[Music] Hi everyone and welcome to HBM Talk, a podcast of the Physician and Advanced Practice Provider Community of my NHPCO. I'm Stephen Bummer, Medical Director of Ballad Health, Palette of Medicine Associates and Associate Editor-in-Chief of the American Journal of Hospice and Palette of Medicine. I'm Amanda Stevens, Nurse Practitioner with BHMA Palette of Medicine Consultants. Well today we're going to finish our series on passing the HPNA ACHPN exam. I'm very excited. We've got a lot of good feedback, people who have taken the exam already, despite us not being quite finished yet and letting us know that in a couple of cases they felt that you know our your tutorial really helped push them over the top to the pass zone particularly since one of the people who emailed me pass by one point and they changed their answer because of something that they heard on this podcast. So there you go. Congratulations. I'm going to grads all the new ACHPN, what do you call that? Certificants? Sounds good. People who pass the exam and now I have ACHPN certification. Alright, so this time we're doing education and communication. There's 36 questions, it's 24% of the exam. What did you guys, what's your good stalled on this one? Was this part, seems like it was one of those that people shouldn't have as much trouble with? What do you think? Yeah, we didn't do as much of a breakdown on that one because it seemed pretty straightforward to me when I was riding it up. Yeah, yeah, yeah, okay, well let's go. Let's do it. So the out one said that it covers age appropriate teaching methods, communication theory and principles within the context of hospice and palliative care. Strategies to overcome communication barriers, cultural and spiritual competence and grief, loss and bereavement, which a lot of those are things that we've covered in previous episodes as well. There's a lot of overlap. Okay. For the education piece specifically, it's looking at patient caregiver and health care communities establishing a therapeutic environment and applying age appropriate teaching methods. Taylor to the needs of the patient, family and other caregivers and developing, implementing and evaluating formal and informal education. Sorry. And then on the community. Some helpful. And then on the communication piece, analyzing your own communication, both verbal and nonverbal and possible interpretations, recognizing incorporate cultural differences when discussing hospice and palliative care, creating an environment for effective communication, demonstrating therapeutic presence while maintaining professional boundaries, using appropriate principles and techniques to communicate serious news and initiating and facilitating conferences among patients, families, caregivers, medical and interdisciplinary team members and all other stakeholders. Okay. Sounds good. So, oh, okay. So you've got the spikes, an demonic from Buckman's Breaking Bad News on here right off the beginning, right at the beginning. And that was right off of the free online practice test for you. Okay. So according to the spikes communication tool, the first step when breaking bad news to a patient is. So should we go over the spikes, an demonic, it's probably a good one, take notes on this. If you're not familiar with it, it is just a demonic. We love mnemonics and the S stands for setting. So find an appropriate setting to have your discussion. P is for a perception, right? Yeah. And I'm doing this off the top of my head because I wasn't expecting to do this. So find out what the patient knows before you just jump in and say, well, I'm here to talk about your cancer. And they're like, cancer, that's, that is naughty. And then information. Invitation. Sorry, invitation, right in that case knowledge. Invitation, thank you. Invitation. Not everybody wants to know everything. And one of the things, I don't know if this will come up on the exam, but it's worth talking about, is what do you do if you walk into a patient's room and say I'm the pilot of medicine specialist and the family grabs you. And takes you outside and says, don't tell mom she's got cancer. Because if you do, she's going to give up now. How many times have we had this same scenario? So many times. So I'll just give you my protocol. I know we all have our own, but I use empathy and validation first. We should always do that. I do a whole talk on just compassionate communication. Empathy. Hey, I understand why you might feel this way validation. I think a lot of people in your situation feel the same way. But, and here comes the but. The pinnacle of Western medical ethics is a concept called autonomy, which means that patients get to accept or reject any medical intervention that's offered to them. But to do that, they've got to be fully informed. And so what I'll do is I'll ask your mom if she wants to know everything or I've got an unbiased way of doing this. Or if she's okay, if you guys know stuff and you help her make decisions. And, but if she tells me she wants to know everything, I have to tell her I'm duty bound to tell her, are you okay with that? So get there a cent. Then we go in the room. Well, ma'am, there's two kinds of people in this world. People want to know everything about their condition, want to make their own decisions. Or those that are okay if their family knows more about their condition than they do. But helps them make medical decisions. What kind of person are you? Well, I want to know everything. And then I just sort of look at the family, give them that look, and then go and proceed and tell them. Now, what happens when you do that is who in that whole interaction actually had the problem with the diagnosis? Family. It's the family, right? Because a 99.9% of the time the patient kind of was expecting it. They take it in stride and you know, because the next part of the pneumonic they were going to get to is what do we do about it? Right. You know, just dump bad news on somebody and leave them there. But what it does is it removes that barrier communication between the family