Q 1 a providers obligation is to do no harm. healing the patient

Q-1
A provider's obligation is to do no harm. Healing the patient
from whatever ails them is a holistic healing process. Advanced
directives are a large part of the healthcare process as well, and
should be discussed earlier and more often than they actually
are (House & Ogilvie, 2020); (White, 2019). Advanced
directives are essentially the wishes of the patient when they
were made when the patient was in a fully coherent mental state
and was able to make their own decisions (House & Ogilvie,
2020); (White, 2019). These are the direct wishes of the patient
to be followed when the patient themselves are either
incapacitated or incoherent (House & Ogilvie, 2020); (White,
2019).
State and federal legislation affect advanced directives in the
way that family members can override them when the patient is
incapacitated as they are the next of kin or the emergency
contact (House & Ogilvie, 2020). Each state has some variations
to this loophole, but they mostly stay the same amongst the
states (House & Ogilvie, 2020). Some believe that this loophole
has arisen due to the massive increase in litigation especially in
healthcare (House & Ogilvie, 2020).
There are many ethical dilemmas that occur when allowing for
such a loophole and having advanced directives at the same
time. A perfect example is from my work in an MSICU
yesterday (2/17). I had a patient who coded last Sunday and was
extubated Tuesday. The patient is no longer neurologically
intact, now on dialysis, and we suspect an anoxic brain injury
that has left the patient lethargic, drowsy, unable to follow
commands, and opens his eyes to his name but does not track.
The family originally brought in a Living will and Advanced
Directive when the patient arrived that clearly stated DNR
status and refusal of lifelong treatments. However, once the
patient began to code, the wife rescinded everything. As
healthcare professionals we are now stuck, as there is

appropriate documentation to validate the DNR, but as the
patient is now incapacitated the next of kin now has medical
decisional making capacity. So at this point, she wanted
everything done. Fast forward a few days to 2/17, I am
explaining to the wife and sister that his prognosis is poor,
dialysis isn't helping, his quality of life is how he is presenting
now, and I even relayed the fact that the patient clearly said he
did not want any of this. The wife acknowledged his advanced
directive, but stated: "We need to do everything anyway".
The ethical dilemma has presented as such: we are going against
the patient's wishes, especially with futile and end-of-life care,
while the wife has the power and authority to change any
medical decision that was made previously. We, as healthcare
professionals, are now forced to prolong this patient's suffering
out of fear of retaliation and litigation.
In my practice, I have always reasonably accommodated the
patient's spiritual practices regardless of what they were. We
have had sermons in the ICU patient's rooms, as well as
celebrations of life, or spiritual rituals.
In my opinion, if that's what the patient wanted, then so be it,
we have to respect their wishes, even if we don't agree with
them.
References:
House, S.A., Ogilvie, W.A. (2020). Advance
Directives. StatPearls Treasure IslandStatPearls Publishing.
Retrieved from:
https://www.ncbi.nlm.nih.gov/books/NBK459133/
White, G. (2019). Do not postpone discussing advanced
directives. CMAJ : Canadian Medical Association Journal =
Journal de l’Association Medicale Canadienne, 191(28), E796.
https://doi-org.lopes.idm.oclc.org/10.1503/cmaj.72212
Q-2
The grieving process is altered in patients who have dementia
living with a spouse (Hovland, 2018). This is suspected because
the outcome of dementia usually ends up being failure to thrive

