Palliative Care and End-of-Life Considerations, Exams of Nursing

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HOSPICE AND PALLIATIVE REGISTERED NURSE CERTIFICATION EXAM 2024/ Which assessment findings would most strongly suggest an issue with morphine? - Precise Answer ✔✔myoclonus is a symptom of the toxic effects of morphine metabolites Which cancer is least likely to metastasize to the bone? - Precise Answer ✔✔Colorectal; it mainly metastasizes to the liver, lung, and peritoneum. What is the drug of choice to relieve a patient's feeling of "air hunger" in end stage pulmonary disease? - Precise Answer ✔✔morphine; opioids provide palliative support for symptoms of breathlessness or suffocation. What is not an appropriate intervention for a bowel obstruction - Precise Answer ✔✔Metoclopramide The classic signs of superior vena cava syndrome (SVCS) - Precise Answer ✔✔facial edema, dyspnea, edematous arms w/bluish color=this is oncologic emergency requiring immediate attention. anticipatory grief - Precise Answer ✔✔the proces of psychological, social, and somatic reactions to a perceived future loss. signs and symptoms of imminent death - Precise Answer ✔✔dysphagia

stage II skin breakdown - Precise Answer ✔✔skin is blistered, cracked or abraded The state of having suffered a loss - Precise Answer ✔✔bereavement Disseminated Intravascular Coagulation (DIC) - Precise Answer ✔✔focal ischemia, widespread thrombosis or bleeding, superficial gangrene, jaundice, acrocyanosis, altered sensation, ulceration of gastrointestinal system, decreased urinary output, and dyspnea. prognosis of days to weeks, intervention for dysphagia - Precise Answer ✔✔teach family the importance of oral hygiene to prevent complications such as mouth soreness and infections. safety is a priority w/persons w/dementia - Precise Answer ✔✔supervision, minimal stimulation, and discouraging sleep during daytime hours maximize night safety. xerostomia - Precise Answer ✔✔dry mouth, and can be a side effect of medications and a long term effect of radiation. spiritual care of the hospice patient and family - Precise Answer ✔✔identifies and strives to relieve the spiritual suffering of the patient and family

Grief - Precise Answer ✔✔the feelings related to the perception of the loss and is a normal reaction to loss. mentoring - Precise Answer ✔✔a relationship between an experienced person and a less experienced person Justice - Precise Answer ✔✔to consider rules and actions that result in fair and equitable use of available resources. medicare hospice benefit periods - Precise Answer ✔✔90-, 90-, and unlimited 60-day periods crossing of professional boundaries - Precise Answer ✔✔providing a personal cell phone number to the family syncopal episodes and falls - Precise Answer ✔✔consider discontinuing antihypertensive medications if blood pressure is consistently low When revoking the medicare hospice benefit - Precise Answer ✔✔The patient will lose the remaining days of the current period if they revoke the medicare hospice benefit The dose-limiting side effect of morphine - Precise Answer ✔✔Myoclonus=myoclonus is the chronic spasm of a muscle; if moclonus is present, accepted practice is to rotate to another opioid.

first priority when pt. unable to make own decisions and being cared for by family - Precise Answer ✔✔knowing how the family makes decisions and who the decision makers are is priority. therapy for stage II wounds - Precise Answer ✔✔relieve pressure and apply protective/occlusive dressings. starting oral dose for methadone - Precise Answer ✔✔2.5-5 mg every 8 hours (half dose for elderly or severe renal or liver disease) side effect of methadone - Precise Answer ✔✔prolong QT interval equianalgesic conversion process -step one - Precise Answer ✔✔step one- add up the total amount of the current drug given in 24 hours remember to add in both the scheduled and breakthrough or rescue doses Calculate separately if more than one drug epuianalgesic conversion process -step two - Precise Answer ✔✔step two- Divide current 24 hour total by the equianalgesic value for the current drug and route of administration. Most commonly used opioid analgesics Morphine-Parental 10mg/enteral 30mg codeine-parental 130mg/enteral 200mg (not recommended) fentanyl-parental 50-100 mcg/ enteral TRIF (transmucosal immediate release fentanyl)