and the patient. Because prior to this, the family was all whispering in the corner and the patient was wondering why aren't they talking to me? Now everyone can speak freely. Yeah. And express their emotions where they really want to or need to. But anyway, okay. So, invitation, thank you. And then K is knowledge. So you impart knowledge in small chunks. And then respond to the emotions, which is the E. And trying to name that emotion in your head. And if you can't name it, ask about it. Hey, this is a lot. You know, how's that making you feel? Because if you don't name that emotion properly in your head, you're not going to respond to it properly. My professor, when I was a second year medical student or no, I was second year resident, brought all of us in. Everybody in clinic, he said, come on in. And I'm going to show you how to break bad news. And he went through this thing with this guy. And when he got to the emotion part, he misidentified the emotion. And he said, you look scared. Now, he was trying to be empathetic. But what it did was the guy took it as an accusation. And he got up and he said, I'm not scared of nothing. And he stormed out of there. And he said, that day, doctor said, I'm scared. I ain't scared of nothing. That's what could hear that all the way down the hall. And it ruined their doctor patient relationship or their provider patient, you know, client relationship. And so you got to be really careful with that. He could have said, yeah, he could have said, you know, in this situation, a lot of people, you know, it's disturbing or frightening to them. How do you feel? And got it. He got that out of him. The guy would say, I'm not scared. Anything. But, you know, this isn't great news, et cetera, et cetera. And they could have moved on, but they never could get passed there. So many. I can see your feeling really strong emotions. Do you want to tell me about that? Right. There you go. Thank you. I'll just give you a. I like that one. Thanks. So, yeah, so that's E for emotion. And then S is strategy. Don't this between emotion and strategy. Do not take a phone call. Do not allow a pager to interrupt. This is the one place where you can't be interrupted. And you should manage that any way to the best of your ability. But what I found is on all the other levels. If somebody calls me, it's an emergency exam. So sorry, it's an emergency. Do you mind if I take this and then get right back to them and then apologize again when you're done. But in this part, if somebody calls you, it doesn't matter if it says, now what I you have to, you have to brush past it because this next part is going to be quick anyway strategy. Here's the bad news. Now here's what we're going to do about it. Yeah. And I remember when I was a kid, I wrote, or I wrote, I read a book by Herman Welk called something of value. It was about the Kakuya revolution in Kenya. But at the beginning of the book, the front is piece. I had a quote and it said, if you're going to take someone's way of life away from them, you better give them something of value to replace it. And if you're going to take someone's hope that they're going to live forever away from them, you better give them something of value to replace it. So here's the bad news. Here's what we're going to do about it. Okay. So that's the review of the spikes.
to this question. According to the Spikes Communication tool, the first step when breaking bad news to a patient is, A, review the current situation. B, explore what the patient already knows. C, create a comfortable and private environment. Or D, ask how much information the patient wants to hear. All of those things are on the spikes in the amount I got, which is the first one. S is for settings, so create a comfortable and private environment. Correct. Very good. All right. So be sure that you read these questions the first step because if you look at the angle, oh, that's on the mnemonic and then you check it. All of these are on the mnemonic. Right. Right. Okay. And I could also see how A would trip you up possibly because I know personally and we work a lot of life, you want to review everything before you go see a patient, make sure you have the knowledge and things you need to have this conversation. And so reviewing the current situation, the way that you're still phrased could, could trip someone up because that's not talking about what you're doing, reviewing the chart and stuff. Or even doing that with the patient, but what they're asking is, according to the spikes mnemonic, what's the first thing? And that you got to, you have to, and when you all take this test, can you, I think we established this before, but on mine you can do highlighting. Nope. Nope. So you can't highlight anything, but you have notes. Yeah. You have a piece of paper and a pencil. Piece of paper. Yeah. See on ours, we can highlight and then you can click an icon to exit out certain things. Yeah. So it's none of that. Okay. That's too bad. We have to talk to them about that. I remember that's right. We talked about they bought the cheap module from whatever the company was. Okay. When are you going to do this next one? I have been told that I give away the answer when I read questions out loud. So really? Oh, by your partner sitting next to you? Yes. We were doing some practice questions in the office with one of our newer teammates. Oh, yeah. So it's like, apologize to a family. But that was right. Yeah. Okay. I mean, maybe not quite that bad. Okay. Well, I'll do that, man. You want me to read him? I can read him. Okay. I mean, you have the radio voice go for. No, you have radio voice. You're on the radio. Go Chris. Go. Yep. When evaluating a patient for hospice, the family approaches you very upset, stating the patients oncologist said that they had at least two years to live and do not understand why you are here. Upon your evaluation, you can clearly see the patient has less than six months to live and is very hospice-appropriate. Your view on college's notes and see the family is right. Oncology stated in the patient's