2017 ocn test blueprint content areas palliative care and

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“The art of palliative care encompasses creative strategies to manage pain and deleterious symptoms so that patients can experience a dignified death and

focus on more pertinent psychosocial or spiritual issues”… Dr. Jeanine M. Bryant

Palliative Care and End of Life Care

Cynthia Smith, RN, BA, MSN, AOCN

Oncology Clinical Nurse Specialist

CHI Franciscan Health Harrison Medical Center

2017 OCN Test Blueprint Content AreasContent Area Percentage of

2017 Test

# of Scored

Questions*

Health Promotion, Screening & Early

Detection

6% 9

Scientific Basis for Practice 9% 13

Treatment Modalities 16% 23

Symptom Management 22% 32

Psychosocial Dimensions of Care 8% 12

Oncologic Emergencies 12% 17

Survivorship 8% 12

Palliative & End of Life Care 11% 16

Professional Performance 8% 12

*To determine the number of scored items from each subject area, multiple the percentage by 145.

2017 OCCC Test Candidate Handbook (2017). Oncology Nursing Certification Corporation, page 8, http://www.oncc.org/files/2017TestCandidateHandbook.pdf .

Objectives– After this presentation, participants will

be able to:

• Compare / contrast palliative care versus end of life care.

• Identify common signs and symptoms of patients who

are experiencing end of life care challenges.

• Review symptom management resources compiled by

the Oncology Nursing Society i.e. Putting Evidence into

Practice (PEP) and by the National Comprehensive

Cancer Network, i.e. Palliative Care Practice Guidelines.

• Engage family and care-givers in assuming an active role

in palliative & end of life care.

The basic medical and nursing approach toward

patients in a hospice program is:

A. Acute Care

B. Curative Care

C. Palliative Care

D. Euthanasia Care

SAMPLE PRACTICE QUESTION

http://www.oncc.org/files/2017TestCandidateHandbook.pdf

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The basic medical and nursing approach toward

patients in a hospice program is:

A. Acute Care

B. Curative Care

C. Palliative Care

D. Euthanasia Care


Radiation is indicated for patients receiving

hospice care to:

A. Decrease brain metastases and prevent seizures

B. Prevent bowel obstruction

C. Decrease pain from bone metastases

D. Stop bleeding from a fungating breast mass


Radiation is indicated for patients receiving

hospice care to:

A. Decrease brain metastases and prevent seizures

B. Prevent bowel obstruction

C. Decrease pain from bone metastases

D. Stop bleeding from a fungating breast mass


/

What’s important to person with chronic illness?

• Maintain independence / Not being a burden

• Pain and symptom management

• Living longer

• 70% of people with advanced chronic illness are admitted to the hospital in the last six months of life.

• An estimated 25% receive inadequate symptom management.

Institute of Medicine (2015)

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Overview of Palliative Care

• To Palliate – to alleviate or to lessen the severity of, without curing (Webster’s)

• Palliative care is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness - whatever the diagnosis.

• World Health Organization defines palliative care:

- The active, total care of patients whose disease is not responsive to curative treatment.

- Control of pain, other symptoms, social, spiritual, and psychological problems is paramount.

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Hospice and Palliative Care

• Hospice

• Provides care for patient and family when patient is terminally ill

• Provides interdisciplinary support and care

• Palliative care

• Approach that improves quality of life for patient / family when facing life-threatening disease (WHO, 2003)

• Focus: symptom management, comfort, and support

• “Palliative care is appropriate at any age and at any stage of a serious illness and can be given with curative treatment”… Dr. Diana Meier, CAPC, 2012

Common Elements of Palliative Care and End of Life Care:

Respect for the Patient Goals, Preferences and Choices

• Palliative care is patient and family-centered.

• Staff should identify & honor patient / family preferences.

• Pay attention to: values, goals, priorities, cultural, and spiritual issues

• Assist patient to establish goals of care; continue to foster patient understanding of diagnosis / prognosis;

• Clarify priorities and enhance informed choices; provides an opportunity to negotiate provider care plan

• Promote Advance Care Planning & Advanced Directives.