hydrocodone- parental n/a enteral 30 mg. hydromorphone- parental 1.5mg/enteral 7.5mg. levorphanol-parental 2 mg acute, 1mg. chronic/enteral 4mg. acute 1 mg. chronic methadone-parental unknown/ enteral unknown oxycodone-parental n/a enteral 20mg. equianalgesic conversion process- step three - Precise Answer ✔✔Multiply the step 2 number by the equianalgesic value for the new drug and route (this will give you the new 24-hour dose equianalgesic conversion process-step four - Precise Answer ✔✔Determine how many doses the patient will take each day and divide this number into the total 24-hour dose (this gives the amount of medication needed per dose) The usual cause of death for patients w/amyotrophic lateral sclerosis (ALS) - Precise Answer ✔✔Respiratory failure from progressive muscle weakness. Patients w/chronic renal failure - Precise Answer ✔✔are not eligible for hospice until dialysis is discontinued which of the following is the most appropriate patient to use a tricyclic antidepressant as an adjuvant analgesic? - Precise Answer ✔✔a pt. w/diarrhea, the anticholinergic side effects of tricyclic antidepressants

can cause constipation. diarrhea is not a major side effect of tricyclic antidepressants. Barrier to patient communication - Precise Answer ✔✔Anticipating what the patient will say, trying to determine what the patient will say limits the ability to listen to what they are saying. Life review - Precise Answer ✔✔Life review is about finding meaning and reflecting on memories of life events. components of burn out - Precise Answer ✔✔cynicism and depersonalization, emotional exhaustion, ineffectiveness and lack of personal accomplishment Long-term cardiac toxicity of chemotherapy has symptoms similar to - Precise Answer ✔✔Congestive heart failure -toxicity to the cardiac system induced by chemotherapy is similar in presentation to congestive heart failure w/dyspnea, cough, pedal edema, and poor response to diuretics or digitalis (most common w/anthracyclines) glucose testing - Precise Answer ✔✔can determine if the oftenvague symptoms of hypoglycemia are hypoglycemia so it can be treated, and thus lead to enhanced quality of life. Pain associated w/patients w/multiple sclerosis - Precise Answer ✔✔spasmodic pain-painful spasms are common in patients with multiple sclerosis as well as paroxysmal trigeminal neuralgia, optic

neuritis, periorbital pain, extremity pain, including dysesthesia, allodynia, and painful electric shock sensations. Brachytherapy - Precise Answer ✔✔implanted radiation therapy, brachytherapy is a radioactive source that is placed inside of or directly on the body. 24 hour ceiling dose of acetaminophen for an 80 year old woman who does not have liver disease - Precise Answer ✔✔3000 gm, this is the max daily recommendation allowance of acetaminophen for an older adult. Type of pain requiring antiepileptics and antidepressants for pain relief - Precise Answer ✔✔neuropathic pain is generally due to damage to the nervous system. Adjuvants are often used to enhance the analgesic efficacy of opioids especially in cases of neuropathic pain. Antidepressants, anticonvulsants, and corticosteroids are examples of adjuvants useful in treating neuropathic pain. Respiratory congestion during the dying phase - Precise Answer ✔✔terminal secretions are caused by respiratory congestion during the dying phase, the less preferred term for noisy breathing is death rattle. Schedule II drugs - Precise Answer ✔✔should be disposed of by the hospice personnel (preferably the nurse who is responsible for medication management) and witnessed by a second individual as per the hospice's policy.

the obligation to "do good" - Precise Answer ✔✔Beneficence according to medicare hospice benefit regulations the 4 members of the core hospice services include - Precise Answer ✔✔nurse, physicians, medical social services, and counselors (spiritual or bereavement) hospice eligibility criteria for patients with late-stage human immunodeficiency virus (HIV) include - Precise Answer ✔✔a CD count of <25/mm3 adn a karnofsky performance score of less than or equal to 50% along w/1 of 9 additional criteria (of which a central nervous system (CNS) lymphoma is 1)meet hospice eligibility criteria for HIV treatment of seizures related to hypercalcemia - Precise Answer ✔✔oral and/or intravenous fluids, this will decrease the effects of the high level of calcium somatic pain - Precise Answer ✔✔is aching, constant and well localized since it causes the activation of nociceptors in cutaneous and deep tissues. nonsteroidal anti-inflammatory drugs - Precise Answer ✔✔are NOT anti-spasmodics major symptom of type A chronic obstructive pulmonary disease (COPD), which IS emphysema - Precise Answer ✔✔dyspnea is the

