041 ACHPN Prep Part 6 Intervention and Management Part 3

(laughs) (upbeat music) - Hi everyone and welcome to HPM Talk, the podcast of the Physician and Advanced Practice Provider Community at Mayan HPCO, formally known as the National Council of Hospice and Plymouth and Professionals, I'm Stephen Bommeracker, Medical Director of Ballad, Health Plymouth Medicine Associates, and Associate Editor-in-Chief of the American Journal of Hospice and Plymouth Medicine. - I'm Amanda Stevens, nurse practitioner with BHMA Plymouth Medicine Consultants, and I'm curious to depute. - Nurse practitioner with BHMA Plymouth Medicine Consultants. - Thanks for being here. Today we're gonna continue our series on passing the HPNA ACHPM exam. And we've gotten some good feedback so far, even though we haven't finished the series. Several people have emailed us saying that they took the exam past it. Congratulations. (audience applauds) And that they credited getting some answers, they knew we're right because of this show, so that's good. - Great. - Very happy to hear that as of, we can help in any way. All right, so we are still on intervention and management part three. And where did we leave off Amanda? - So we were just about to go into life support devices. - Okay, let's do it. - And some test questions on that, or some practice questions, I should say. - All right, question number one, a hospice patient has an AICD. It is recommended to do what with the device? Which I had like, jeopardy music. You know, like that, yeah. I'm gonna get that for next time. We probably get a copyright strike, but it'll be cool. All right, so a hospice patient has an AICD. It's recommended to do what with the device. I'm assuming everyone knows what an AICD is. - It's an automated, implantable cardiac defibrillator. - Very good, well, let me give you a bell from that. - Give thyself a bell. (dramatic music) - All right, very good. All right, so back to the question, here are the distractors. Number one, stay activated for quality of life. Number two, remove it. Number three, okay, I don't wanna give away my bias, but that is hilarious. Number three, deactivate it, or number four, stay activated, but apply magnet if it discharges a shock. Now remember, we're not always necessarily looking for the correct answer, we're looking for the best answer given the four. Gotta remember that when you're doing these. So what do you feel about this question? - So I think a really important thing to focus on on the question part is that this is a hospice question, not a palliative question. - Correct. - Because I think the correct answer would be to deactivate it in a hospice patient, but that might not be the right case in a palliative patient. - Correct, and again, patients, they have autonomy, you gotta talk to them. Obviously, we're not going to just go in and just deactivate the thing without having a conversation about it, but they didn't ask about that. They're asking of the four distractors, which one is the best. - Chris, I think you have. - I have no additional insight. - Okay, very good. - Definitely never move it. - That one's pretty straightforward. - Yeah. - Please don't remove it. - That is not a bedside procedure. - No, which of the following, okay, number two, which of the following statements is false regarding a left ventricular assist device? Now, let me ask you something. When you all took the exam, do you have the ability to highlight words? - No, no. - So the HPNA went for the cheapo version of the software, because you can pay extra and have software that allows you to do these things. At least that's my understanding. If I'm wrong, they can correct me because we're gonna have them on at the end of this. And we've got some questions for that. But this is one of, if you could. So you can have a pencil and paper though, right? - Yes. - Okay, so on questions like this, from a test taking standpoint, I always recommend if you can highlight it, highlight the word false, or at least write it down so you don't forget that you're looking for the false answer, because sometimes you'll see the first one going, oh, no, that one's true, and then you click on it and it's actually wrong. - Right. - Okay. - And that's what I did at first when I was going through these two. - Yes. - This part, a correct answer. - Yes. Yeah, the answer is, would be correct if they were looking for the correct answer, not the false answer, okay? So which of the following statements is false? Regarding a left ventricular assist device. Number A, many patients have an LVAD implanted as they await her transplant. Number two, an LVAD is a type of pacemaker with leads entering the left ventricle and atrium. Number C, a 2015 study reported 65% of patients died within three years of receiving an LVAD, and letter four, and LVAD is used in patients with end stage heart failure. So what do we think about this one? - Number B. - Okay, so let's talk about that. So what is a left ventricular assist device? That's important. Some people may-- - A pump that we use for patients who have reached end stage heart