chart, a prognosis of approximately two years. What do you do? So this can happen these days, particularly with EMR, because I could have been a template that they used and just didn't change it. Right. Okay. So the distractors are, apologize to the family, and pretend you have the wrong patient. Am I doing an Amanda with that one? Thank you. That's ridiculous. Why you've never done that? Tell the family the oncologist was wrong. Let me do that one again, hang on. Recognize this as an overestimated prognosis secondary to the family wanting aggressive treatments, ablame it on the family, or schedule a meeting with oncology to further discuss the patient's case. Ding, ding, ding. I think that was pretty obvious. Yeah, I'm, man, yes, that's, I think that's fair. You can talk to them first and say, if they go, oh my god, yeah, that's a mistake. But, you know, the stakeholder being the, the, you know, the specialist may have knowledge about their case that we don't have. Right. Hey, we have this new thing, this new immunotherapy. And yeah, it's probably, you know, back in the day, patients like this would have a six-month prognosis. But now, you know, so it's, their cancer may have a two-year prognosis, but their kidney failure may have a five-day prognosis. Correct. Correct. So there's all kinds of factors in there. So it's absolutely worth going over with, reviewing with the oncologist. And then you could even do a joint family meeting with the oncologist. Absolutely. All right. Patient has been receiving dialysis for end-stage renal failure for many years. Tells you they want to stop because they've had enough. Patient has a medical advanced care plan, a signed DNR, and has appointed their son as healthcare proxy. After several days, the patient becomes confused and lethargic. The son states, he's the healthcare proxy, and I cannot just let my father die. Quote unquote. He tells you he wants to reverse the DNR and restart his father's dialysis. You should. Now, this is a very common thing. Oh, absolutely. You should, A, call a family meeting and allow the son to express his emotions and concerns. B, tell the son his father trusted him to carry out his wishes. C, explain to him what a healthcare proxy is and inform him. He is breaking his father's trust in him. Or, decal, bereavement and have them counsel the son. Again. You're reading questions a little bit like Amanda. Love you guys. Okay, so what should we do in this case? Not see. No. Yes. You are wrong, sir. Call a family meeting, allow the son to express his emotions and concerns. And just we need to remember that a medical advanced care plan is not legally binding. And that a surrogate can make any choices that the patient would make. Were they able to do so? And I've had patients themselves change their code status five times. Right. Yeah. Sometimes you look at a situation like this. You go, well, that person's a terrible surrogate. Well, the person shouldn't have named him. Okay. Well, what it should have cut off, what I was going to say is that the, you know, the patient had some responsibility to appoint someone that is going to do what they wanted them to do or at least have that discussion with them now. The, yeah, now if there's an ethical concern, let's say you have a patient that came to you and said, listen, my son is going to try to reverse my DNR, but please don't let him do that. Don't want any of this. I'm done. I don't want anything. And then the, all of a sudden they lapse into a coma before you've had a chance to really get any witnesses in there or do anything else. Have them sign a new piece of paper, assign anybody else. Now the sun comes in and says, no, I'm reversing everything. Now you have a, an ethical issue. And you can, there is a protocol for not obeying an unethical request. And this goes by state by state. So you got to look at your state in our state. And the protocol is mostly the same everywhere. You would say, you would inform the decision maker. I, this, I feel this is unethical. I don't think I can comply with this. And then you have to try to transfer them to somebody who will do it. When you can't, you're not under any obligation to perform an act that you find morally reprehensible or unethical or will cause you moral harm. Now that protects you if you go through the protocol from getting sued but it doesn't protect you from somebody showing up on your doorstep saying, you know, you killed my mama. So it's always better to achieve consensus when you can. Absolutely. All right. Very good. Okay. Chris. Chris. Did you want to do the next one? Do you want to do it? Absolutely. Okay. I thought we were going to. Yes. Okay. A physician enters a patient's room to discuss a patient's disease trajectory and prognosis. He starts by asking the patient what they already know about their illness and to what detail they would feel comfortable discussing it. The physician is using a communication technique called Ask, tell ask communication technique linear communication permissive communication authoritarian communication. Okay. That seems very straightforward to me. Yes. So you asked something. He told them something and then asked them something. Yes. Yes. So I think that's that's not even certain what some of those are but that's just me. Well authoritarian communication is when you live in a like certain countries where they don't. I mean, I can. Yeah. Yeah. Okay. I don't know that any of the rest of them are actual communication techniques. Fair. Yeah. I think I would think linear communication would be, you know, you just start talking and you keep going until you're done. I've witnessed that several times. Yeah. I have to. It's unfortunate for the family. And I don't think permissive communication is a thing I agree with you on that. I'll look, I'll Google that while we're in the next one. Okay. All right. You want to read one Amanda? I will try. Well, obviously I'm doing. I think we all do. I was very flat on mine or else I can show inflation. You just discussed with a patient and their family a new diagnosis.