major symptom of type A copd, emphysema, it is also a symptom of type b copd, chronic bronchitis calculating dose for breakthrough pain - Precise Answer ✔✔guidelines recommend using 10% to 20% of the 24 hour oral dose, given every 1- hours as needed end stage liver disease symptoms - Precise Answer ✔✔encephalopathy, coagulopathy, malnutrition the state of adaptation in which over exposure to a drug induces changes that result in a diminution of one or more of the drug's effects over time - Precise Answer ✔✔definition is tolerance dying patients adn their families - Precise Answer ✔✔Patients and families search for meaning of the individual's life and seek a purpose during the dying phase Hospice is - Precise Answer ✔✔a philosophy of care to improve quality of life for the terminally ill persons and their families in 2014 palliative care was primarily delivered - Precise Answer ✔✔in acute care settings, either in a dedicated unit, outpatient clinic, or through palliative care teams

hospice care, private ins. vs. medicare - Precise Answer ✔✔if a program is medicare certified, all patients must receive all the services available to a medicare beneficiary whether or not the insurance company pays side effect of chemotherapy, can be asymptomatic but have serious life- threatening potential - Precise Answer ✔✔neutropenia is silent but dangerous leaving no neutrophils to fight the threat of infections. Neutropenia can be the cause of a septic situation, which is life- threatening. The focus of palliative care - Precise Answer ✔✔The patient and family are the unit of care of both hospice and palliative care It is inappropriate to suggest aggressive curative treatment - Precise Answer ✔✔when the side effects of the treatment are more distressing than the potential benefits. abstinence syndrome - Precise Answer ✔✔occurs when a person who is physically dependent on an opioid abruptly stops taking the opioid. lorazepam - Precise Answer ✔✔can help w/insomnia and also is effective at reducing anxiety. a patient is taking his breakthrough pain medication 6 times per day, the nurse should suggest - Precise Answer ✔✔and increase in the amount of the scheduled dose. The baseline dose of long-acting opioids should be increased if more than 3 rescue doses are used in 24 hours.

lymphedema - Precise Answer ✔✔can be treated w/lymphatic massage hepatocellular cancer - Precise Answer ✔✔has the best 5-year survival rate in the United States, overall survival rate for hepatocellular cancer is 17% in the U.S. Barrier to pain management - Precise Answer ✔✔fears regarding addiction, tolerance, and diverse effects related to analgesics, particularly opioids, still persist. Allodynia - Precise Answer ✔✔Pain from a stiumlus that does not usually cause pain Reversible cause of anorexia/cachexia syndrome (ACS) in end stage illness - Precise Answer ✔✔xerostomia, this is dry mouth and can be reversed or mitigated A physical modality for pain relief that involves "life force energy" - Precise Answer ✔✔Reiki, a japanese technique that is administered by "laying on hands" and is based on the idea that an unseen "life force energy" flows through us and is what causes us to be alive First step in the assessment of new onset diarrhea in a patient who uses dietary fiber - Precise Answer ✔✔perform a digital rectal exam to rule out impaction; use and overuse of dietary fiber, especially with decreasing food and fluid intake, often causes impaction, which could

manifest itself as new onset diarrhea (liquid stool is able to pass the impaction) hypnosis - Precise Answer ✔✔is a technique to enhance the mind's ability to affect the physical body. Hypnosis is a mind-body therapy. Angina - Precise Answer ✔✔typical angina includes constricting discomfort in the anterior chest (e.g. tight, heavy, squeezing), neck, shoulders, jaw, and/or arms; it can be precipitated by physical exertion; and is usually relieved by rest or nitroglycerine in 5 minutes. Medicare Hospice benefit recertifications - Precise Answer ✔✔Require a hospice physician or hospice nurse practitioner (NP) must have a face- to-face encounter w/each hospice patient prior to the beginning of the patient's third benefit period, and prior to each subsequent benefit period. pain management for patients w/serious and persistent mental illness - Precise Answer ✔✔studies have indicated that pain in undertreated in people w/a history of psychiatric disorders Extrapyramidal symptoms (EPS) are a common symptom of - Precise Answer ✔✔Parkinson's disease Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) - Precise Answer ✔✔results in abnormal laboratory values of a urine