failure. - Correct, very good. Yeah, it actually assists the left ventricle. They're surgically implanted, they're battery operated at some mechanical pump. So B would be correct. If you know what an LVAD is, just because you know it's not a pacemaker. - Correct. - But they may ask this question a different way, so we should go through all the distractors. It is true, many patients have an LVAD implanted as they await heart transplant. It's to keep them going until they can have definitive procedure. So that also implies that the 2015 study reported 65% of patients died within three years of receiving an LVAD. Now that, when I see a question like that on an exam like this, I'm assuming they don't actually think that we would know that. - Right. - In other words, was it 65%? Was it 68% was it 55? So when I see that, I'm always very suspect about those distractors. How could they possibly be expecting us to know a statistic like that in a field that's not our field? So I would throw that one out just because of that. And then an LVAD is used in patients within stage heart failure. Well, of course, that's what it's there for. Okay. - Yep. - All right, very good. Anything else on that one? - Fun fact of the day. - Yeah. - This time I had an LVAD patient. They, I didn't know it 'cause they wear them like a fanny pack now. And he asked me to fill his pulses and they don't have peripheral pulses that are palpable. - Really? - Yeah. - I wasn't aware of that. - Yeah. - Interesting. Because it's just only pumping just enough to, that's interesting. Okay. Can we look that up? Is it, yeah. What does it say? - It's fascinating. - I haven't finished reading it. - Okay. - I mean, it just says they do not typically have palpable peripheral pulses. - Wow. I figured they would still, because they're pumping blood that they would still, maybe it's because it's less rapid. In other words, it's more, it's a slower up ramp. - There's no risk of pumping. - Okay, interesting. - So it's just like a, - Yeah, and you can't measure their blood pressure either. - Wow. - I will never forget that person. And that was when I was doing clinical. (laughing) He was great. - That's fascinating. It's got to be because of the upswing. The upstroke isn't as rapid. That would be my guess. Huh. Yeah, it says here since LVAD patients do not typically have palpable peripheral pulses and blood pressures that could be measured by automated cuffs, first use ultrasound to get your patient's map. And then it talks about attach a manual blood pressure. But we might as well just, the more you know about this stuff, the better, right? (laughing) Attach a manual blood pressure cuff to your patient's arm and inflate it to greater than 128 millimeters than slowly deflate it while having the Doppler ultrasound probe over the brachial artery. The pressure reading at which arterial flow becomes audible equal or visible equals the map. - Yeah. - Wow. Well, you know what? So I learned something today, thank you. - It's because the pump is continuous, continuously cycling, so it's not kind of like CRT, yeah, I see, okay, yes. Okay, now that I see how it works, I've never, these things came out since I trained. Yeah, wow, it says first generation, no longer in your second generation devices, have continuous non-pulsatile flow. Oh, that's why. See, I am-- - I'm trying to find that. Like, it was making sense in my head. - I imagined a balloon next to the ventricle that was assisting the ventricle. We had those at one point. So that's fascinating. Okay, well, yeah, well, no wonder. It's just they have continuous flow, they don't have pulsatile flow. All right, good. - In fact of the day. - All right, yeah, that was very fun. - Give myself a bell. (bell ringing) All right. I am just Mark. Okay. Very good. Okay. Which of the following statements best describes the, you know, and all the cardiac ICU nurses, you know, nurse practitioners who were nurses at one point were all just screaming at their podcast players while we were going through that. But still. Which of the following statements best describes the proper process for compassionate extubation? And I like the turn to, did you all write this or was it? I did. Yeah. Okay. Good. Cause we are not calling it terminal extubation anymore and we're not even calling it palliative extubation. It's compassionate extubation. I like that the best. Okay. Which of the following statements best describes the proper procedure for compassionate extubation? Number A, do not provide symptom management prior to extubation. Wait till the patient begins to show signs of discomfort. Letter B, always have the family leave the room prior to removal of ventilator support. Next, discuss with the family the process of post extubation care so they know what to expect. And number D, educate family the compassionate extubation is a way to hasten demise in a patient who is lingering. Okay. So there's usually one ridiculous answer and that would be that one. But there's actually two. Right. I agree. The first priority forgot about the first one. So do not, I'll read them then