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/

Palliative Care and Hospice Comparison

• Both focus on symptom management & quality of life.

• All hospice care IS palliative care for use at end of life.

• All palliative care IS NOT hospice care i.e. the patient may still pursue active treatment with curative intent.

• If a patient’s intractable symptoms can’t be managed by the

primary care provider (PCP) and/or hospitalist expertise, ask the

patient PCP to order a Palliative Care referral / consultation.

• Palliative Care consults seek to identify & to apply best practice

strategies chosen S/P interdisciplinary review of the evidence.

• Palliative Care submits orders that support the plan of care, e.g.

to relieve uncontrolled symptoms; to mitigate suffering; and to

improve quality of life for the patient and family./

Palliative Care is Different from Hospice

Palliative Care

- May be offered from the time of diagnosis to the

end of life – any age, stage or setting

- Patients may receive palliative care even if curative

treatments are planned

Hospice

Under Medicare, patients must:

- Have a prognosis of 6 months or less if the disease follows

its usual course AND

- Be willing to relinquish curative treatments and Medicare

Part A (hospital and acute care)

d

/

Hospice Benefits

• Interdisciplinary team and home services

• Care until death occurs and for family for 13

months after death

• Respectful death

• Low hospital re-admission rate

• Bereavement care

Sample Practice Question

• The adult children of a patient who has just died approach the nurse expressing feelings of sadness, helplessness, and numbness. The nurse can provide support to this family by:

• A. Encouraging a family conference

• B. Validating needs for counseling for these feelings

• C. Encouraging discussion with the physician

• D. Validating these as normal feelings of grief

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• The adult children of a patient who has just died approach the nurse expressing feelings of sadness, helplessness, and numbness. The nurse can provide support to this family by:

• A. Encouraging a family conference

• B. Validating needs for counseling for these feelings

• C. Encouraging discussion with the physician

• D. Validating these as normal feelings of grief

Patient Physical Symptoms During Terminal Illness

• Fatigue (90%)

• Anorexia (85%)

• Pain (75%)

• Dyspnea (79%)

• Nausea (68%)

• Constipation (65%)

• Delirium & Confusion (60%)

• Death rattle (56-92%)

• Xerostomia (10%)

Putting Evidence Into Practice (PEP) – Cancer Symptom Management

(Problem, Incidence, Risk Factors, Assessment, Interventions, & Application to Practice)

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Sample Practice Questions

• A patient scheduled for chemotherapy complains of shortness of

breath, fatigue, and facial swelling. Physical assessment reveals

neck vein distension, edema of the hands, tachycardia, and

cyanosis. The nurse calls the physician and instructs the patient to:

• A. Sit up and anticipates an order for a chest X-ray

• B. Lie flat and prepares the patient for an echocardiogram

• C. Lie flat and prepares the patient for a thoracostomy

• D. Sit up and begins the chemotherapy infusion


• A patient scheduled for chemotherapy complains of shortness of

breath, fatigue, and facial swelling. Physical assessment reveals

neck vein distension, edema of the hands, tachycardia, and

cyanosis. The nurse calls the physician and instructs the patient to:

• A. Sit up and anticipates an order for a chest X-ray

• B. Lie flat and prepares the patient for an echocardiogram

• C. Lie flat and prepares the patient for a thoracostomy

• D. Sit up and begins the chemotherapy infusion

So Happy to have all of my symptoms managed!

Symptom Recognition

and Management

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Management of Pain

• Pharmacy Options: Opioids, adjuvants, NSAIDs, tricyclics, steroids, muscle relaxer, neurontin, gabapentin and pre-gabalin.

• Other invasive interventions (radiation, radiopharmaceuticals).

• Intrathecal route, nerve blocks, epidurals, TENs units are back!

• Non-pharmacologic Options include: cold, heat, re-positioning, topical patch, distraction, progressive muscle relaxation, guided imagery, medical hypnosis, acupressure, acupuncture, multi-modal models, acute on chronic pain, integrative health therapy, assessing function, therapeutic duplication, overuse of opioids.