osmolality that is higher than plasma osmolality and elevated urinary sodium. Haloperidol - Precise Answer ✔✔does NOT lower the seizure threshold indication of an aggressively progressing lymphoma - Precise Answer ✔✔T-cell origin; Lymphomas (Hodgkin's and non-hodgkin's) with a T- cell origin are known to be most aggressive in progression. Most common symptom at end of life regardless of underlying disease - Precise Answer ✔✔Fatigue is the most common symptom, followed by pain, terminal secretions/noisy breathing, delirium, dyspnea/cough, and urinary incontinence/retention. Volunteer service hours - Precise Answer ✔✔Volunteer service hours must account for 5% of all direct patient care hours for all paid hospice employees and contract staff in a medicare certified hospice program Pleural effusion - Precise Answer ✔✔exam will likely reveal decreased breath sounds on auscultation on the affected side , reduced transmission of the voice to the chest wall (vocal fremitus), and stony dullness on percussion The first Palliative care program - Precise Answer ✔✔Balfour Mount, a physician, founded the first palliative care program in 1975 in Montreal and was the first to use the the term "palliative" This was located at Royal Victorian Hospital, Montreal, Canada

Example of advocacy in hospice and Palliative care - Precise Answer ✔✔advocacy is defined as promoting patient and family values, wishes, and preference of care, legal and ethical decision-making, and improved access to care and community resources by influencing or formulating health and social policy. An example of advocacy in hospice and palliative care would be negotiating continuous care reimbursement w/a private insurance company. Hospice care became a medicare benefit - Precise Answer ✔✔1983, the tax equity fiscal responsibility Act created the Medicare Hospice Benefit and defined hospice care in the United States as legitimate medical care. Most common non-cancer hospice admitting diagnosis, nationally - Precise Answer ✔✔dementia; persons w/dementia comprise 15.2% of hospice diagnoses nationally with all non-cancer diagnoses at 63.5% Scholarship assistance for certification - Precise Answer ✔✔hospice and palliative Nurses Foundation (HPNF) National Consensus Project for Quality Palliative Care - Precise Answer ✔✔An organization that promotes quality palliative care, fosters consistent and high standards in palliative care, and encourages continuity of care across settings. has its roots in the early hospice movement - Precise Answer ✔✔care of the whole person; Early hospices, as early as the middle ages, promoted whole person care, including mind, body, soul, and spirit

Centers for medicare & medicaid - Precise Answer ✔✔Do not regulate palliative care The 3 common types of healthcare teams - Precise Answer ✔✔multidisciplinary, interdisciplinary, and transdisciplinary A multidisciplinary team - Precise Answer ✔✔can be organized in a hierarchical manner according to the medicare hospice benefit, the interdisciplinary group must review, revise, and document the individualized plan - Precise Answer ✔✔at least every 15 days; Peer review - Precise Answer ✔✔a collegial, systematic , and periodic process by which clinicians are held accountable for practice and that fosters the refinement of one's knowledge, skills, and decision-making at all levels and in all areas of practice. volunteers - Precise Answer ✔✔are required by the centers for medicare & medicaid services to be part of the hospice interdisciplinary team compassion fatigue - Precise Answer ✔✔is almost identical to posttraumatic stress disorder (PTSD), except that it applies to those emotionally affected by the trauma of another ( usually a patient or family member)

3 of the 4 most common sites of metastatic disease in breast cancer - Precise Answer ✔✔Bone, brain, and lung, symptoms include, bone pain, visual disturbances, shortness of breath Neoadjuvant therapy - Precise Answer ✔✔defined as treatment given prior to the primary treatment, e.g. chemo given to a patient w/colon cancer prior to surgical resection most significant factor in prognostication in patients w/a cancer diagnosis - Precise Answer ✔✔functional status; literature shows the patient's functional status is the most significant predictor in treatment tolerance and in overall survival the most common presentation of spinal cord compression (SCC) - Precise Answer ✔✔Back pain symptoms of right-sided heart failure - Precise Answer ✔✔as systemic congestion occurs in right-sided heart failure, symptoms include weight gain, dependent peripheral edema, ascites, weakness, anorexia and nausea. Hospice eligibility guidelines for persons with neurodegenerative diseases include - Precise Answer ✔✔rapid progression of symptoms, breathing difficulties, infections, diminished nutrition w/wt. loss and decreased albumin, sepsis, use of scales such as Karnofsky, palliative performance scale, and FAST are helpful.

