A 67-year-old patient comes to the physician because of a 4-month history of weight loss, chest pain, dry cough, and shortness of breath on exertion. He worked as a shipbuilder for 45 years and is now retired. Since the death of his wife 2 years ago, he has lived with his daughter. He has never smoked. His temperature is 38.1°C (100.6°F), pulse is 85/min, and blood pressure is 134/82 mm Hg. Fine, end-inspiratory rales are heard at the left lung base; breath sounds are absent at the right lung base. A CT scan of the chest shows pleural thickening and a right hemothorax. Thoracocentesis confirms the diagnosis of mesothelioma. The patient and his family are informed about the poor prognosis of this condition and that the mean survival time is 1 year. The patient states that he wishes to receive radiation. He would also like to receive home hospice care but is unsure whether his health insurance would cover the costs. The patient's son, who has been assigned power of attorney, does not agree with this decision. The patient does not have a living will but states that if his heart stops beating, he wants to receive cardiopulmonary resuscitation. Which of the following disqualifies the patient from receiving hospice care?

Wish for cardiopulmonary resuscitation

Uncertain coverage by health insurance

A 72-year-old woman with metastatic ovarian cancer is brought to the physician by her son because she is in immense pain and cries all the time. On a 10-point scale, she rates the pain as an 8 to 9. One week ago, a decision to shift to palliative care was made after she failed to respond to 2 years of multiple chemotherapy regimens. She is now off chemotherapy drugs and has been in hospice care. Current medications include 2 mg morphine intravenously every 2 hours and 650 mg of acetaminophen every 4 to 6 hours. The son is concerned because he read online that increasing the dose of morphine would endanger her breathing. Which of the following is the most appropriate next step in management?

Counsel patient and continue same opioid dose

Change morphine to a non-opioid analgesic

Initiate palliative radiotherapy

Initiate cognitive behavioral therapy

An otherwise healthy 67-year-old woman comes to your clinic after being admitted to the hospital for 2 weeks after breaking her hip. She has not regularly seen a physician for the past several years because she has been working hard at her long-time job as a schoolteacher. You wonder if she has not been taking adequate preventative measures to prevent osteoporosis and order the appropriate labs. Although she is recovering from surgery well, she is visibly upset because she is worried that her hospital bill will bankrupt her. Which of the following best describes her Medicare coverage?

Medicare Part A will cover the majority of her hospital fees, including inpatient drugs and lab tests.

Medicare Part C will cover the majority of drug costs during her inpatient treatment.

Medicare is unlikely to cover the cost of her admission because she has not been paying her premium.

Medicare Part B will cover the majority of her hospital fees, including inpatient drugs and lab tests.

Medicare Part D will cover the cost of drugs during her inpatient treatment.

A 31-year-old physician notices that her senior colleague has been arriving late for work for the past 2 weeks. The colleague recently lost his wife to cancer and has been taking care of his 4 young children. Following the death of his wife, the department chair offered him extended time off, but he declined. Resident physicians have noted and discussed some recent changes in this colleague, such as missed clinic appointments, 2 intra-operative errors, and the smell of alcohol on his breath on 3 different occasions. Which of the following is the most appropriate action by the physician regarding her colleague?

Inform the local Physician Health Program

Alert the State Licensing Board

Confront the colleague in private

Contact the colleague's friends and family

Advise resident physicians to report future misconduct to the department chair

A 76-year-old woman is brought to the physician by her daughter for evaluation of progressive cognitive decline and a 1-year history of incontinence. She was diagnosed with dementia, Alzheimer type, 5 years ago. The daughter has noticed that in the past 2 years, her mother has had increasing word-finding difficulties and forgetfulness. She was previously independent but now lives with her daughter and requires assistance with all activities of daily living. Over the past year, she has had decreased appetite, poor oral intake, and sometimes regurgitates her food. During this time, she has had a 12-kg (26-lb) weight loss. She was treated twice for aspiration pneumonia and now her diet mainly consists of pureed food. She has no advance directives and her daughter says that when her mother was independent the patient mentioned that she would not want any resuscitation or life-sustaining measures if the need arose. The daughter wants to continue taking care of her mother but is concerned about her ability to do so. The patient has hypertension and hyperlipidemia. Current medications include amlodipine and atorvastatin. Vital signs are within normal limits. She appears malnourished but is well-groomed. The patient is oriented to self and recognizes her daughter by name, but she is unaware of the place or year. Mini-Mental State Examination score is 17/30. Physical and neurologic examinations show no other abnormalities. A complete blood count and serum concentrations of creatinine, urea nitrogen, TSH, and vitamin B12 levels are within the reference range. Her serum albumin is 3 g/dL. Urinalysis shows no abnormalities. Which of the following is the most appropriate next step in management?

Evaluation for alternative methods of feeding

A 72-year-old man presents to the emergency department with chest pain and shortness of breath. An EKG demonstrates an ST elevation myocardial infarction, and he is managed appropriately. The patient suffers from multiple comorbidities and was recently hospitalized for a myocardial infarction. The patient has a documented living will, which specifies that he does wish to receive resuscitative measures and blood products but refuses intubation in any circumstance. The patient is stabilized and transferred to the medical floor. On day 2, the patient presents with ventricular fibrillation and a resuscitative effort occurs. He is successfully resuscitated, but his pulmonary parameters warrant intervention and are acutely worsening. The patient's wife, son, and daughter are present and state that the patient should be intubated. The patient's prognosis even with intubation is very poor. Which of the following describes the best course of action?

