Examkin

Question

Difficulty: EasyDisposition and Care Setting Transitions

A 78-year-old man is evaluated for hospital discharge following a 3-day admission for acute decompensated heart failure. He has severe ischemic cardiomyopathy with a documented left ventricular ejection fraction of 15%. This marks his fourth hospitalization for severe volume overload in the past six months, despite maximum tolerated guideline-directed medical therapy. The patient is currently euvolemic, resting comfortably in bed, and breathing easily on room air. During bedside rounds, he tells the physician, "I am completely exhausted from these constant hospital visits. I know my heart is failing, and I just want to go back to my house and be kept comfortable without any more aggressive treatments or readmissions." His family is highly supportive of his wishes and is continuously available to assist with his daily needs. Which of the following is the most appropriate disposition for this patient?

  1. Home with enrollment in a hospice programAnswer
  2. B
    Home with skilled home health nursing
  3. C
    Inpatient hospice or palliative care facility
  4. D
    Subacute rehabilitation at a nursing facility
  5. E
    Transfer to a specialty hospital for prolonged acute care

Answer

Home with enrollment in a hospice program
The correct answer is discharging the patient home with hospice care. The patient meets the clinical criteria for hospice (terminal illness with an expected survival of less than six months) due to his end-stage ischemic cardiomyopathy with frequent exacerbations despite optimal medical therapy. Furthermore, he explicitly expresses a desire to forego life-prolonging treatments in favor of comfort measures in his own home. Because he is currently symptomatically controlled (euvolemic, breathing easily) and has reliable family support, he can safely be transitioned to home hospice rather than an inpatient facility.

Step-by-Step Solution

1
Determine the patient's clinical trajectory and prognosis.
The patient has end-stage heart failure (LVEF 15%, frequent readmissions despite optimal therapy), indicating a life expectancy of less than six months.
Establishing prognosis is the first step in identifying eligibility for end-of-life care services.
2
Identify the patient's specific goals of care.
The patient explicitly requests to avoid further hospitalizations and aggressive treatments, preferring to focus entirely on comfort at home.
Disposition must directly align with a patient's stated goals, especially when transitioning to palliative or hospice care.
3
Match the clinical status and goals to the appropriate care setting.
Home hospice is selected because the patient is currently hemodynamically stable, has adequate family support at home, and desires comfort-focused care outside of a hospital.
Hospice care at home provides the necessary interdisciplinary support to maximize quality of life without inappropriate restorative or intensive interventions.

Key Concept

Identifying appropriate clinical criteria and patient goals for transitioning to home hospice care.
Rate this question

Topics

Disposition and Care Setting Transitions

More questions from this topic