• Be alert for opioid-induced neurotoxicity; may see hyperalgesia and / or allodynia. Opioid rotation / excess hydration may be required to manage myoclonic / dystonic reactions, seizures, and poorly controlled and/or uncontrolled pain.

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Dyspnea - Breathless Sensation

“Uncomfortable awareness of breathing or shortness of breath”

Dyspnea Management: Breathless Sensation• Goal - Change or reduce breathless sensation

• General Symptom Measures - Consider O2 therapy

- Position patient upright

- Use overhead / bedside table to support arms, upper body

- Raise head of bed or add pillows

- Pace activities: allow rest periods, change times (S/P sleep)

- Cool fan blowing breeze on patient

• Breathing Techniques – pursed lip, diaphragm.

• Distraction - massage, music, movie, internet, progressive relaxation

• Reassurance – very frightening experience like drowning.

• Treat pain

• Occurs days to weeks before death in up to 79% patients.

• May see symptoms without change in O2 or CO2 saturation.

Dyspnea: Pharmacologic ManagementBronchodilators

• Albuterol by metered aerosol or 2.5-5 mg by nebulizer, Q 4-6 hours

• Aminophylline, theophylline

Anxiolytics

• Benzodiazepines may reduce dyspnea (anxiolytic / sedative effect)

• Diazepam 2 mg po Q 8 hours (5-10 mg at HS)

• Lorazepam 0.5-2 mg PO / IV / SL

Opioids

• Morphine Sulfate & other opioids are most useful drugs to treat dyspnea

• Obtain order for morphine 5-10 mg PO / IV / SQ q 4 hr; titrate to effect

• Pt. already on morphine–increase dose by 25-50%

• Nebulized morphine or hydromorphone (Dilaudid)

Corticosteroids

• May improve dyspnea associated with lung cancer

• Prednisolone 40-60 mg/d PO

• Dexamethasone 8-12 mg/d PO

Anticholinergics (for excessive secretions)

• Scopolamine 0.4-0.8 mg IM Q 4 h; 0.8-2.4 mg/d SC infusion or injections

• Scopolamine patch (several hour delay onset of action)

- Benzodiazapines (Ativan, Valium, Versed)


When a patient end of life complains of dyspnea, the nurse

should most appropriately focus on which of the following?

A. Determine degree of dyspnea by assessing arterial

blood gases and pulmonary function tests

B. Monitor pulse oximetry to determine need for oxygen

C. Administer opioids to lessen the sensation of

breathlessness

D. Administer bronchodilators as needed.

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When a patient end of life complains of dyspnea, the nurse

should most appropriately focus on which of the following?

A. Determine degree of dyspnea by assessing arterial

blood gases and pulmonary function tests

B. Monitor pulse oximetry to determine need for oxygen

C. Administer opioids to lessen the sensation of

breathlessness

D. Administer bronchodilators as needed.

Chronic Nausea and Vomiting

Unrelated to Chemotherapy

Management: Chronic Nausea / Vomiting unrelated to

ChemotherapyManagement: Chronic Nausea / Vomiting

unrelated to Chemotherapy

Non-pharmacological.

• Surgery may be considered in cases of mechanical bowel

obstruction. However, surgery should be individualized, with

physicians weighing risks / benefits of the procedure.

• Use of acupuncture to treat N/V in advanced illness has not

been conclusively proven as best practice

• Lavender aromatherapy & use of ginger are being studied

• Cold compresses on neck (sides, back) may be helpful

• Some people wear copper bracelets to manage N/V

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• Nursing interventions for the management of nausea

include encouraging patients to:

• A. Use sauces and gravies

• B. Eat foods that are cold or at room temperature

• C. Eat high-protein and high-potassium foods

• D. Avoid brushing their teeth when they are nauseated


• Nursing interventions for the management of nausea

include encouraging patients to:

• A. Use sauces and gravies

• B. Eat foods that are cold or at room temperature

• C. Eat high-protein and high-potassium foods

• D. Avoid brushing their teeth when they are nauseated

HiccupsHiccups: Causes

• Diaphragmatic Irritation• Malignant infiltration

• Inflammation/infection

• Hepatomegaly, ascites

• Gastric distention/obstruction/compression• Obstruction, gastric tumor

• Esophagitis

• Phrenic nerve irritation (mediastinal tumor)

