End-of-life Care, Advance Directives, Hospice, Long-term Care Facilities, and Transitions of Care Practice Questions

25 multiple-choice questions on End-of-life care, advance directives, hospice, long-term care facilities, and transitions of care for paramedic and EMT students, from Chapter 45 (Geriatric Emergencies). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. A nursing home resident's POLST shows 'No CPR' and 'Comfort-focused treatments.' She has a painful hip fracture, and staff cannot control her pain at the facility. You should:

   1. A. Leave her at the facility, as the POLST forbids it
   2. B. Withhold care because she has a DNR order
   3. C. Start full trauma care, since the order is void
   4. D. Treat her pain and transport for comfort care
   Show answer

   Answer: D. Treat her pain and transport for comfort care

   Comfort-focused treatment allows oxygen, suction, positioning, and medications for symptoms, and the National POLST form directs transfer to the hospital when comfort cannot be achieved in the current setting, as here; give analgesia, splint gently, and transport while honoring No CPR. The POLST does not forbid transport for comfort. A DNR applies to cardiac arrest, not to pain management. An injury does not void a valid POLST.

2. A durable power of attorney for health care allows the named agent to make decisions:

   1. A. Whenever the agent disagrees with the patient
   2. B. When the patient lacks capacity to decide
   3. C. About the patient's finances
   4. D. After the patient has died
   Show answer

   Answer: B. When the patient lacks capacity to decide

   The health care agent (proxy) speaks for the patient only when the patient cannot make decisions; a capable patient's own choices take precedence. A financial power of attorney is a separate document.

3. A home care aide hands you a clear photocopy of a patient's completed POLST; the original is with her lawyer. In states that use the National POLST form, the copy is generally:

   1. A. A valid medical order, like the original
   2. B. Invalid because it is not the original
   3. C. Not usable until a notary stamps it
   4. D. Not usable until the hospital confirms it
   Show answer

   Answer: A. A valid medical order, like the original

   The National POLST form states that a copied, faxed, or electronic version is a legal and valid medical order, so a legible, completed copy can be followed in the field. Because POLST and out-of-hospital DNR rules are set by each state, know your state's form and protocol, and contact medical control if the document is unclear. An original is preferred but not required. POLST forms do not need notarization. EMS acts on the form in the field without waiting for hospital confirmation.

4. A man enrolled in hospice for heart failure is found in cardiac arrest. His wife says, 'He's on hospice,' but there is no DNR order or POLST in the home. Under most protocols, you should:

   1. A. Withhold CPR because he is on hospice
   2. B. Call the hospice before you touch him
   3. C. Start CPR and contact medical control
   4. D. Pronounce death because it was expected
   Show answer

   Answer: C. Start CPR and contact medical control

   Hospice enrollment is not itself a DNR order; hospices cannot require one for admission, and many hospice patients have not completed one. Without a valid DNR, POLST, or state-approved identifier, most protocols require starting resuscitation while contacting medical control and the hospice, which can often confirm a valid order quickly. Some states allow other documentation, so know your protocol. Withholding CPR on hospice status alone is not supported. Delaying CPR to call the hospice wastes the critical first minutes. Unless obvious signs of death are present, death cannot be presumed without a valid order.

5. A 92-year-old in cardiac arrest has a valid POLST marked 'YES CPR' and 'Full treatments.' Her niece, who is not her health care agent, says, 'She wouldn't want this.' You should:

   1. A. Withhold CPR on the niece's word
   2. B. Delay CPR until the niece calms down
   3. C. Start CPR but stop after a minute
   4. D. Begin full CPR as the POLST directs
   Show answer

   Answer: D. Begin full CPR as the POLST directs

   A valid POLST is a medical order that records the patient's own choices; when it requests CPR, start full resuscitation, explain kindly to the niece, and contact medical control if questions arise. A relative who is not the legal surrogate cannot revoke the order, and even a surrogate generally cannot void a POLST during an emergency without a clear process. Delaying CPR or giving a token attempt violates the order and the patient's wishes.