due to cognitive decline (Hovland, 2018). The spouse
recognizes the end result, and pre-emptively begins to grieve as
they become aware of the end result of the disease (Hovland,
2018). The stages of grief differ in each individual in terms of
intensity, duration, speed, and accpetance to move onto the next
stage (Hovland, 2018). Some people take it well, while others
do not, and my need support from family, friends, or healthcare
team members (Hovland, 2018).
The nurse practitioner can offer many options for support for
both the patient and the spouse, especially once the information
has been obtained of advancing metastatic cancer (Mughal,
Azhar, Siddiqui, 2020). Palliative care, respite care, or hospice
placement can be offered as the criteria is met for hospice
placement with a life threatening illness, futile care, and/or
failure to thrive (Mughal, Azhar, Siddiqui, 2020). The etiology
of hospice admission could be either dementia, or the advanced
metastatic cancer (Mughal, Azhar, Siddiqui, 2020).
In terms of actually offering these options to the spouse, careful
conversations would need to be had regarding what hospice is,
what they do, and what they can offer (Mughal, Azhar, Siddiqui,
2020). I usually begin this conversation with the idea that the
goal now has changed from treating and curing, to making the
patient as comfortable as possible. A common question I usually
get asked in the MSICU is "well how long will it take?" as in
how long will it take for the patient to expire, and I usually
answer "Only God knows, and all we can do is what the patient
wants us to do". However, I also explain that if the patient
persists for an extended time, hospice lasts up to 6 months in
Florida, and can be extended at any time. Also, I am sure to
mention that if they need a break, or begin suffering from
caregiver fatigue, that hospice offers respite care as well, where
the patient can be moved into the hospice home and the fmaily
member can take a break. I belive that the patient being
comfortable is just as important as the family members involved
being able to take care of themselves as well.
Usally these conversations are difficult to begin, but once the

explanation process starts, it ususally sets in with teh family
members that this si the best course of action tso theeir loved
one can die with dignity.
References:
Hovland, C. (2018). Welcoming death: Exploring pre-death
grief experiences of caregivers of older adults with
dementia. Journal of Social Work in End-of-Life & Palliative
Care, 14(4), 274–290. https://doi-
org.lopes.idm.oclc.org/10.1080/15524256.2018.1508538
Mughal, S., Azhar, Y., Siddiqui, W.J. (2020). Grief
Reaction. StatPearls Treasure Island StatPearls
Publishing. Retrieved from:
https://www.ncbi.nlm.nih.gov/books/NBK507832/
Q-3
Providers must address the advance directives to their patients
to determine the future medical care when the patient becomes
incapable of making medical decisions. Advance Directives are
described as the legal mechanisms that reinforce the
fundamental professional and moral responsibilities of health
care providers and institutions to promote and to protect patient
autonomy, welfare, and dignity (Armstrong & Silverman, 2017,
p. 224). There are two types of advance directives namely the
living will and the health care proxy. The living will is also
known as instructional directives that define the type of
decision that should direct the patient’s care. The second type
of advance directive is the health care proxy that is often called
a durable power of attorney for health care. It is an individual
that is selected by the patient to make decisions.
Some states have a state-authorized portable order. State-
authorized portable orders are described as a specialized form
of an identifier such as a do not attempt to resuscitate bracelets
or necklaces that are authorized by state law or a state medical
director that translates to the patient’s preference regarding

specific life-sustaining treatment decisions into portable
medical orders (National Archieves and Records
Administration, 2020). Oregon’s Physician Orders for Scope of
Treatment (POST) and New York’s Medical Orders for Life-
Sustaining Treatment (MOLST) are some of the examples of the
state- authorized portable orders that aim to make the patient's
desire more easily available to emergency medical personnel
(National Achieves and Records Administration, 2020). Some of
the ethical or spiritual dilemmas that patients and families
encounter during these discussions are unethical
experimentation, life-prolonging treatment, life-sustaining
treatment, and medical orders of end-of-life care. For example,
providers support that each person has the right to determine
what medical treatment they will receive including what life-
sustaining treatment should be provided if an individual has a
terminal issue. Providers need to ensure that they know the
current state laws, living wills and durable power of attorney,
they are considerate of the patient’s cultural beliefs and practice
and should discuss the issue of life- sustaining measures with
each of their patients before medical emergency happens or
before institutionalization to prevent ethical dilemma during
end-of life care.
References:
Armstrong, K. & Silverman, R.D. (2017). Medical- Legal
Concepts: Advance Directives and Surrogate Decision Making.
S.C. McKean, J.J., Ross, D.D. Dressler, D.B. Scheurer
(Eds). The Principles and Practice of Hospital Medicine 2nd
edition (pp. 224-230). Mcgrawhill education.
American Academy of Family Physicians (2020). Ethics and