you guys comment on do not provide symptom management prior to extubation. No. So we know that with compassionate extubation, they are going to have symptom management needs and premedicating is the best way to prevent distress for the patient and the family. Correct. But aren't we then euthanizing the patient? Because we hear that one from time to time. We are withdrawing support that is prolonging the natural dying process and not speeding up the dying process. Correct. And the principle of double effect points us in the direction that the intent matter. So if the intent is to relieve suffering knowing that the demise may be hastened as okay as long as well it's allowed under the principle of double effect as long as the intent is to relieve suffering and not to hasten the patient's demise. And there's actually been some small studies that were done that showed that patients who received opioids just post extubation actually lived longer in this one study than people who didn't. Now it was probably biased because the ones who didn't get anything probably died immediately but and so it skewed the data but you may not even have to invoke the principle of double effect in a situation like that. Okay. So we're going to so that is incorrect. We are going to provide symptom management prior to extubation. Number B always have the family leave the room prior to the removal of ventilator support. So while that is preferred the family should have a choice in that matter. Correct. Especially if it's somebody that you think is going to die instantly when the machine is turned off the family needs to be allowed to be there for those final breaths if they want to be. Correct. I think you're right on that. And it's when we say it's preferred it's I tell people less than you're welcome to stay. But if you feel compelled but it's a very intense moment and it may be the only thing that you remember afterward and so it's okay to step out let them do their thing and then come right back and don't go get a sandwich or anything. Right. But just come right back in. So families should have that choice. Okay. Discuss with family the process of post extubation care so they know what to expect. Ding ding ding ding ding. I agree. I would say had a ding ding ding. It's sound effect over here. But yeah, that's obviously anytime you see on any of these exams the choice of enhancing autonomy and choice and shared decision making et cetera et cetera. That's probably going to be the right answer. And education first. Yes. That's what's drilled into our minds from a nursing standpoint and that's what makes the last one even though it's absolutely ridiculous for all of us the use of the word educate. Right. Could distract you easily because that's what you want to do first is educate. Correct. Educate the family and compassion. Exhibition is a way to hasten death in patients who are in lingerie. I mean like obviously we know that is incorrect. Right. And that's a distractor for somebody who's taken this exam and actually has never practiced. And or doesn't read all the answer. Right. Just read. I've done that. I've made that mistake because I'm such a fast test taker to just. Okay, what are they looking for? What's the correct process run through there and not read anything and just see the word educate and click it move on. It's pretty clever that they did that because the correct answer they said discuss rather than educate. I see where you're coming from. That's good. Thank you. Very good. Always read the question and take notes if you have to if you have to write down keywords whatever it takes. And we will again I'm we'll talk to them about paying the extra five bucks or whatever it is to allow you all to take the exam in a way that you can highlight. And you should be able to to like on my my boards I can mark through things and I can highlight things. All right. Let's go to serious illness loss dying death grief and bereavement. All right. Number one. What cancer has the highest association with depression? And I would have gotten this one wrong. The distractors are breast, pancreatic, prostate, and lawn. Now they're all associated with reactive situational depression, but which one has the highest? So the correct answer on this is pancreatic. And I think you're right. It's it's a tricky one because you know you think of breast cancer and the disfigurement and all of the effects that go along with that. You think of self image. Yeah. Self image. You think of lung cancer and a lot of times patients with lung cancer. It's self inflicted in air quotes there. Right. Because it's something they see up. And you know prostate cancer and men that can be a self image thing as well. Sure. So but pancreatic cancer is the answer and that's most likely we think due to what it has a bad recognition that is. Yeah. And how advanced it usually is when it's found. Yeah. Yeah. Pancreatic cancer has a very bad reputation. And we've got to that's one that you know the oncologists are working feverishly on to improve. Yeah. It's a tough one. Okay. Yeah. I think we we actually before