• Intracranial disease (cerebellar or medullary tumor)

• Metabolic (uremia, hyponatremia, hypocalcemia)

• Meds (Benzodiazepines, Barbiturates, IV corticosteroids)

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Hiccups: Nursing Interventions• Vagal, pharyngeal stimulation

• Swab, NG tube

• Massage external auditory meatus

• Sneezing

• Elevation of pCO2

• Reduce gastric distention• Aerated drink

• Peppermint water

• Metoclopramide

• NG tube

• Pharmacological• Chlorpromazine (10-25 mg PO Q 6 h)

• Baclofen

• Haldol

• Midazolam (if sedation not a concern)

Delirium

Delirium: Identification and Treatment

• A history of patient's baseline mental status prior to symptom onset should

be obtained from his or her family, caregivers, or both parties.

• Fluctuating consciousness is hallmark of delirium

Commonly used screening tools: Tools to rate severity:

- Mini Mental State Examination - Memorial Delirum Assessment Scale

- Confusion Assessment Method - Disability Rating Scale

Delirium differs from dementia: dementia doesn’t have acute alterations LOC.

Delirium is classified according to level of agitation; for example, an agitated

patient has hyperactive delirium; patient who is withdrawn / somnolent has

hypoactive delirium. Commonly see mix of both.

Prevalence rates for delirium range from 30% to 50% for hospitalized patients

and is typical in the hours or days before death. May be reversed 50% of time.

Delirium is a clinical emergency characterized by changes in consciousness,

hallucinations, and changes in the sleep–wake cycle and language.

Delirium: Management ApproachesInterventions

• Inquire about alcohol intake, as alcohol withdrawal can precipitate delirium;

responds to benzodiazepines, clonidine.

• Non-pharmacological approaches to delirium are:

- Keeping room lights on

- Have calendars and pictures at the bedside

- Frequent redirection

- Allow patients to participate in their care.

• Treat reversible causes.

• Provide a calm environment and minimize disturbances.

• Teach family safety precautions / Support family with additional help.

• Provide respite for client and family / Use medications when appropriate.

• Minimize disturbances in environment / Provide explanations & support to family.

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Delirium Management: Common Pharmacological Drugs

Drug Dosage Adverse Events Comment

Haloperidol0.5 mg orally 2–3 times

a day

Acute extrapyramidal

events (eg, torticollis,

oculogyric crisis,

tongue and laryngeal

spasm)

Mild to moderately

agitated elderly

patients

1–2 mg intravenous /

subcutaneous every 30

min to 1 h until agitation

resolved

Severe agitation in

patients aged < 60 y

Risperidone1 mg orally each day or

every other day

QT interval and

cardiac arrhythmia

Potent dopamine

blocker

Olanzapine 2.5–11 mg dailyQT interval and

cardiac arrhythmiaVery anticholinergic

Quetiapine25–75 mg orally every

day

QT interval and

cardiac arrhythmia

Lorazepam

0.5–1 mg

intravenous/subcutaneo

us

Do not use alone

Useful for severe

agitation in

conjunction with

haloperidol


Delirium is common in the final days of life. Which of the following

nursing interventions would be counterproductive in the management

of delirium?

A. Concentrate on orienting an individual to what is real & what is not

B. Administer low-dose haloperidol to decrease anxiety

C. Discontinue benzodiazepines because they can worsen delirium

D. Encourage the individual to speak about a loved one that has

died.

Sample Practice QuestionDelirium is common in the final days of life. Which of the following nursing interventions would be counterproductive in the management of delirium?

A. Concentrate on orienting the individual to what is real

and what is not

B. Administer low-dose haloperidol to decrease anxiety

C. Discontinue benzodiazepines because they can worsen

delirium

D. Encourage the individual to speak about a loved one that

has died.

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Assessment: Depression and Anxiety

• Factors related to psychologic distress i.e. anxiety, depression, and neurocognitive changes. (Sivesind & Baile, 2001).