6. A healthy, active 68-year-old with no serious illness asks you whether she should get a POLST form. The best answer is that POLST is intended mainly for people who:

   1. A. Have turned 65, regardless of their health
   2. B. Have a serious illness or advanced frailty
   3. C. Want to name a health care agent instead
   4. D. Plan to donate their organs after death
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   Answer: B. Have a serious illness or advanced frailty

   POLST is a portable medical order for people with a serious life-limiting condition, which may include advanced frailty, for whom an emergency could be expected; a healthy adult is better served by an advance directive that names a health care agent and records her wishes. Age alone is not a reason for POLST. Naming an agent is done in an advance directive (health care power of attorney), not a POLST. Organ donation is recorded through a donor registry or driver's license.

7. A woman with COPD has a POLST marked 'NO CPR' and 'Full treatments.' She has a pulse but is in severe respiratory failure that is not improving on CPAP. You should:

   1. A. Treat fully, including intubation if needed
   2. B. Withhold treatment because she has chosen No CPR
   3. C. Limit care to comfort measures on scene
   4. D. Start chest compressions on her right away
   Show answer

   Answer: A. Treat fully, including intubation if needed

   Section A (CPR) applies only when the patient has no pulse and is not breathing; Section B guides care when she has a pulse, and 'Full treatments' allows all indicated interventions, including advanced airway management and intensive care. The National POLST form lets a patient choose No CPR with any level of treatment in Section B. Withholding care or limiting to comfort care ignores her chosen full treatment. She has a pulse, so compressions are not indicated; if she arrests, honor No CPR.

8. A dying hospice patient has stopped eating and drinking. Her son asks you to start an IV 'so she won't die of thirst.' The most accurate response is that in actively dying patients:

   1. A. IV fluid will reliably make her feel better
   2. B. Stopping eating means she is in pain
   3. C. Mouth care eases thirst better than IV fluid
   4. D. Dehydration this late causes severe suffering
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   Answer: C. Mouth care eases thirst better than IV fluid

   Loss of appetite and thirst is a normal part of dying; IV fluids rarely relieve the sensation of thirst and can worsen edema, secretions, and breathlessness, while moist swabs, ice chips, and lip balm relieve dry mouth. Explain gently, involve the hospice team, and follow the care plan. IV fluid does not reliably improve comfort at this stage. Not eating reflects the dying process rather than pain. Most dying patients do not experience severe distress from reduced intake when mouth care is provided.

9. A dying hospice patient has become restless, moaning and pulling at her sheets. She has not urinated in 10 hours. Before giving a sedative, you should first check for:

   1. A. A fever high enough to need active cooling
   2. B. Thirst that calls for a large IV fluid bolus
   3. C. A new stroke that calls for a stroke alert
   4. D. A full bladder or other source of discomfort
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   Answer: D. A full bladder or other source of discomfort

   Terminal restlessness often has a correctable cause: urinary retention, constipation, uncontrolled pain, a wet bed, positioning, or hypoxia; a distended bladder in a patient who has not voided in 10 hours is a likely culprit. Address it with the hospice team, then treat remaining distress per the care plan. Fever may contribute but is not the first thing this history points to. A large IV fluid bolus rarely helps a dying patient and can add secretions and edema. Restlessness without a focal deficit and with no urine for 10 hours points to retention rather than a stroke.

10. A dying patient with lung cancer feels breathless even though her SpO2 is 95%. A simple nondrug measure that often eases her breathlessness is:

    1. A. Laying her flat in bed with one pillow
    2. B. Raising the oxygen to a nonrebreather
    3. C. Asking her to breathe into a paper bag
    4. D. A fan blowing cool air across her face
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    Answer: D. A fan blowing cool air across her face

    Cool air moving across the face, from a handheld fan or open window, stimulates facial nerves and reduces the sensation of breathlessness; it is a recommended palliative measure. Sitting upright also helps, while lying flat usually worsens dyspnea. Extra oxygen does little for breathlessness when the SpO2 is already normal.