of metastatic cancer and that the patient has a likely prognosis of three months to live. The patient is currently a full code and has never complete an advanced directive. What should you do next? A, immediately discuss advanced directives and code status. B, provide therapeutic silence and allow time for asking questions. C, revisit code status the next day if patient and family have had adequate time to process the new information. D, A, and B or E, B and C. That was delightful. Excellent. Yeah. Well, it was really hard to put extra inflection on the right answer there. Right. So I think immediately discussing advanced directives would be incorrect at this point. Right. Sure. You've got to give them a call. I hate to just jump into that after delivering bad news. So it's like, well, yeah, you got cancers and now let's talk about what's going to happen when you die. As a matter of fact, though, I will use that as a technique to sell this idea to people and saying, you know, it's ridiculous every time you come into the hospital, like we have a post-form and some states have most forms, post-forms, the traveling DNR forms. And I'll say that, you know, you come into the emergency room wanting to get better. And the first thing they do is ask you what do you want when you die. Yeah. And if you have this form, then you just shove this in their face and they'll shut up about it. And it gets old every, you know, every time you come into the hospital having to talk about this. So anyway, so that's a, that's a sales technique for the post-form. So where are we going with the, with this question? Obviously, A is incorrect. Right. Providing therapeutic silence and allowing time for asking questions. When is that ever wrong? Yeah, there. And revisit the code status the next day after they've had time to process. So I would guess it would be B and C. You would be correct. Yeah. Yeah. Yay. All right. I'll read the next one. What's the first thing you should determine when discussing disease trajectory with a patient? A, determine their desired healthcare agent. B, assess what they already know about their condition. C, ask where the patient wishes to be buried. D, how often the patient has been hospitalized in the past year. That one's also very straightforward to me. Yeah. Yeah. Yeah, ask what they already know. That's what usually the first thing I ask before I do anything else, I introduce myself. Yes. What are these doctors telling you about what's going on? Absolutely. I've been burned by that one. Same. When I was in training. No. Now I also like to add on, hey, I've read through your chart and I know what's going on, but what have you been told? Yeah. Because otherwise you get hit with the, well, you've got my chart. Don't you know what's happening? Right. Right. Right. On sometimes too, when you introduce yourself and that you're with palliative medicine, the very next thing out of their mouth might be where they wish to be buried, because they have no idea what's happening. Right. That's right. Yes. You get in the conversation, well, when I'm dead, okay, honey, let's talk about that. Well, I would love for you. I would love for you. You know, we need to do a podcast just on the editorial that Caleb Nisely and I wrote about e-liology about how palliative medicine might need a new name, which really drives me crazy, because we fought for years for palliative medicine to be a medical subspecialty. And then here I am already trying to, you know, change the name to something else. But I do think we need an allergy name. Yeah. Physical medicine rehab has the same problem. If you say I'm going to send you to physical medicine rehab specialists, they think you're sending them to a nursing home. There. But that's the name of their specialty. Yeah. You know, so physiatry really doesn't work either. They need an allergy name too. But the thing that we proposed was e-liology, because e-lios was the god of mercy. And Greek mythology, but anyway. All right. Yeah, assess what they already know about their situation is the correct answer. All right. Who's taking the next one? Okay. Advanced care planning is important in all palliative and hospice patients, in which patient population should it be considered of the utmost important? Serosis, COPD, ALS, or metastatic cancer. Is there no all of the above? No. Okay. Of the utmost important. So that's a tricky one. Go ahead. Because we see a lot in cirrhosis patients, you know, those patients come in uptunded. Right. And have no advanced directive, no decision maker. And so you would think that getting it for them is going to be a really important one. Same with metastatic cancer, COPD. We know we've got this horrible trajectory. What do we do with it? But according to. No, according to us. Yeah. Well, according to the research or the books, ALS is the most important one, because determining what they want as far as ventilator support, surrogate decision maker when they reach those latter stages is apparently of the utmost importance. Well, yeah. To have greater than those. Because it'll be difficult for them to communicate that later. The metastatic cancer patient can hopefully make decisions up to the point where you know, they're very close to the end as well as COPD, same way, cirrhosis, you know, that one would be the next one. Yeah. Because they can become abtunded and unable to answer questions. But yeah, so many folks with ALS will say that they don't want a ventilator, but a significant fraction of them get it anyway. Because it's terrifying when you have that