IMPORTANT:The CME/MOC for this accredited activity is set to expire on 01/31/2023 and has undergone content validity review through the AAHPM peer review process. The reviewed and renewed CME activity, HMD PREP 2nd Edition (Reviewed 2023), will be available on 02/01/2023 through 01/28/2026.
Hospice Medical Director Practice Resource and Exam Prep, 2nd Edition (Reviewed 2022)
Assess your knowledge and prepare for your Hospice Medical Director Certification Board (HMDCB) Exam with HMD PREP, 2nd Edition. This online practice module contains 75 new or revised multiple-choice practice questions and includes explanations and up-to-date references to provide guidance for further study and is based on the HMDCB Blueprint. It is available in both study and test modes.
How You Will Benefit
- Pinpoint topic areas where you can benefit from further study.
- Experience an online test first hand before sitting for the certification exam.
- Earn CME credits and MOC points.
Access to HMD PREP
You can access HMD PREP on AAHPM Learn. The assessment provides the correct answer and explanations throughout the test to provide references for further study.
Content is based on the HMDCB Content Blueprint for the actual certification examination, and each question includes explanations for the correct and incorrect answers and references for further study.
A 42-year-old woman with metastatic cervical cancer who is enrolled in hospice is seen for a follow-up visit at home. The patient reports 9/10 pain in the perineal and suprapubic areas. She essentially is bedbound. Current medications include a fentanyl transdermal patch 50 mcg changed every 72 hours, gabapentin 600 mg three times a day, and hydromorphone 4 mg by mouth every 2 hours as needed for pain, which she takes 4 to 6 times per day on average. She has refused chaplain and social work visits and does not want to discuss her code status. She has heard about palliative sedation from the hospice nurse and now is requesting this treatment so she “doesn’t have to feel pain anymore.” You explore the patient’s understanding of palliative sedation. She believes that after palliative sedation is started, she can sleep most of the time but wake up intermittently to interact with her two children. She is looking forward to a sedative taking the place of her opioid regimen as she has never liked taking opioids. The patient has had a poor appetite and is asking whether she would have to be “fed by tube” during palliative sedation.
Which of the following is the most appropriate response to this patient’s request?
a. Aggressive symptom-directed interventions should be attempted first.
b. Artificial nutrition should be initiated prior to consideration of palliative sedation.
c. Other medications can be discontinued once sedation is achieved.
d. Palliative sedation is not possible in her situation as it will hasten her death.
e. Palliative sedation is irreversible once achieved.
Option A, aggressive symptom-directed interventions should be attempted first, is correct. Palliative sedation may be indicated when a patient is suffering from refractory symptoms, meaning symptoms not responding to aggressive treatment efforts. More aggressive pain management should be tried for this patient before her pain is designated as refractory and palliative sedation is considered. It also would be prudent to explore other dimensions of her pain and suffering, including spiritual, social, and psychological to see if nonpharmacologic interventions could be helpful in alleviating her suffering.
Option B, artificial nutrition should be initiated prior to consideration of palliative sedation, is incorrect. Although artificial nutrition and hydration (ANH) needs to be addressed prior to initiating palliative sedation, the decision regarding ANH should be treated separately from the decision to proceed with palliative sedation. ANH generally does not benefit patients who are undergoing palliative sedation or at the end of life.
Option C, other medications can be discontinued once sedation is achieved, is incorrect. Treatment directed at other symptoms should continue and be titrated if the symptoms are perceived to increase over time. Medications that normally should not be discontinued abruptly because of the risk of discomfort with abrupt discontinuation should be tapered even when the patient is sedated.
Option D, palliative sedation is not possible in her situation as it will hasten her death, is incorrect. Patients are dying of the disease for which they are enrolled in hospice. It is unclear whether palliative sedation will hasten death, especially since palliative sedation generally is offered to patients with a short prognosis, typically hours to days. Some studies have found no difference in survival between hospice patients with and without palliative sedation during their last days of life.
Option E, palliative sedation is irreversible once achieved, is incorrect. Prior to initiating palliative sedation, patients and families may request that sedation be lessened intermittently. This can allow the patient to interact with loved ones but also serves to reassess the comfort level and hence the continued indication for palliative sedation. Documentation of the planned intervention and the plan to reassess in the future is necessary as with any intervention.
Take Home Point
Aggressive attempts at symptom control need to be undertaken before a patient should be considered for palliative sedation.
Won YW, Chun HS, Seo M, Kim RB, Kim JH, Kang JH. Clinical patterns of continuous and intermittent palliative sedation in patients with terminal cancer: a descriptive, observational study. J Pain Symptom Manage. 2019;58(1):65-71.
Maltoni M, Scarpi E, Rosati M, et al. Palliative sedation in end-of-life care and survival: a systematic review. J Clin Oncol. 2012;30(12):1378-1383.
Ruth Thomson, DO FACOI FAAHPM HMDC
Miguel A. Paniagua, MD FACP FAAHPM
Authors and Reviewers
Lyla Correoso-Thomas, MD HMDC FAAHPM
Catherine Deamant, MD FAAHPM FACP
Jane E. Loitman, MD MBA MS FAAHPM
Martina Meier, MD HMDC
Miguel A. Paniagua, MD FACP FAAHPM
Joel S. Policzer, MD FACP FAAHPM
Beth Popp, MD HMDC FACP FAAHPM
Earl Quijada, MD HMDC FAAHPM
Alan R. Roth, DO FAAFP FAAHPM
Renato Samala, MD HMDC FACP FAAHPM
Ruth Thomson, DO HMDC FACOI FAAHPM
Denise G. Waugh, MD FAAHPM