11. Which finding suggests that death is approaching in a terminally ill patient?

    1. A. Mottled skin and pauses in breathing
    2. B. Increased appetite and thirst
    3. C. Rising urine output
    4. D. Warm, flushed skin and alertness
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    Answer: A. Mottled skin and pauses in breathing

    As death nears, circulation fails, causing mottling and cool extremities, along with irregular breathing such as Cheyne-Stokes respirations and falling urine output. Appetite and urine output decrease, not increase.

12. A hospice patient has died peacefully at home, as expected, and the family called 911 in a panic. Your role is mainly to:

    1. A. Start CPR and continue until a physician arrives
    2. B. Move the body to the hospital
    3. C. Confirm death and support the family
    4. D. Leave once the family has calmed
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    Answer: C. Confirm death and support the family

    In an expected death with proper documentation, EMS confirms death, follows local notification rules (often the hospice nurse and law enforcement or the medical examiner), and supports the family. CPR is not indicated when it conflicts with the patient's documented wishes.

13. A family member at an expected death begins blaming herself for 'not doing enough.' The best response is to:

    1. A. Tell her that she should not feel that way
    2. B. Listen and acknowledge her feelings
    3. C. Explain the medical details of the death
    4. D. Leave her alone to grieve in private
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    Answer: B. Listen and acknowledge her feelings

    Listening, acknowledging feelings, and offering to call support people help grieving family members. Telling someone how she should feel dismisses her grief.

14. Which type of facility provides 24-hour nursing care for residents with significant medical needs?

    1. A. Independent living community
    2. B. Adult day care center
    3. C. Senior apartment complex
    4. D. Skilled nursing facility
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    Answer: D. Skilled nursing facility

    Skilled nursing facilities have licensed nurses around the clock and care for residents needing ongoing medical care or rehabilitation. Independent living communities and senior apartments provide housing with little or no medical care.

15. An assisted living facility mainly provides:

    1. A. Round-the-clock skilled nursing care
    2. B. Acute hospital-level medical care
    3. C. Help with daily tasks, little nursing
    4. D. Meals, with no personal help
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    Answer: C. Help with daily tasks, little nursing

    Assisted living offers housing, meals, medication help, and assistance with ADLs, but staff are often not nurses and may know little about a resident's acute condition. Round-the-clock skilled nursing is the role of a skilled nursing facility.

16. When transporting a resident from a skilled nursing facility, you should obtain the:

    1. A. Transfer sheet, drug list, and DNR status
    2. B. Resident's full billing and insurance file
    3. C. Facility's staffing records for the shift
    4. D. Resident's personal belongings inventory
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    Answer: A. Transfer sheet, drug list, and DNR status

    The transfer packet gives the hospital the reason for transfer, baseline, diagnoses, medications, allergies, and code status, reducing errors at handoff. Billing and staffing records do not support patient care.

17. Residents of long-term care facilities are at increased risk for infection with:

    1. A. Lyme disease from outdoor walks
    2. B. Drug-resistant bacteria
    3. C. Measles from visiting grandchildren
    4. D. Foodborne botulism
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    Answer: B. Drug-resistant bacteria

    Frequent antibiotic use, invasive devices, and close quarters make MRSA, VRE, and other resistant organisms common in long-term care. Lyme disease comes from tick bites outdoors and is not linked to facility residence. Most older adults are immune to measles from childhood infection. Botulism is a rare foodborne illness unrelated to facility residence.

18. Errors during transitions of care, such as from a nursing home to the ED, most often involve:

    1. A. Excessive detail in the verbal handoff report
    2. B. Overly frequent vital sign checks
    3. C. Duplicate copies of advance directives
    4. D. Missing or wrong medication information
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    Answer: D. Missing or wrong medication information

    Medication omissions and discrepancies are the most common transition errors, which is why medication lists and structured handoffs matter. Extra detail and duplicate directives do not cause harm.

19. The best way to give a handoff report for an older patient transferred from a facility is to:

    1. A. Give the chief complaint and age
    2. B. Use a structured report with baseline status
    3. C. Leave the transfer packet on the stretcher for staff
    4. D. Report the abnormal vital signs
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    Answer: B. Use a structured report with baseline status

    A structured handoff that includes baseline function, code status, and medications reduces information loss. A packet left on the stretcher may never be read.