respiratory event in your wide awake and you can't breathe. Right. But there are lots of things we can offer and we could do a whole thing on ALS. I've got to have a talk on ALS that we could do, you know, for symptom management and prognostication and stuff. Absolutely. And I think that was the, when going through the books here with ALS, the most important thing by saying, doing an advanced directive ahead of time, because it's kind of like when you are coming to the ER and somebody asks you about your code status and you're like, well, I'm here to get better. Same with ALS. They're just looking for when the day comes that they will need a ventilator. Right. And so if you try to start those conversations early of what's quality of life to you, what's important to you and having those wishes down so that when that day comes, if they said, well, yeah, I would want to live on a ventilator, then we're talked about it and if that day comes and they say, no, I didn't want this. Of course, that decision could always change, but you can revisit that conversation. Right. That you had back when they were healthy of, is this quality of life, is this really what you want to do? Right. Yeah, if I'm cognizant, I'm on the ventilator for the new Batman movies coming out. Yeah, it gave me go untolings. I mean, everybody has different things that they're willing to live for and that's one for me. Just give me my audiobooks. Yeah, there you go. If your Stephanie just turned the light out every once in a while. It's like one of our partners. Yes. All right, well, let's move on to professionalism and practice. This is going to wrap it up, right? Yes. And this is a long one. So this is going to be a long episode, but that's okay. If people can listen to it and, you know, and chunks if they want to. So professionalism and practice, 38 questions on the exam, quarter of the exam. And it covers principles of biomedical ethics, professional boundaries, scope of practice, opioid stewardship, national hospice and palliative care standards and guidelines, self-care, including burnout, compassion, fatigue, and moral distress, clinical decision-making, continuous quality improvement, hospice criteria, and professional developments. There's a lot in this one. Yeah, yes. And then under professionalism, there's ethics, scope, standards, and guidelines, leadership and self-development. Do you want me to go through each one of those and break them down? You don't have to. Okay. All right. And then system issues, good. Goodness gracious, okay. Resource access, utilization, continuum of care, advocating for timely access, et cetera, et cetera, and quality improvement. All right. So who wants to do the first question? I'll do it. Okay. I've got this. Okay. You've got this. The referring physician tells the MP that he prefers to keep his patients in their homes as much as possible. He tells the MP to start performing paracentesis procedures on in-stage liver disease patients in their homes to reduce the need for frequent hospitalizations. What should the MP do? A, do as the physician tells you and add paracentesis to your collaborative protocol. I know, I'll just add that to my list. Right. B, check with your state's scope of practice for nurse practitioners prior to proceeding. C, state you would be happy to if the physician showed you how. Okay. D, tell the physician that a paracentesis cannot be performed in a patient's home. All right. Well, I'm going to say D is incorrect. Because obviously, any, basically any procedure could be performed in a patient's home. Right. Don't just willy nilly add stuff to your collaborative protocol. So A is out. So it's between B and C. But you need to make sure you're legal to do it. Go ahead. I was going to say, and while it is,
important to be trained in the procedure that you're being asked to do knowing if it's legal for you to do it is going to take precedence. Right. We had a state that wouldn't accept a prescription for a schedule two from one of our nurse practitioner partners because that state doesn't allow nurse practitioners to write schedule twos. Oh goodness. Yeah those people listening to that know what state they're in but if you're not in that state don't worry about it but you know so yeah you got to know what this copier practices. Yeah and that's one thing about the exam too is obviously it doesn't know what state you're in it's not state specific so don't get bogged down by trying to know exactly I mean you should know obviously but for the test it's general laws. There will be no state specific stuff. Right. You get one of those will know. Alright. Read the next one. Chris, if you don't mind. I will be happy to if you show me how that's my response. Is it in your scope of practice to read this? Okay. You're in the process of being credentialed for a hospital in your local area and are asked for documentation of what services you can provide in your specialty area. What documentation should you provide? The scope of practice guidelines for advanced practice nurses in the state of which you will be practicing. The scope of practice guidelines for hospice and palliative care advanced practice nurses in conjunction with the practice restrictions governed by the state in which you are practicing treatments and procedures that have been included in your collaborative agreement and filed with your state board of nursing. Your state license to practice your DEA your board certification your Medicare and Medicaid provider numbers your MPI number your recent CEUs and specialty certificates