• Patients at end of life may experience anxiety (Pasacreta et al, 2001)

• Depression and anxiety are appropriate to the stress of having a serious illness (Pasacreta et al., 2001).

• Recognize evidence of depression such as hopelessness, helplessness, worthlessness, guilt, and sustained suicidal ideation (Block, 2001).

• Assess for anxiety (Sivesind & Baile, 2001).

• Review medications for drugs contributing to anxiety i.e. steroids.

• Assess for suicide plan.

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Interventions: Depression and Anxiety• Use antidepressants or antianxiety medications.

• Consider need to refer to mental health care provider.

• Use holistic communication e.g. active listening skills (Klagsbrun, 2001).

• Seek immediate help if suicidal ideation.

• Identify support systems and referrals to community agencies.

• Discontinue medication or change dose of drug increase anxiety/depression.

• Seven Dimensions:

- Redefining roles within family

- Dealing with burden of caring for the family member

- Struggling for paradox of living and dying

- Contending with daily life

- Searching for meaning

- Living day to day and attempting to enjoy the time left

- Preparing for death in concrete ways, e.g. legal, financial.

• Important to assess family as a system (Goetschius, 2001).

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Patient & Family Supportive Care Needs in Terminal Illness

▪ Physical Symptoms / Needs

Delirium

▪ Psychological Needs

Anxiety

Depression

Grief / Bereavement

▪ Spiritual Needs

▪ Cultural Needs

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Assessment: Social Support

• Assess family functioning and structure:- Assess strength i.e. member has healthcare training; challenge i.e. frail, dementia.

- Assess knowledge deficits in end-of-life care.

- Collaborate with social worker to complete a family assessment.

Interventions: Social Support

• Strengthen family:- Encourage communication among family

- Respect the privacy of family

- Provide access to resources for family needs

- Spend time with family (Goetschius, 2001)

• Teach caregiving skills to primary caregiver; demonstrate technical skills.

• Help client redefine long-term goals, set immediate goals.

• Families desire a few basic interventions from the nurse.

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Spiritual and Cultural• Spirituality involves finding meaning, finding hope, defining

relatedness, finding forgiveness.

• Spirituality and religion are complementary but not identical

concepts (Highfield, 2000).

• Culture identifies a group of people with similar values, norms,

lifestyles, rules, language, beliefs.

• Spirituality and culture overlap (Taylor, 2001).

• Assess for spiritual distress and needs.

• Identify religious practices that have meaning for the patient.

• Assess for cultural values that may impact the patient’s

terminal care.

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What is your culture? Who is in your tribe?

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Interventions: Spiritual and Cultural

• Recognize spiritual and cultural values of client and family.

• Allow client to talk about spiritual concerns (actively listen, remain non-judgmental).

• Encourage family to remain present with client.

• Share information about fears, guilt, doubts.

• Activate client’s spiritual resources.

• Include cultural aspects in providing care to client and family.


• In order to assist in reaching the patient’s spiritual pain

during end-stage disease, the priority nursing intervention is:

• A. Encourage random reflection of life’s events

• B. Mobilize the patient’s support system

• C. Acknowledge the legitimacy of the patient’s pain

• D. Encourage the patient to avoid focusing on those issues


• In order to assist in reaching the patient’s spiritual pain

during end-stage disease, the priority nursing intervention is:

• A. Encourage random reflection of life’s events

• B. Mobilize the patient’s support system

• C. Acknowledge the legitimacy of the patient’s pain

• D. Encourage the patient to avoid focusing on those issues

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Terminal Dehydration:

Nurse Role and InterventionsTerminal Dehydration

• As patient approaches death, desire to consume food

decreases

• Dehydration predictable

• Emotional & ethical dilemma in palliative care

• Families/care providers find it difficult to hold

• May feel they are starving patient or causing suffering

• Experience sense of guilt, frustration, no control over death

• However, may lead to enhanced comfort

Terminal Dehydration: Nursing Interventions

• Describe possible positive effects of dehydration

• Discuss disadvantages of hydration (invasive

procedure, increased cardio/pulmonary load, possible

need for catheter, may decrease comfort)

• Recognize family needs and respect wishes if they

choose hydration

• Oral care every 2 hours to moisten mouth and protect

mucous membranes


As your patient nears death, his daughter is distressed and believes

he is suffering because he is unable to drink fluids. She insists you

give him intravenous fluids. In an attempt to help her understand her

father’s condition and provide optimal end-of-life care, which of the

following is the MOST appropriate response?