20. During a community paramedicine visit, you screen an 80-year-old for fall risk using CDC's STEADI program. Which question is one of its three key screening questions?

    1. A. 'Have you fallen in the past 5 years?'
    2. B. 'Do you use a cane?'
    3. C. 'Do you worry about falling?'
    4. D. 'Do you take vitamin supplements?'
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    Answer: C. 'Do you worry about falling?'

    STEADI screens with three questions: Have you fallen in the past year? Do you feel unsteady when standing or walking? Do you worry about falling? A yes to any one prompts a fuller assessment of gait, strength, balance, medications, vision, and the home, and referral. The fall question covers the past year, not 5 years. Cane use and supplements are not among the three key questions, although assistive devices and medications are reviewed in the follow-up assessment.

21. A 92-year-old with metastatic cancer and full decision-making capacity declines transport for her pneumonia, saying she wants to die at home. You should:

    1. A. Respect her choice and arrange support
    2. B. Transport her against her stated will
    3. C. Have her adult daughter overrule her choice
    4. D. Sedate her so you can transport
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    Answer: A. Respect her choice and arrange support

    A capable adult may refuse treatment, even life-saving treatment; document her capacity and understanding, involve hospice or her physician, and advise calling back. Family members cannot overrule a capable patient.

22. A 90-year-old collapses in a restaurant and is in cardiac arrest. She wears your state's approved out-of-hospital DNR bracelet. In most states, the bracelet:

    1. A. Is valid in this public setting as well
    2. B. Applies inside her home but not in public
    3. C. Applies in nursing homes but not elsewhere
    4. D. Becomes void once she has left her home
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    Answer: A. Is valid in this public setting as well

    Out-of-hospital DNR orders and their approved identifiers (bracelets, necklaces, or forms) are designed to travel with the patient and apply in any out-of-hospital setting, including public places; verify that it is the state-approved identifier, honor it, and contact medical control if unsure. Programs vary by state, so know your protocol. Limiting it to her home or to nursing homes defeats its purpose. Leaving home does not void it.

23. A nursing home resident with a valid DNR is found dead. She has fresh, unexplained bruises on her neck and both wrists, and staff give conflicting stories. You should:

    1. A. Start CPR because the death is suspicious
    2. B. Clean the body before the family arrives
    3. C. Leave, since the DNR settles the matter
    4. D. Honor the DNR and notify law enforcement
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    Answer: D. Honor the DNR and notify law enforcement

    A DNR means no resuscitation, but it does not remove the duty to report a death with signs of possible abuse; do not attempt resuscitation, disturb the body and scene as little as possible, document the injuries objectively, and notify law enforcement and the medical examiner per protocol and state reporting law. A suspicious death does not make CPR appropriate when a valid DNR exists. Cleaning the body destroys evidence. Leaving without reporting fails the resident and the law.

24. A dying patient with end-stage lung disease is gasping and frightened despite oxygen. Her hospice orders include low-dose morphine for breathlessness. Regarding the morphine, you should know that:

    1. A. It treats pain but not breathlessness
    2. B. Low doses ease dyspnea without hastening death
    3. C. It will stop her breathing even in low doses
    4. D. It should be held until she becomes unresponsive
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    Answer: B. Low doses ease dyspnea without hastening death

    Low-dose opioids are a first-line treatment for refractory breathlessness at the end of life; titrated doses reduce the sensation of air hunger and anxiety and, in studies, do not shorten survival. Give them per the hospice order or protocol along with positioning and a fan. Morphine treats dyspnea as well as pain. Titrated doses do not stop breathing. Waiting until she is unresponsive leaves her suffering.

25. Older adults are at high risk in the weeks after hospital discharge mainly because of:

    1. A. Frequent home health nurse visits at home
    2. B. Physical therapy that is too intensive
    3. C. Medication changes and poor follow-up
    4. D. Discharge papers that are too detailed
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    Answer: C. Medication changes and poor follow-up

    New or changed medications, confusion about instructions, and missed follow-up appointments drive readmissions after discharge. Home health visits and therapy reduce, not raise, that risk.