Advance Planning for End-of-Life Care. Retrieved from
https://www.aafp.org/about/policies/all/ethics-advance-
planning.html
National Archives and Records Administration, (2020). Federal
register: Informed consent and advance directives. Retrieved
from
https://www.federalregister.gov/documents/2020/05/27/2020-
10264/informed-consent-and-advance-directives
By Lesley Kadlec, MA, RHIA, CHDA, and Annessa Kirby
We hear so much about the amount of data available in
healthcare today. But we are just beginning to understand the
importance of analyzing that data to make decisions. As
buzzwords like “information governance” and “data analytics”
are becoming more mainstream, the analysis of data is becoming
an expectation—a requirement, in fact—for
healthcare organizations. It is no longer an acceptable practice
to ask for information and not do anything with it. In
order to continue to be progressive in healthcare and to meet the
“triple aim” we need to analyze and use healthcare
data more effectively to produce the kind of outcomes in
healthcare that are needed and that our consumers expect.
Given this lofty goal, the members of the AHIMA Informatics

and Data Analytics Task Force were asked to share some
thoughts about how HIM professionals are putting this
expectation into action. One task force member started with
sharing some background definitions: “In general, informatics is
the natural progression of health information
management. Webster’s definition of informatics is: the
collection, classification, storage, retrieval and disseminatio n of
recorded knowledge. HIM has been doing that even with the use
of paper records—providing the records to other
people—and natural progression into the electronic world, free
text, structured data fields.”
Resoundingly, the overwhelming feeling of the team members
echoed the importance of HIM to the progression of
informatics and data analytics in healthcare organizations. One
of the respondents stated, “We are the profession who
has this knowledge to manage and analyze data accurately. We
have the text book knowledge and best practice
experience (and) can contribute to the informatics war, the new
terminology, the new demand and broader aspects and
domains of healthcare.” In fact, another member went on to say
that “Our profession needs to emphasize that we
understand the data and what it is saying. It justifies that we are
needed for that [type of new role]. HIM professionals
make the best data analysts because they truly understand the

data!”
One of the members also mentioned that HIM is the perfect
middleman. So, we looked up “middleman” and found this
book called “The Middleman Economy” and the editorial about
it on this link. It states:
“Middlemen are more prevalent—and more important—than
ever. Agents, brokers, dealers, and resellers get a bad rap,
but they play a crucial role in almost every platform today—
including the ones that were meant to cut them out of the
transaction. As a result, being an effective middleman has
become an even more valuable skill than it was in the past.”
The book’s author, Marina Krakovsky, outlines six roles to
embrace and execute to be an effective middleman:

While an HIM professional could play all of these roles within a
24-hour period, the role that seems to complement HIM
the most is that of the Concierge. “The Concierge reduces
hassles and helps clients make good decisions in the face of
information overload.” Sound familiar? Our clients could be the
patient, the clinician, the health information exchange
organization, the payor, the federal government… the list goes
on and on.
So what does all of this mean for today’s HIM professional?
One task force member summed it up best: “[There is] huge
potential in the direction that HIM is going toward. It will take
time to convince people of the value that we as HIM
professionals hold. The return on investment needs to be
envisioned and the HIM profession needs to be sold—[HIM
professionals must be the] lobbyists in making the change
happen in today’s healthcare environment.” Another task
force member described our value and the value of data as being
able to “…bring about a proactive versus a reactive
approach. Being able to identify and mitigate the ‘why’ and be
proactive for these situations can have a financial impact