you have received your CPR card and your transcripts. Okay. That was a lot. That was a lot. Right. So not that one. Right. Right. Right. Right. Might as well add your social security number. It's too specific. Yes. And so when they give you a list of really really specific things like that it's often incorrect. But the scope of practice guidelines for advanced practice nurses you may have to do that but that's not the best answer. Right. And they should already. And do you have to file your collaborative agreement with the state board of nursing? See that again that's a state thing. I don't think that's a thing. Did you ever have to did you have to file our collaborative agreement with the state? I don't think so. We had to file something saying who our collaborating physicians were. Right. But not like the details of it. Right. Yeah. So that just really leaves be scope of practice guidelines for hospice and plight of care and advanced practice nurses in conjunction with practice restrictions governed by the state which are practicing. That makes sense. Yes. Okay. All right. You want to do the next one Amanda? Sure. All of the following are examples of professional development activities except a striving to stay under the radar and inch toward retirement. Sorry. Sorry. Be participating in professional organizations. See presenting at conferences and publishing and de educating colleagues and mentoring students. Okay. And so I think the only tricky thing about that one is the accept. You got to pay attention to the whole question. Correct. Yeah. So staying under the radar and inching toward retirement. Please don't make the mistake of reading half the question and then seeing an answer. It says, oh, well, that's right. And then circling it. Right. Because very often that's exactly what will happen as you miss the accept and you mark something that is true. But that's someone it's asking. Read the whole question. And even can you. So you're saying you can't highlight anything. Correct. Nothing. You can't do anything. You just can't do anything on the screen. Okay. Never mind. Because I was going to say, you know, highlight the word except take your pencil and write on the computer screen. Yes. Don't don't do that. I did not tell you to do that. All right. Choose the best definition of quality improvement. A quality improvement is a method for continual organizational restructure for upholding accreditation standards. B quality improvement is a division or a department within organizations, divine to review pitfalls or recommendations for punitive action. C quality improvement is a philosophy that organizations use to benchmark, reduce waste, increase efficiency and improve outcomes using research as a means for continuous evaluation and improvement. And then D quality improvement is an avenue for punishing employees for misconduct and medical errors as a way of reducing lawsuits. Now, this one violates my rule about having a big long list of things, but the long big long list of things and this is quite reasonable. Right. And so what do you think? It's the long list of a definition of quality improvement. Right. Right. All the facilities are ridiculous because it is the definition and not your perception. Oh. Wait. Wait. A lot of people don't know this next one. Okay. Good. That would be a good one. Yeah. I struggled with this one any time I had it on a practice test. Oh, I know this one. Of course you do. No, you know everything. Well, it's because I am old enough to know the answer. This will become obvious in just a second. Go ahead. You say that, but it's not a lot of people don't know it. I know, but I know what because I have I have this kind of insurance. Go ahead. That makes sense. Okay. Got it. Now got it. All right. An 82 year old patient tells you they have had enough and no longer want aggressive treatment for their terminal illness. They state they just want to go home with hospice, but they do not know if they can afford it. You know the patient has Medicare and explain a Medicare part D covers your hospice benefit. B, you pay up front, but Medicare will reimburse you. C, Medicare part B covers your hospice benefit or D, Medicare part A covers your hospice benefit. Okay. So Medicare part D is your medication benefit. And then we know you don't pay up front. Right. So it's between B and A. And this you just have to know the answer to this. B is your hospital insurance. No, I'm sorry. A is your hospital insurance. B pays for everything else. So for example, I do not have Medicare part B because I'm covered for health insurance, you know, to go see my doctor and all that kind of stuff with my employers insurance. So, but I Medicare part A is free and so and it covers your hospitalization stuff. So you just have to know that it's bundled into the hospital sign. So part B pays for services from doctors and other healthcare providers, outpatient care and home healthcare, which is where people get screwed up. And part A pays for hospital and your Medicare hospice benefit. All right. Part A also covers skilled nursing facilities and lab tests and some parts of home healthcare as well. All right. And that's a hard one for those of us that do palliative and not hospice because that's not just in your rolodex of information up there. Correct. That's what a lot of this professionalism and practice I think what benefited me personally when I took the exam was, oh, what was that program that we did? Elnick? Elnick. Yes. Elnick. Elnick really hones you in on the hospice knowledge as far as I mean things