A. She is right; dying of thirst is painful and you will call the doctor

for intravenous hydration.

B. Assure her that he is not suffering or experiencing any

discomfort from dehydration

C. Suggest they insert a small nasogastric tube to administer fluids

to prevent dehydration

D. Suggest that she try to encourage her father to drink fluids in

small amounts

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As your patient nears death, his daughter is distressed and believes

he is suffering because he is unable to drink fluids. She insists you

give him intravenous fluids. In an attempt to help her understand her

father’s condition and provide optimal end-of-life care, which of the

following is the MOST appropriate response?

A. She is right; dying of thirst is painful and you will call the doctor

for intravenous hydration.

B. Assure her that he is not suffering or experiencing any

discomfort from dehydration

C. Suggest they insert a small nasogastric tube to administer fluids

to prevent dehydration

D. Suggest that she try to encourage her father to drink fluids in

small amounts

Engage Family / Caregiver in Care

• Music

• Assist with turning every few hours, reposition head on pillows

• Massages, lotion rubs

• Washcloths placed inside patient’s hand

• Avoid bright lights, loud noises

• Frequent oral care: Moisten lips with lip salve, lip balm

Plan with Family for Death Event

• Who does the family want to notify? Make a list of phone numbers

• See if patient / family wishes to notify chaplain or social worker

• Requirements regarding pronouncement at time of death

• Has funeral arrangement been made? Share list local mortuaries

• Assess for signs of impending death (Berry & Gribbie, 2001; Matzo

& Sherman, 2001).

• Assess caregiver knowledge related to recognition of impending

death.

• Assess for symptom control: unrelieved pain, dyspnea, terminal

delirium, agitation

Imminent Death: Recognize Physical Changes

Skin becomes cooler (hands, arms, feet, & legs) and

color may change to blue with purple splotches

• Normal indication that circulation is decreasing to

extremities and being reserved for vital organs

• Keep warm with blankets (no electric – burn risk)

Respiratory Congestion (“Death Rattle”)

• Gurgling (“as though marbles rolling around”)

• Caused by decreased fluid intake, ineffective cough

• Suctioning may increase secretions & discomfort

• Gently turn patient’s head to side

• Sound of congestion does not indicate pain

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Imminent Death: Recognize Physical Changes

• Incontinence• May lose control of urine and/or bowels as the muscles in area begin to relax

• Discuss measures to keep patient clean & dry

• Decreased urine output

• Urine output normally decreases & becomes tea color (concentrated urine)

• Due to decreased fluid intake & decrease circulation through the kidneys

Imminent Death: Recognize Physical ChangesBreathing pattern changes

• Apneic periods: spaces of 10-30 seconds where there is no

breathing at all

• Cheynes-Stokes respirations: irregular shallow breaths with

periods of up to 5-30 seconds & up to full minute no breathing

• Common, indicate decrease internal organ circulation

• Elevating head and/or turning may increase comfort

Other Changes: Mentation, Affect & Cognition• Increased sleeping * Disorientation

• Restlessness * Withdrawal

• Vision-like experiences * Hallucinations

67

Grief and Bereavement

• Bereavement is a human experience occurring with the

death of a loved one (Corless, 2001).

• Tasks of bereavement include accepting the reality of

the loss, experiencing the pain of grief, and adjusting

to the new environment.

• Grief may take many forms in the loss of a loved one.

• Possible factors e.g., re-awakening of an old loss,

multiple losses, social isolation (Potter, 2001)

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Interventions: Bereavement

• Encourage family / friends to say good-bye to client.

1. One positive memory 2. Bilateral forgiveness 3. Declaration of love

• Provide time for family and others to relive traumatic

event of death.

