CHPN cheat sheet

A comprehensive hospice assessment covers physical, functional, psychosocial, spiritual, and cultural domains and must be completed within 5 calendar days of election.

The interdisciplinary plan of care is established within 5 days of election and reviewed by the IDT at least every 15 days.

Karnofsky Performance Status runs 0-100; hospice eligibility generally requires a score of 70% or less with documented functional decline.

The Palliative Performance Scale (PPS) adds ambulation, activity, self-care, intake, and consciousness to the Karnofsky construct and is scored in 10% increments.

Reisberg FAST describes severe dementia: 7a speech limited to one word, 7b loss of ambulation, 7c loss of ability to sit up; hospice eligibility for dementia is usually supported at 7c or beyond.

Braden Scale score of 18 or less indicates pressure injury risk; lower scores indicate higher risk (9 or less is very high risk).

PAINAD scores range 0-10 for pain in advanced dementia: 1-3 mild, 4-6 moderate, 7-10 severe.

Medicare hospice eligibility requires a prognosis of 6 months or less if the illness runs its expected course, certified by two physicians.

Total pain includes physical, psychological, social, and spiritual components; assessment must address all four before escalating analgesics.

Equianalgesic conversions: morphine 30 mg PO = 10 mg parenteral; hydromorphone 7.5 mg PO = 1.5 mg parenteral; oxycodone 20 mg PO is approximately equal to morphine 30 mg PO.

The breakthrough dose is 10% to 20% of the total 24-hour opioid requirement, ordered every 1 hour as needed.

Meperidine (normeperidine accumulation, seizures) and propoxyphene are avoided in hospice and palliative care.

In renal impairment, avoid morphine because of morphine-6-glucuronide accumulation; fentanyl is preferred and hydromorphone requires dose reduction.

Transdermal fentanyl is not for opioid-naive patients; onset is 12-24 hours, each patch lasts 72 hours, and fever or external heat increases absorption.

Opioid-induced constipation does not resolve with tolerance; start a stimulant laxative prophylactically rather than treating after symptoms appear.

Neuropathic pain usually requires adjuvants (gabapentinoids, tricyclics, SNRIs, methadone, ketamine) because opioids alone are often insufficient.

Dyspnea: low-dose systemic opioid is first-line; supplemental oxygen helps only documented hypoxemia, while a fan and upright positioning benefit normoxemic patients.

Match antiemetics to mechanism: metoclopramide for gastric stasis, haloperidol for metabolic or chemical causes, ondansetron for serotonin-mediated nausea, dexamethasone for raised intracranial pressure or liver capsule stretch.

Terminal delirium: nonpharmacologic measures first, then haloperidol 0.5-2 mg; avoid benzodiazepines except in alcohol or benzodiazepine withdrawal and Lewy body dementia.

Terminal secretions are managed with anticholinergics (glycopyrrolate, scopolamine, atropine ophthalmic drops) and repositioning; deep suctioning is avoided.

Malignant spinal cord compression: give dexamethasone 16 mg daily, obtain urgent MRI, and arrange radiation or surgery before neurologic deficits become fixed.

Hypercalcemia of malignancy: isotonic IV fluids plus a bisphosphonate such as zoledronic acid, with calcitonin added for rapid effect; watch for confusion, constipation, and polyuria.

Malignant bowel obstruction: octreotide reduces secretions and vomiting, dexamethasone reduces tumor edema; routine nasogastric suction is avoided when comfort is preserved.

Hiccups persisting at end of life respond to chlorpromazine, haloperidol, baclofen, or gabapentin.

SPIKES structures bad-news disclosure: Setting, Perception, Invitation, Knowledge, Empathy, and Strategy or summary.

NURSE statements are Naming, Understanding, Respecting, Supporting, and Exploring; they acknowledge emotion without false reassurance.

Ask-Tell-Ask first elicits what the patient already knows and wants to know, then provides information, then checks understanding.

The Patient Self-Determination Act (1990) requires Medicare-funded facilities to inform patients of their right to accept or refuse treatment and to complete advance directives.

A living will records treatment preferences; a durable power of attorney for health care names a surrogate; a POLST/MOLST converts preferences into portable medical orders.

Capacity is a clinical determination made at the bedside; competence is a legal status determined by a court.

When no agent is named, default surrogate hierarchy is typically guardian, spouse, adult child, parent, then sibling, with state variation.

Title VI requires qualified interpreters for limited-English-proficiency patients; using minor children as interpreters is inappropriate for goals-of-care discussions.

The four guiding principles are autonomy, beneficence, nonmaleficence, and justice.

Rule of double effect: the intent must be relief of suffering, the harmful effect (such as respiratory depression) must be foreseen but not intended or used as the means, and benefit must be proportionate.

Withdrawing and withholding life-sustaining treatment are ethically and legally equivalent.