The major medication group used to manage dyspnea in chronic lung conditions at the end of life - Precise Answer ✔✔opioids and anxiolytics terminal event of end stage liver disease - Precise Answer ✔✔One possible terminal event in liver disease is bleeding from gastrointestinal or esophageal varices Late-stage human immunodeficiency virus (HiV) is diagnosed when - Precise Answer ✔✔CD4 count is less than 200 cells/mm hospice eligibility for human immunodeficiency virus (HIV) - Precise Answer ✔✔viral load greater than 100,000 copies/ML signs and symptoms of opioid abstinence (withdrawl) - Precise Answer ✔✔anxiety, nausea, and lacrimation visceral pain - Precise Answer ✔✔pain that is poorly localized, cramping, and referred to distant sites. nociceptive pain - Precise Answer ✔✔pain generally well localized and described as aching or throbbing Breakthrough pain - Precise Answer ✔✔incidental, idiopathic, or can occur as end-of-dose failure

acetaminophen - Precise Answer ✔✔is hepatotoxic in high doses and can compromise renal function Nonsteroidal anti-inflammatory drugs - Precise Answer ✔✔can increase the risk of myocardial infarction (MI) and stroke in people at risk for cardiovascular events. opioid-induced respiratory depression - Precise Answer ✔✔occurs more often in those with obstructive sleep apnea subcutaneous morphine - Precise Answer ✔✔has a delayed peak effect when compared with intravenous injections antiepileptic drugs are effective for neuropathic pain - Precise Answer ✔✔pregabalin has better bioavailability than gabapentin and can be given twice daily Antidepressants are useful in relieving neuropathic pain - Precise Answer ✔✔amitriptyline has significant anticholinergic effects and is not considered first line therapy as a result. Corticosteroids, such as dexamethasone - Precise Answer ✔✔Can relieve bone pain and right upper quadrant pain associated with liver metastases

Principles of opioid use include - Precise Answer ✔✔reducing the dose by approximately 25% after performing an equianalgesic conversion accounts for incomplete cross-tolerance Delirium - Precise Answer ✔✔an acute change in level of arousal is the hallmark indicator of delirium nonpharmacological intervention for myoclonus - Precise Answer ✔✔Gentle massage may help with muscle relaxation and is an appropriate intervention Healthy sleep practices - Precise Answer ✔✔Listening to calming music, meditation, reading something soothing, or taking a hot bath are all examples of ways to help relax prior to bedtime what is the most important piece of information when assessing dyspnea

• Precise Answer ✔✔patient's level of distress; dyspnea is a subjective symptom reported by the patient Given in appropriate doses, morphine will slow respirations and relieve the feeling of air hunger - Precise Answer ✔✔morphine's response is dose dependent and families should be reassured that starting with low doses and taking as prescribed would not hasten death. stage II pressure ulcer - Precise Answer ✔✔skin that is red and blistered; stage II pressure ulcers are partial loss of dermis as in the case of a blister

Irreversible cause of anorexia-cachexia - Precise Answer ✔✔metastatic pancreatic cancer; metastatic pancreatic cancer is in its most advanced stage and is not curable or reversible. In addition, pancreatic cancer can have direct effects on digestion and advanced cancer can cause metabolic abnormalities leading to anorexia-cachexia nonpharmacological treatment for nausea and vomiting - Precise Answer ✔✔serve meals at room temperature treatments required for opioid-induced constipation - Precise Answer ✔✔stool softener and stimulant laxative daily; cause of hiccoughs in a patient who has ascites - Precise Answer ✔✔Phrenic and vagus nerve irritation; Ascites can cause hiccoughs by irritating the phrenic and vagus nerves A patient treated for known psychosis exhibits uncontrollable muscle movements and spasms around the mouth, the pt. is experiencing - Precise Answer ✔✔tardive dyskinesia; uncontrollable muscle movements and spasms around the mouth are classics signs of tardive dyskinesia, it is also associated w/antipsychotic medications signs of posttraumatic stress disorder - Precise Answer ✔✔Anxiety, intrusive memories, and distressing dreams