on facilities. HIM can prove this benefit of a proactive
approach.”
We’re in an economy—whether the financial, housing, or
healthcare sector—where convenience is expected. When
online shopping, we expect websites such as Amazon.com to
know our preferences because of what we’ve clicked on in
the past. We expect our social media accounts such as Facebook
to remember our password and only show us posts
from friends and businesses that we’ve demonstrated preference
for within the website. All of this convenience is based
on data. Amazon and Facebook have made the data meaningful
to the consumer. Healthcare is in the process of doing
the same thing. Person-centric care is an expectation, not just a
quality measure. HIM is the perfect and essential
middleman. We just need to put ourselves in the right light.
Lesley Kadlec ([email protected]) is a director of practice
excellence and Annessa Kirby
([email protected]) is practice council manager at AHIMA.
Q-1
I would recommend a short term acute rehab for the patient due
to the patient's difficulty walking. This difficulty in mobility is
one admission criteria, but we can expand this to include
problems in the activity of daily living, and transfers (Bielecki
& Tadi, 2020). The other side is that there are special pieces of
equipment that can help the patient advance quickly that are

unable to be obtained at the home such as a Hoyer lift (Bielecki
& Tadi, 2020). However, there are requirements that the patient
has to be able to perform or agree to. Such requirements include
being able to participate in at least three therapies a day, three
hours of therapy for five days a week, and is agreeable to
participate (Bielecki & Tadi, 2020).
If the patient can meet the criteria, most insurances will issue
precertification or speak with the case manager to apply the
patient's benefits to a rehab facility, and most of the time the
insurance will elect to pay for a rehab stay (Smith, Kulhari,
Wolfram, & Furlan, 2017).
I have found acute rehabilitation facilities to be highly
beneficial for many reasons. These facilities are able to provide
intense training programs that are patient-specific and designed
to bring the patient back to their prior level of functioning as
quickly as they can. I would not want to see a patient who has
been deconditioned to the point of motility issues return to the
hospital because of a fall, or a subsequent injury from a fall.
Also, there is the timing aspect. For example, home health has a
limited amount of availability per week, so this patient may
only receive three one-hour sessions per week, increasing the
time it takes for the patient to return to their prior level of
functioning. This increase in return time also increases the risk
of an injury due to decreased mobility. While rehab facilities
can perform multiple rehab sessions per day for these patients
to quickly return their lost strength.
I would evaluate each patient individually, but in my opinion, I
would still elect to send this patient to an acute rehab facility in
order to gain his strength back as quickly as possible. There are
some things we can weigh against the decision such as
evaluation of the patient's home status. For example, if the
patient had the ability to even have the specialized equipment in
the home, or family members who were physical therapists. I
think this would be the only exception to where I would change
my mind and write for home health.
References:

Bielecki, J.E., Tadi, P. (2020) Therapeutic Exercise. StatPearls
Treasure Island StatPearls
Publishing. Retrieved from: https://www.ncbi.nlm.nih.gov/book
s/NBK555914/
Smith, A. L., Kulhari, A., Wolfram, J. A., & Furlan, A. (2017).
Impact of Insurance Precertification on Discharge of Stroke
Patients to Acute Rehabilitation or Skilled Nursing
Facility. Journal of Stroke and Cerebrovascular Diseases, 26(4),
711–716. https://doi-
org.lopes.idm.oclc.org/10.1016/j.jstrokecerebrovasdis.2015.12.0
37
Q-2
A safe discharge would depend on the patient, the home
situation, and the patient needs. If a patient is recovering slowly
it could be beneficial for them to go to a rehab facility for help
and supervision. The patient isn’t ambulating well and if he
lives alone that wouldn’t be a safe discharge as this could
increase risk of falls, decreased mobility, and deconditioning.
PT/OT would be beneficial to the patient to improve mobility
and safety. Requirements include the need of therapy for 3
hours of therapy for 5-7 consecutive days for physical therapy,
occupational therapy, and speech/language therapy, they need
nursing assistance with specialized training, a case manager,
and the expectation that the patient will benefit from therapy
(Forrest, et al., 2019). I would begin with getting a PT/OT
consult in the hospital and assess for general patient safety. I
would use their recommendations to guide my decision and
recommend the appropriate services. I would then ask about
home life and what type of house he has, what help he has at
home, and if he had a plan with getting help if he lived alone
(such as having a friend/family stay with him). I would then
assess patient’s cognitive function and the ability to safely
decide on what he wants. If he was deemed safe to go home
with home health services, then I would be ok with sending him

