
Grief and bereavement
Distinguish anticipatory grief, bereavement, and prolonged grief disorder (DSM-5-TR: persistent yearning or preoccupation with impairment beyond 12 months in adults, 6 months in children/adolescents). Screen risk factors and offer follow-up. Recognize disenfranchised grief.
Ethics and law
Honor self-determination and informed consent. Capacity is decision-specific; competence is legal. Use substituted judgment before best interests for incapacitated patients. Maintain team confidentiality and follow mandated reporting.
Worked example
Mr. L, 72, has metastatic pancreatic cancer and elected hospice. His daughter demands IV fluids and refuses morphine, fearing addiction. First assess both parties' understanding and goals rather than argue. Explain that hospice does not mean no treatment: symptom-focused medications are covered; curative treatment for the terminal diagnosis is waived. Address the addiction concern in plain language, explore cultural and spiritual beliefs, and convene a family meeting with the nurse and physician. Document the patient's wishes. If capacity is absent, apply advance directives or surrogate standards.
Traps that cost marks
Do not equate palliative care with hospice; assume election forbids all treatment; treat Kübler-Ross stages as mandatory; label grief prolonged before duration criteria; confuse capacity with competence; disclose information to uninvolved relatives; overlook caregiver burden; or omit documentation of goals-of-care talks.