like that just criteria and definitions and things like that. Right. That's the end of life nursing education consortium education thing. Yes. And it really it put a lot of hospice knowledge up there in my personal rolodex but when you do work in palliative and or vice versa, if you work strictly in hospice you might see some of the very straightforward palliative questions and get tripped up on them and not have that right. Just based knowledge that's there all the time. Yeah. I know when our colleagues that are are in with hospice had taken the nursing version of this. A lot of them got tripped up on the palliative questions because that wasn't in their will. Yeah. Interesting. Yeah. Yeah. Yeah. All right. So the four levels of care included within the Medicare hospice benefit are a 24/7 nursing care routine hospice care hospice travel care and caregiver support. B, routine hospice care general and patient care continuous home care and inpatient respite care. C, home visits by RN, LPN and CNA, emergent hospital transportation and procedural care coverage of medical medically necessary supplies and equipment and physician oversight of medical needs and medication review. D, all medications periodic nursing care caregiver support and adjunct professional services such as social work, [BLANK_AUDIO]
clergy and dietician. Okay. So there's some tricky ones in here. Reading all of those answers, the question was what are the four levels of care correct included in the Medicare hospice benefit? So all medications is not correct either. It's all medications related to comfort for the hospice diagnosis, but that's not a level of care. Right and that's where this one is tricky because a lot of the things in the lists are things that are part of hospice, but they are not the levels of care. Social work, clergy, that kind of stuff is also included, but that's not a level of care. Right. And so there you go. So the correct answer is B, routine care, GIP or general inpatient care, continuous home care and respite care. I actually spent some time yesterday when I was working on the Medicare website looking at what all is covered under hospice because I just get confused still myself sometimes. And I was trying to figure out if TPN could be done on hospice. Right. I know what you're asking that. And then I found it interesting on like the main site where it just kind of goes down a bullet point of just things that hospice offers. It does list physical therapy, occupational therapy, all these things that like we know can be done, but it's and sometimes in practice is difficult to have that achievable. What happens sometimes is the liaison themselves that you're talking to are not aware that they can offer those things. Right. And so you know when I tell people if you're going to be certified in this specialty, it's just like you, if you're going to be a poker player, if you know the rules of the game, if you're played poker against somebody, it doesn't know the rules, you're going to win every time. That's why always know that we'll let go. But we need to be the ones that know the rules because that way we can best advocate for our patient. So what I tell people is the rule of hospice is if you couch it in comfort, then they almost have to give it to you. The patient would be more comfortable if only they had X. Whatever X is would be something that you could argue for hospice covering. So yeah, we've had people get radiation therapy in hospice before because it was for pain. Right. And they got you know two fractions or whatever and then went on their way. So yeah. All right, very good. And I think that's that's what I learned on on their website yesterday is that TPN can be covered by hospice if a patient has a functional status to where they can still live and have quality of life and be functional. And that is their main source of nutrition if they have like a metastatic bowel obstruction or something like that. And that's very interesting because you and I talked about that. And I you know, I've always felt that that should be covered, but I've never had one be covered. Yeah, right. But we don't take away people's food. Right. And this is the argument that I have with hospice agencies all over the place. That you know, they're like, well, they want to continue enderal feeding. It's like so. I mean, we don't say you can't eat. So why would we say the person can't eat because that's what you're saying. And that's not a litmus test. Right. Also being DNR just for the new folks out there is not a litmus test for hospice. You can't have the only litmus test for a hospice. I'm every such stage. The only litmus test for hospice is six month prognosis. That's it. Yeah. None of those criteria that we have, those are just slam dunks for six month prognosis. But you don't have to have those if you don't meet for any of the criteria, but you can make the argument that the patient despite that as a six month prognosis. And you can get the medical director to sign off on it. Then that patient qualifies for hospice care. Yeah. Yeah. And that's a good one. Remember because I mean, even with that knowledge that I obtained yesterday, it didn't end up helping you. Helping because yes, because the criteria is so specific. This patient's performance status was say 20%. Right. So it would not have been covered because they are supposed to be able to be up and functional. Oh, really? Okay. That's the same. I'll have to look at that. Again, the local coverage determination. I don't know what I'm talking about. I just didn't research