the show tried to confirm that it wasn't really easy to find in the medical literature, but what we could find seemed to show that pancreatic cancer at the highest range and the highest upper limit. So all right. What are signs of a patient coming closer to the dying phase? Number one, sleeping more. Number B, not wanting to eat. C talking about seeing dead relatives or next all of the above. All of the above. Correct. I don't think we really even need to discuss this one. Right. Correct. Yeah. I can't say I don't remember it being any more challenging than this, but there were. This just triggered my mind. There were questions that did talk specifically about dying phases, etc. As far as just know what they are like, agonol respirations. Right. Did you have questions about different types of respirations like who small and Shane Stokes and that kind of stuff. I don't think so. If they were, it was like this patient has has that. Yeah. What does that mean? Maybe, but I honestly don't remember. Okay. So reviewing the phases, the recognizable phases of the dying process, probably a good thing to do. Yeah. Yeah. Yeah. All right. And next question. A nurse approaches the APRN with concerns that the medications prescribed to her dying patient may hasten death. The APRN educates the nurse that number A, it's okay to hasten death in a dying patient. B, this is an example of physician assisted suicide. See, this intervention is known as the double effect when an intervention causes both the positive and negative effect with the positive outweighing the negative or D. No medications prescribed would hasten the patient's death. All right. So number A, it's okay to hasten death in a dying patient. No. That should never be our intent. That's right. That's correct. That's. So when you look at the principle of double effect, there's a good effect and a bad effect. If you intend the good effect, you can tolerate the bad effect. Now, let's say you have an 18 year old who had a car wreck. And you say, and they are emcephalopathic and you just sedate them to the point where, you know, they can't eat or drink and they die. That would actually violate the principal of double effect because even though the intent was to create comfort, the bad effect far out ways the good effect in that situation. 'Cause that's part of the equation as well. And that's the arguable thing. So if you have a patient who has three days to live and you sedate them and they die into in a half days, you have hastened their demise. But as long as they had, you know, unremitting severe symptoms that you were relieving that also relieved the anxiety and pain of the family, that would meet the criteria of the principal of double effect. - Absolutely. - Okay, so yeah. And this is where, by the way, position, well, Kavorkian and other people, Euthanasia violates the principal of double effect. We can argue that whether the Euthanasia or physician aid in dying or any of those things is a moral act and if it's ethical, reasonable people can have that discussion. But when you create, when you hasten dying to relieve suffering, that is the opposite of the principal of double effect. Well, you can say as it doesn't meet the criteria of the double effect, then we can say, well, maybe we need to throw out the double effect. But for right now, what they're asking is, you know, is this, does this act that you're doing with this patient, you know, meet the criteria of the principal of double effect? And I suspect that there, I know on my boards, this is all over the place, I suspect principal of double effect, questions are on your boards too, they're certainly on these practice questions. So that is something to look at. And if we need to someday, maybe we'll do a whole podcast on that where we can walk through each of the four criteria of the principal of double effect. - And ultimately our intent is to alleviate suffering. - Correct. And so I've documented that too. - Yeah. - I sounded like a 12 year old document. - I've documented that. - And my wife is cracking again. Wonder what that means, what phase of my life I'm getting ready to go into. Okay, a 70 year old male died 20 months ago and his widow calls you crying, stating, she still can't believe he has gone. She states she rarely leaves the house anymore and states she doesn't want to get out of bed in the morning. What is the APRN's most important action? Number one, make a four week follow up. Number two, find a local grief support group. Number three, refer to a bereavement counselor. And number four, call in a prescription for a surgery. Someone put Zoloft on here, boo. - Okay, they use both on the test. - Okay, but they'll say both, right? - No, necessarily. One question might have, Zoloft the next might have surgery. - Zoloft parentheses surgery. - Nope. - Okay, well, all right, I'm booing myself then for that. - It's, they really should, are they? - Really, let's not use trade names. I mean, I-- - They should be consistent at least. - Agreed. And if you're gonna use trade names, put both names in there. That's what they do on