Informed consent requires capacity, disclosure of risks and alternatives, comprehension, and voluntariness.

Substituted judgment asks what the patient would have chosen; best interest applies when the patient's values and preferences are unknown.

Where medical aid in dying is legal, patient self-administration is required; no nurse or hospice is obligated to participate, and organizations may opt out.

HIPAA permits disclosure of relevant information to family involved in care when the patient has not objected, limited to the minimum necessary.

Suspected abuse, neglect, or exploitation of a vulnerable adult must be reported to the state agency regardless of hospice enrollment.

Pronouncement of death requires absence of heart sounds and respirations, fixed pupils, and unresponsiveness, with time documented and the attending or agency notified per policy.

FICA assesses Faith and belief, Importance of spirituality, spiritual Community, and how care should Address spiritual needs.

HOPE assesses Hope and sources of hope, Organized religion, Personal spirituality and practices, and Effects on care and decision making.

Spiritual distress presents as meaninglessness, abandonment, anger at the divine, or fear of death and is distinct from depression.

Major depression is suggested by anhedonia and excessive or inappropriate guilt; grief and demoralization fluctuate and are tied to specific thoughts, though PHQ-9 somatic items can confound screening at end of life.

Psychostimulants such as methylphenidate act within days rather than weeks and are useful for depression when prognosis is short.

Caregiver burden is physical, emotional, and financial strain measured by tools such as the Zarit Burden Interview and addressed with respite and support services.

Dignity-conserving care (Chochinov) addresses illness-related concerns, a personal dignity repertoire, and a social dignity inventory using life review, legacy work, and respect.

The LEARN model guides cross-cultural encounters: Listen, Explain, Acknowledge, Recommend, and Negotiate.

Kubler-Ross described denial, anger, bargaining, depression, and acceptance as common reactions to dying and loss, not sequential mandatory stages.

Worden's four tasks of mourning are accepting the reality of the loss, processing the pain, adjusting to a world without the deceased, and finding an enduring connection while moving forward.

Prolonged grief disorder in DSM-5-TR requires persistent longing or preoccupation plus impairment beyond 12 months in adults and 6 months in children.

Anticipatory grief occurs before the death and often coexists with the demands of caregiving.

Disenfranchised grief is loss that is not socially recognized or openly mourned, such as a stigmatized relationship or the death of a pet.

Risk factors for complicated grief include prior mental illness, multiple or sudden losses, a highly dependent relationship, ambivalence, and lack of social support.

Medicare requires hospice bereavement services for up to 13 months after death, including a risk assessment and an individualized bereavement plan of care.

Normal grief may include brief hallucinations or a sense of the deceased's presence, particularly in the first months after the death.

Signs of imminent death include mottled extremities, cool skin, decreasing urine output, Cheyne-Stokes respirations, terminal secretions, and restlessness, usually within hours to days.

Hearing is believed to persist near death; continue speaking to the patient and avoid discussing distressing information at the bedside.

Terminal dehydration does not itself cause suffering and may reduce pulmonary secretions, edema, and vomiting; meticulous mouth care replaces IV fluids.

In the actively dying phase, discontinue non-beneficial medications, routine vital signs, and laboratory monitoring, documenting the rationale.

Implantable cardioverter-defibrillators should be deactivated at end of life to prevent painful shocks, with the discussion documented before the final hours.

The four levels of hospice care are routine home care, continuous home care (at least 8 hours in a 24-hour period), general inpatient care for uncontrolled symptoms, and inpatient respite care of no more than 5 consecutive days.

Postmortem care includes positioning supine with the head elevated, closing eyes and mouth, removing tubes per policy, applying identification tags, and notifying the family and agency.

Palliative sedation for refractory symptoms requires informed consent, proportional dosing titrated to symptom relief, and clear documentation that the intent is comfort, not hastening death.

Medicare hospice Conditions of Participation are codified at 42 CFR Part 418 and enforced through state survey agencies and accrediting organizations.

The IDT includes the hospice physician, registered nurse, social worker, and spiritual counselor, and must review each plan of care every 15 days with documentation.

Hospice aides require 75 hours of training, 12 hours of in-service education every 12 months, and registered nurse supervision every 14 days.

The Hospice Item Set is submitted at admission and discharge, and the CAHPS Hospice Survey measures family caregivers' experience of care.

A QAPI program is required, using data to monitor quality and complete performance improvement projects.

Hospice must provide 24-hour on-call nursing availability and coordinate care across settings.

Controlled substances that are wasted must be witnessed and documented per DEA and state rules; nurses assess for diversion and impaired colleagues.

Documentation must reflect the assessment, the intervention, and the patient's response; if it is not documented, it is considered not done.

Compassion fatigue and burnout are recognized occupational risks addressed through debriefing, employee assistance, and workload review.