A delusion in which the individual is preoccupied with their state of health - Precise Answer ✔✔Preoccupation with health is a sign of somatic delusions Hoarding disorder - Precise Answer ✔✔characterized by a persistent difficulty in parting with possessions to the point of excess often resulting in extreme clutter throughout the home Patients with a psychiatric history - Precise Answer ✔✔Often have undertreated pain Excessive alcohol use is often underreported by patients - Precise Answer ✔✔Insomnia, shaking, sweating, and agitation are common sign of alcohol withdrawal. Nurses caring for patients with schizophrenia - Precise Answer ✔✔should avoid physical contact when possible and warn patients when they must touch them Complicated grief - Precise Answer ✔✔yearning, intrusive thoughts and dreams, and guilt are all indicators of complicated grief more than 6 months post-loss Puchalski's FICA - Precise Answer ✔✔Faith (what faith does individual have), Influence (how influential is this faith), Community (what faith community does individual participate in), and Address (how would

individual like the interdisciplinary team to address the individual's spiritual needs) The search for ultimate meaning and purpose of life, which may involve a connection to a higher power - Precise Answer ✔✔spirituality In palliative care the "unit of care" consists of - Precise Answer ✔✔Patient and family; patient and family make up the unit of care, providing care for the patient must include care for the family (as defined by the patient) as a singular unit Comprehensive resource assessment - Precise Answer ✔✔Includes collaboration with the interdisciplinary team Cultural humility - Precise Answer ✔✔a life-long process addressing power imbalances due to race, class, gender, sexuality, nation, ability, language, etc. Culturally sensitive communication by the interdisciplinary team - Precise Answer ✔✔is demonstrated by using professionally trained interpreters; try to avoid using family members as translators as they interpret through their own emotional and cognitive reactions. good communication - Precise Answer ✔✔fosters seamless continuity of care and improved patient outcomes.

Volunteer offender aides working in hospice prisons - Precise Answer ✔✔report being able to atone for their own offenses; Volunteer offender aides have reported finding their own humanity and found value in being able to atone for their past offenses. All veterans - Precise Answer ✔✔have been impacted by the time they served in the military each in their own way. Characteristic many rural dwellers share - Precise Answer ✔✔they equate being healthy with being able to work; Health is viewed as the ability to work Goals of advance care planning - Precise Answer ✔✔determining values and priorities for end-of-life care; Values and priorities must be determined so that other planning/ decisions can be made. Patients with an out-of-hospital do not resuscitate order - Precise Answer ✔✔may revoke it at any time The physician orders for life sustaining treatment (POLST) differs from a liveing will , POLST - Precise Answer ✔✔Is a signed medical order by a provider; The Physician/provider/medical orders for life-sustaining treatment (POLST/MOLST) provides specific instructions/orders on several medical interventions and is signed by the provider The self determination act (PSDA) was passed as a result of - Precise Answer ✔✔The Nancy Cruzan case

The nurses' role in advance care planning - Precise Answer ✔✔to complete his/her own advance directive; nurses who have already completed their own advance directives will be more comfortable discussing advanced directives w/patients Barriers to completion of an advance directive include - Precise Answer ✔✔fear of substandard care; Patients may feel care will not be provided In the treatment of dyspnea, what is the rationale for directing a fan to the patient's face - Precise Answer ✔✔stimulation of the baroreceptors; the baroreceptors, when stimulated, cause bronchial dilation, which is thought to reduce dyspnea the guiding principle when providing care of the body after death - Precise Answer ✔✔postmortem changes are temporary; All the postmortem changes, in particular rigor mortis, are temporary Lethargy - Precise Answer ✔✔is characteristic of hypoactive delirium Restlessness can also occur as death nears - Precise Answer ✔✔Benzodiazepines can have a paradoxical effect and worsen restlessness An ethics of care focuses - Precise Answer ✔✔on how and why nurses care for patients and not just caregiving actions; an ethics of care

incorporates how and why nurses provide care to patients, integrating a professional moral life in to professional caregiving The first step in resolving an ethical dilemma - Precise Answer ✔✔identify the issue. The patient's medical record - Precise Answer ✔✔is not a professional resource Patient's have the right to - Precise Answer ✔✔refuse additional information about their condition and refer decision-making to a surrogate Substituted judgment - Precise Answer ✔✔a surrogate relies on known preferences of a patient to make a decision about medical care Time- limited trial - Precise Answer ✔✔establishes clear goals and boundaries of continuing life-prolonging therapy, thereby helping to frame the conversation for patients and families about withdrawal of care. Rule of Double Effect (RDE) - Precise Answer ✔✔The ethical justification for actions that have positive intended and negative unintended but foreseen effects.