my boards. Trade names are marketing tools, I'm not a fan, but anyway, but if they're doing that, then we need to be aware of it. Okay, so you need to know both. So what do you think about this one? Make a four week follow up? - No. - No, why? I mean, do we really need to? - Four weeks. - Right, and she needs help now. - She needs help now. - Yeah. - Okay, number B, find a local grief support group. - Yes. - Yes, I agree. But the next one is referred to a bereavement counselor. - She's not your patient. And it's beyond the 12 month bereavement period. - Oh, it says 20 months ago. - Yeah. - Oh, myself a down. (laughing) - Good one, good one. Now, if they had said hospice bereavement program or whatever benefit, then absolutely, you might have caught that, but yeah, I didn't catch the 20. That's again, highlight these things, write these things down, because you know that's the direction they're pointing you in. - Yeah. - Oh, that's a good one, you did good. Okay, and then call in a prescription for a brand name SSRI. - For a patient who is not your patient. - Correct. - Yeah. - That'll go well. That was a good one. - That is a good one. - Yeah. - Oh, I might have gotten that one wrong because I didn't see the 20, 20 months. - Lots of the questions were tricky like that in that aspect, thinking about tricky. I mean, just pay attention to those little details. - Yeah, yeah, they tell you those things for a reason. - Yeah. - Sometimes, sometimes it's just, that's to distract you as well. But don't re gloss over it because you think they're just trying to distract you, because in this case it was crucial. - Very good. - I can't take credit for that one. That was from that out of print book. - Yeah, no, that's fantastic. - Nice. - Thank you. What's the first stage of grief that all people experience? Number one, acceptance, number two, denial, number three, anger, number four, none of the above. - Okay, fair. I sold a question. I was like, whoa, that's awful presumptive of someone to say that everyone experiences something. - Well, that's the whole point. - Yeah, all right. Yeah. None of the above is the correct answer. - Chris will always be angry. - Obviously. - Just in that all the time. (laughing) When she has grief, she'll just stay in anger. - I'm still angry because my dad died like eight years ago. It's fine. - I'm sorry. I got a heavy all of a sudden. I'm sorry. I mean, the anniversary of his death is on Halloween. - Oh, is that right? - Yeah. - Of course he had to die on a holiday. - Yeah. Makes it hard to, you know, to. - I don't want to remember it. I don't remember when anyone else died. - I'm the same. I don't remember. I have no anniversary phenomenon because I don't keep anniversaries in my head. The only birthdays that I remember are my own and that's a struggle sometimes. And then if I put them on my calendar. - Yeah. - So, you know, I know that. - And I was at making him also scary Halloween. - Oh, come on. - Right. - Oh, I'm sorry. - It's fine. - Anger. - Goodness. (laughing) - I'm just now getting to the acceptance phase and my mom's 20 year death anniversary is coming up next month. - Oh my goodness. Yeah. I was in disbelief for a long time when my dad died because he would always be the one that you would. This would be for GPS. And my dad was GPS back then. You'd say, "What's the best way to get to Franklin, North Carolina from, I don't know, Johnson City, Tennessee or something." And you'd say, "Well, you go down 26 and take right on 40." And all this stuff. He was that guy. And I remember about a month after he died, I called my dad and it was like, "Aff." Put the phone back down. Seemed like he was still there. I just couldn't call him. - Yeah. - You know? Well, anyway. - Okay, sorry guys. - Yeah, so we got to have a, we're sharing. So yeah, there's no first stage of grief that all people experience. When you see all never, those kinds of things be very suspect of that question. - Absolutely. - Okay. Or if you have a distractor that says all or never. - And also those stages of grief don't go in the same order for every person. And sometimes you may experience multiple ones at the same time. - That is absolutely correct. And even Elizabeth Kupleros, when she first created the stages, I think she intended for them to be sort of an algorithm that people marched through, but later on she came to the conclusion that the stages demonstrated a range of emotions. - Right. - And if you read about Elizabeth Kupleros, my understanding is at the end, she got stuck in anger and never got out of it. - Right. - Yeah, that's what I read anyway. So it happens to all of us. You just don't know how you're gonna react to these things. Grief that does not fit in with society's attitude about coping with death and loss, which can lead to prolonged emotional pain due to lack of support is called. Hoof, number one, anticipatory grief. Number two, complicated grief. Number three, disenfranchised grief, or number four, dysfunctional grief. - Disenfranchised grief. - I believe that is correct. So let's walk through each one. Anticipatory