Do not intubate the patient given his living will

Intubate the patient - the family is representing the patient's most recent and accurate wishes

Consult the hospital ethics committee

Intubate the patient - a patient's next of kin take precedence over a living will

Do not intubate the patient as his prognosis is poor even with intubation

An 85-year-old man with terminal stage colon cancer formally designates his best friend as his medical durable power of attorney. After several courses of chemotherapy and surgical intervention, the patient’s condition does not improve, and he soon develops respiratory failure. He is then placed on a ventilator in a comatose condition. His friend with the medical power of attorney tells the care provider that the patient would not want to be on life support. The patient’s daughter disputes this and says that her father needs to keep receiving care, in case there should be any possibility of recovery. Additionally, there is a copy of the patient’s living will in the medical record which states that, if necessary, he should be placed on life support until full recovery. Which of the following is the most appropriate course of action?

The durable medical power of attorney’s decision should be followed.

Withdraw the life support since the patient’s chances of recovery are very low

Contact other family members to get their input for the patient

Act according to the patient’s living will

Follow the daughter’s decision for the patient

A 67-year-old man presents to the emergency department following an episode of chest pain and a loss of consciousness. The patient is in critical condition and his vital signs are rapidly deteriorating. It is known that the patient is currently undergoing chemotherapy for Hodgkin’s lymphoma. The patient is accompanied by his wife, who wants the medical staff to do everything to resuscitate the patient and bring him back. The patient also has 2 daughters, who are on their way to the hospital. The patient’s written advance directive states that the patient does not wish to be resuscitated or have any sort of life support. Which of the following is the appropriate course of action?

Respect the patient’s advance directive orders

Contact the patient’s siblings or other first-degree relatives

Take into account the best medical decision made by the physician for the patient

Respect the wife’s wishes and resuscitate the patient

Hospice eligibility and services for USMLE Step 3: High-Yield Patient Safety Lessons

Hospice Eligibility - The Six-Month Rule

Core Criterion: Life expectancy is ≤ 6 months if the terminal illness runs its natural course.
Certification: Two physicians must certify the prognosis:
- The patient's primary physician (or specialist).
- The hospice medical director.
Patient Choice: The patient must voluntarily elect hospice care, forgoing curative treatments for their terminal condition in favor of palliative and comfort measures.

⭐ Patients can be re-certified for subsequent benefit periods if they live beyond the initial 6 months, as long as a physician continues to certify a terminal prognosis.

Hospice Services - Comfort & Compassion

Focus: Palliative, not curative. Manages symptoms (pain, dyspnea, nausea) to enhance quality of life.
Interdisciplinary Team:
- Medical: Physician & nursing care (RNs, aides).
- Psychosocial: Social workers, spiritual counselors.
- Rehabilitation: Physical/occupational/speech therapists as needed.
- Support: Volunteers for companionship, bereavement counseling for family for up to 1 year.
Medications & Equipment: Covers drugs for symptom control and medical supplies (e.g., hospital beds, oxygen).
Respite Care: Provides temporary relief for primary caregivers.

Hospice Interdisciplinary Team Roles

⭐ Location of Care: Hospice services are most commonly provided in the patient's home; however, they can also be delivered in freestanding hospice facilities, hospitals, or nursing homes.

The Hospice Team - Your Care Crew

Hospice Team Structure

An interdisciplinary team (IDT) provides holistic, patient-centered care. The team collaborates with the patient and family to create and maintain the plan of care.

Core Team Members:
- Physician: Medical director; certifies terminal illness.
- Nurse (RN): Manages pain & symptoms; primary contact.
- Social Worker: Addresses psychosocial & financial needs.
- Chaplain: Offers spiritual & emotional support.
Additional Support:
- Home Health Aides, Therapists, Volunteers

⭐ The IDT must review the patient's plan of care at least every 15 days.

Levels of Hospice Care - Shifting Gears

Routine Home Care (RHC):
- Standard level of care provided where the patient resides.
- Services are intermittent, not continuous.
Continuous Home Care (CHC):
- For acute symptom crises (e.g., severe pain, nausea) to avoid hospitalization.
- Requires a minimum of 8 hours of direct nursing/aide care in 24 hours.
General Inpatient Care (GIP):
- Short-term care for symptoms that cannot be managed at home.
- Provided in a hospice facility, hospital, or skilled nursing facility (SNF).
Inpatient Respite Care:
- Temporary admission to relieve caregivers.
- Limited to 5 consecutive days.

⭐ Most hospice care is Routine Home Care. Continuous care is intended only for short-term management of a crisis, not as a long-term solution for patients with high care needs.

Hospice requires a prognosis of ≤6 months, certified by two physicians.

The focus of care shifts from curative treatment to palliative and comfort-focused measures.

Services are comprehensive, addressing medical, psychosocial, and spiritual needs for the patient and family.

Care can be provided at home, in a nursing facility, or a dedicated hospice center.

Patients can revoke the hospice benefit at any time to resume curative therapy.

It is primarily funded by the Medicare Hospice Benefit (Part A).

Continue reading on Oncourse

CONTINUE READING — FREE

or get the app

App Store|Google Play