• Add to stability of the family’s social world.

• Ensure bereavement follow-up.

• Provide information regarding grief response.

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Questions?References

• Abernathy, A.P., McDonald, C.F., Frith, P.A., Clark, K., Hendon, J.E., Marcell, J. et al.(2010a). Effect of palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnea: a double-blind, randomised controlled trial. Lancet, 376(9743), 784-793.

• American Academy of Hospice and Palliative Medicine (AAHPM) Board of Directors. (2013). Position statement : Statement on artificial nutrition & hydration near the end of life. Retrieved September 25, 2014 from: http://aahpm.org/positions/anh

• American Geriatrics Society. (2012). Guiding principles for the care of older adults with multimorbidity: an approach for clinicians. American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity. Journal of the American Geriatric Society, 60(10), E1-E25.

• American Geriatrics Society. (2014). A guide to dementia diagnosis and treatment. Retrieved on September 25, 2014 from http://dementia.americangeriatrics.org/

• American Geriatrics Society. (2014). Position statement on interdisciplinary team training in geriatrics: An essential component of quality health care for older adults. Washington, DC Accessed: 9-2017 http://www.americangeriatrics.org/pha/partnership_for_health_in_aging/interdisciplinary_team_training_statement/

• American Geriatrics Society. (2014, April). Statement regarding the value of advance care planning. http://www.americangeriatrics.org/files/documents/Adv_Resources/AGS.Statement.on.Advance.Care.Planning.042014.pdf

• American Lung Association. (2014). Facts sheet chronic obstruction pulmonary disease. Accessed 10-2014 at: http://www.lung.org/lungdisease/copd/resources/factsfigures/COPD-Fact-Sheet.html

• Institute of Medicine (2006). Executive Summary - From Cancer Patient to Cancer Survivor: Lost in Transition; page 24, Box 2-2. The Academies Press, Washington.

• Morrison, R. S., & Meier, D. E. (2004). Palliative Care. New England Journal of Medicine, 350(25), pp. 2582-2590.

• Solano, J. P., Gomes, B., & Higginson, I. J. (2006). A Comparison of Symptom Prevalence in Far Advanced Cancer, AIDS, Heart Disease, Chronic Obstructive Pulmonary Disease and Renal Disease. Journal of Pain and Symptom Management, 31(1), pp. 58-69.

• Washington State Plan on Aging 2010-2014. Centers for Disease Control (CDC), 2012. Chronic Diseases and Health Promotion. Retrieved 9-22-17 at: http://www.cdc.gov/chronicdisease/overview/index.htm

• Institute of Medicine (2006). Executive Summary - From Cancer Patient to Cancer Survivor: Lost in Transition; page 24, Box 2-2. The Academies Press, Washington.

• Morrison, R. S., & Meier, D. E. (2004). Palliative Care. New England Journal of Medicine, 350(25), pp. 2582-2590.

• Solano, J. P., Gomes, B., & Higginson, I. J. (2006). A Comparison of Symptom Prevalence in Far Advanced Cancer, AIDS, Heart Disease, Chronic Obstructive Pulmonary Disease and Renal Disease. Journal of Pain and Symptom Management, 31(1), pp. 58-69.

• Washington State Plan on Aging 2010-2014. Centers for Disease Control (CDC), 2012. Chronic Diseases and Health Promotion. Retrieved 9-22-17 at: http://www.cdc.gov/chronicdisease/overview/index.htm

http://aahpm.org/positions/anh

http://dementia.americangeriatrics.org/

http://www.americangeriatrics.org/pha/partnership_for_health_in_aging/interdisciplinary_team_training_statement/

http://www.americangeriatrics.org/files/documents/Adv_Resources/AGS.Statement.on.Advance.Care.Planning.042014.pdf

http://www.lung.org/lungdisease/copd/resources/factsfigures/COPD-Fact-Sheet.html

http://www.cdc.gov/chronicdisease/overview/index.htm

http://www.cdc.gov/chronicdisease/overview/index.htm

2017 ocn test blueprint content areas palliative care and

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