grief, what is that? - So anticipatory grief is when you are grieving something that has not yet happened. You are dealing with end-stage cancer. You know that you are approaching the end of your life or your loved one is and you are grieving what's gonna be lost before the loss actually happens. - Correct, and the patient can experience that or the family can. - Right. - A complicated grief. That's, I can answer that. It's, you know, defined as a continuing heightened state of mourning that keeps you from healing. And so there'd be intense sorrow, pain, rumination over the loss of your loved one. That would be the person from the question before. - Right. - And then disenfranchised grief. - So disenfranchised grief is a loss that would not be considered a traditional loss. So loss of a partner who's not your spouse. loss of a friend who's closer than a blood relative, loss of your pet, or loss of a limb, even. These are things that people don't think of as traditional grief. Therefore, you don't get the same support when you're grieving it. Right. Yeah. The lack of support you get can prolong the emotional pain. Yep. So, yeah, it could be a long time paramour that society didn't approve of. Right. You know, and then they just have nobody to fall back on. Right. Because everybody's like, "Who are you?" You know, what about dysfunctional grief? So dysfunctional grief is very close to complicated grief as far as becoming overwhelmed and just consumed by the grief. That's all you can. That's all the person is able to do is focus on grief and nothing else. Right. Okay. So, it's almost like a step worse than the complicated grief fare. I'm looking at a journal of psychosocial nurse and mental health services. And they said, "Despunctional grieving represents a failure to follow the predictable course of normal grieving to resolution." And the process deviates from the norm. The individual becomes overwhelmed and resorts to maladaptive coping. So, that first statement you said, so do they. that person, it sounds like, doesn't ever reach resolution of the grief? That's not until you help them get there. I fear. At the point where you're evaluating them, they have not reached because if they've gotten to acceptance, then, you know, you don't need you. This was all over my test. Yeah. Okay. Really? The types of grief. The types of grief, very, very, specific. Like, I mean, this is basically just a definition on this example question, but me personally, I wasn't, you know, I was familiar with anticipatory complicated. You can make sense of, but disenfranchised and dysfunctional grief were new to me. Yeah. Good. Until we started doing this review and discussing and. That might get somebody of a couple of points. Yes. If I find something interesting, I'll stick it up on Ipyanypalitive.com. Remember, we've got a couple of things up there from the exam that you can do some review on. So, all right. Absolutely. Yeah. If you guys will remind me, I'll see if I can find an article that that concisely goes through these different types of grief. That would be great. Yeah. And I'll stick it up there. Okay. One more. Exandples of disenfranchised grief include loss of a partner who's not a spouse, loss of a friend who is closer than blood relative, loss of a pet, loss of a limb. Well, you just said that. Wow. Yeah. Very good. So, okay. Oh, that's just the last thing. Yeah. Yeah. I'm a dope. All right. Well, in summary, examples of, okay. Number seven. Number last. Cremation is preferred in which of the following cultures? A. Buddhism, B. Islam, C. Hinduism, D. Judaism, or E. A. and C. I'm sorry, or E. Both Buddhism and Hinduism. So, the correct answer there is both Buddhism and Hinduism. Correct. And I am not an expert on Islamic or Gideic tradition, but I am aware that there, you know, rapid burial is part of the culture. And that is also on epianypaliative.com. E. P. I. O. and E. palliative.com. And there's a whole thing on cultural attitudes toward death. Go ahead. I found an article. Okay. Oh, for the grieving thing. Okay. Yeah. If you'll send that to me, I'll go ahead and put it up. And we'll put liner notes as well. Okay. So, that's it for that section. Now, where are we going next after this? Because we're getting close to wrapping up, right? Okay. We'll have a few more of these before we wrap this thing completely up. And then when we know when it's going to be wrapped up, then we'll have the people from the ACHPN exam because they've offered to be on the show. And, you know, we'll give them some props, but we have some questions too, but special things. But anyway, but yeah, in a very professional way, of course. All right, my friends, you've been listening to HPM talk, the podcast of the My NHPCO physician and advanced practice provider community. If you have a topic or question you'd like to explore it on the show, send me an email hospice doc at charter.net, our executive editor is Dr. Amjad Riyar, our administrative editor is downcook. Thanks for being with us and we'll see you soon for another edition of HPM talk. Thanks. Thank you. Thank you.