1) You are asked to see an 85-year-old African-American Female with advanced multiple myeloma and known history of hyperviscosity syndrome, the patient is alert and oriented to person and place only. The patient’s daughter is present for the entirety of the interview and exam. During the interview and exam, the patient answers “yes” to all queries during the review of systems. When asked about her understanding of her medical issues, she states “I think so” but is unable to offer more detail despite further probing questions. Which of the following is the next best step towards completing her orders for life-sustaining treatment?
Answer: D – The patient may have previously completed advanced directives, living will or assigned a healthcare power of attorney. It is best to evaluate if this has been done already prior to proceeding with any further actions.
2) You are called by a home hospice nurse for “medication changes.” The patient is a 78-year-old male with a hospice diagnosis of COPD and long history of chronic back pain taking oxycodone 5mg by mouth every four hours around the clock. The patient is no longer able to swallow and the family would like to know what to give the patient. The patient appears to be actively dying per the home nurse and morphine oral/sublingual concentrate 20mg per mL is available in the home. Which of the following would most closely mirror the patient’s prior oxycodone regimen?
Answer: B – The patient was taking 45mg of daily oral morphine equivalents with their prior oxycodone. Given incomplete cross-tolerance a 25% reduction in dose yields ~34mg of daily oral morphine equivalents. The regimen which is closest to this is B which yields a total of 30mg of daily oral morphine equivalents.
3) You are currently providing hospice care for a 7-year-old with recurrent neuroblastoma and despite the patient being comfortable, death is imminent. In discussing the parent’s needs with the social worker, which of the following are correct?
Answer: D – The parents will be at risk for complicated grief, depression and suicide. Comprehensive bereavement evaluation and services should be offered to the family.