yesterday. The local coverage determination also may vary by your CMS provider too. Right. And that was very specific to I was looking at Tennessee. Yeah. Okay. Very good. All right. A 65 year old patient with end stage gastric cancer repeatedly verbalizes her desire to stop her tube feedings. Her physicians refusal to comply with her decision is a violation of the patient's autonomy. Be an example of beneficence. See mandated by the law or D surrogate decision. Okay. It's come on. Speaking of patients who are getting non-oral nutrition. Yeah. Yeah. Right. Well, it's obviously a violation of their autonomy. Yes. And it's not you're not it's not beneficence because you're not doing this to to benefit them in their and it's not mandated by the law. And it's not surrogate decision making because the physician can't be the surrogate decision maker. So all right. They can sometimes make in some states make decisions for patients who cannot make decision for themselves and don't have a surrogate decision maker. But that will not be on the exam because that not every state has that that are fact for Tennessee does. Virginia does not. So there you go. All right. Next. And then just a couple of little additional things that I did not come up with questions for is knowing effective leadership qualities and also ways to remain professionally active within your specialty are a couple of big things to know for this test. Absolutely. My number one for leadership is do as I say not as I do. It's good advice. I don't remember specifics or even a good like to come up with a question off hand but that I had a lot of that. I mean just how to be active in your profession and I would think that those questions may be mostly common sense that those are not the ones we're going to get tripped up on. Like how to communicate with your state board of nursing or how to stay in contact with colleagues when you go to conferences or things like that I think. Yeah. Would be the general oversweeping idea there. I want to do that. Well I think those sound pretty straightforward. I can't imagine too many people getting tripped up with that. Well do we have anything else? I think we're done right? I think so. Wow. Okay. Well done. You all I'm giving you one of these. And I had the AI do some words of encouragement for you. Here you go. Harken to thine inner voice and give thyself a bell. No task shall be denied if I will be strong and true. For when a bell is wrong it carries with it the sound of courage that give its strength to even the meekest of hearts. So ring thine own bell and be mindful of its power and might. For it will be thy guide in whatever task thou sets thy sight. I don't know what was just said. Well it's saying that's beautiful. It was wonderful. Keep your eyes on the price. Yeah of course. It's really saying nothing but sounded awesome. It did. So yeah well thank you. So Chris this is your last live podcast with us. We're going to miss you because Chris is moving on to she got a new job with a new big promotion and she's moving to another part of the country and further some personal reasons there as well that are all good. So we're very happy for you and we're going to miss you and I'm going to probably cry on Friday as I know that you're in the on the road leaving because you've been a just a wonderful partner and you're sense of humor and your dog goodness staying on top of your patience and making sure that they're that their well-being is cared for above everything else despite you know challenges with some attendings who don't seem to understand this that or the other some other things like that without going into too much detail I mean just in general you know you put your patience first before everything else and we really appreciate that and so we're going to miss you. Thank you. We'll miss you a lot. But you know you can still do you can still do this podcast with us you just do it through Skype and I think that would be some room for insight in having you know a different perspective you're going to be in the northeast. Yes. In a major kind of metropolitan area I'll be very interesting to see the differences between what we're doing now and what you're doing then so please do join
As soon as you get settled in, I'll send you the Skype link and we'll do this again. Wonderful. Alright, yay. Okay, well, there we go. Amanda, I will see you in a couple of weeks where we'll find something to do. Alright. We just said we were going to do something I already forgot what it was. Pure nervous. Well, we'll. Yeah, we talked about it. Oh, yeah, we did the last one. We talked about getting the ACHP and people on here and another one too. And berating them for their low pass rate, which hopefully we're making a dent in. They have not yet posted the updated numbers from 2023. Okay. I'll be very interesting to see. I'll see. I also would. If it goes up, we're taking credit for it. Yes. I would join, like to join that podcast too, just a. Yeah, absolutely. Or I'll listen. Yeah, no. You're more than welcome anytime. Alright, my friends. Well, thank you. We've been listening to HPM Talk, the podcast of the MyNHPCO physician and advanced practice provider community. If you have a topic or question you'd like to explore on the show, send me an email at
[email protected]. Our executive director is Dr. Amjad Riyar. Our administrative editor is Don Cook. Thanks for being with us and we'll see you soon for another edition of HPM Talk. Thanks, everybody. Thank you. [Music]
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