home with that. He would get the help he needs, and someone
would be able to check on him. There is a benefit of less chance
of complications with being at home versus in a facility. The
rehabilitation at home and in a facility of knee replacements
was evaluated and shown there was no significant difference
besides the reduced post-discharge complications (Buhagiar, et
al.,2017). If the patient isn’t safe to go home and requires
intensive rehabilitation and continuous supervision then the
rehabilitation facility would be the safest discharge for the
patient.
Buhagiar MA, Naylor JM, Harris IA, et al. Effect of Inpatient
Rehabilitation vs a Monitored Home-Based Program on
Mobility in Patients With Total Knee Arthroplasty: The HIHO
Randomized Clinical Trial. JAMA. 2017;317(10):1037–1046.
doi:10.1001/jama.2017.1224
Forrest, G., Reppel, A., Kodsi, M., & Smith, J. (2019). Inpatient
rehabilitation facilities: The 3-hour rule. Medicine, 98(37),
e17096. https://doi.org/10.1097/MD.0000000000017096
Q-3
A 72-year-old male with a past medical history for
hypertension, congestive heart failure, chronic back pain, and
diabetes is admitted to the hospital for hypotension suspected
from a possible accidental overdose. What are the criteria for
discharge? Explain the importance of utilizing hospital
recommendations and teachings. List some meaningful
community resources in the response.
Discharge planning is characterized as a development of an
individualized discharge plan of the patient before leaving the
hospital to ensure that the patients are discharged at the right
time and that adequate resources are given after discharge
(Alper et. al, 2020). Patient cognitive status, activity level, and
functional status, nature of the patient’s current home and
suitability for patient’s conditions, family support,

transportation from the hospital to home and follow - up visits,
and the availability of services in the community to assist the
patient with ongoing care are some of the factors that providers
consider when deciding where to send the patient after
hospitalization. One of the hospital standards when discharging
patients in the hospital is a discharge summary. A discharge
summary is an important tool that is written by the discharging
physician that is usually reliable and standardized to ensure that
there will be clear communication about the hospital
course(Sponsler,2017, p. 94). The recommended components of
the discharge summary are the primary and secondary
diagnoses, pertinent test results, pending results, patient’s
condition at discharge, recommended additional workup or
treatment plan, a complete list of the reconciled medications,
follow-up arrangements, resuscitation status, documentation of
patient education and identification and contact information for
the sending and receiving providers (Sponsler,2017, p. 94). In
this case, providers need to ensure that the medication is
reconciled properly and the instructions are clear to prevent any
errors or adverse effects such as hypotension to the patient.
Patients need to be educated and instructed on how to prevent
falls while at home and to make sure that the patient is capable
of safely preparing and taking their medications on time. Also,
providers need to identify any pending results and follow -up
appointments after discharge. It is also important that patients
who have the chronic condition is well-informed about their
disease, the disease process and what can they do to prevent
further exacerbation or hospitalization. Some of the community
resources such as adult day health, pharmacies that offer blister
packs, medication therapy management, and those pharmacies
that deliver medications at home are available in elderly or
disable patients.
References:
Alper, E., O’Malley, T.A. & Greenwald, J (2020). Hospital
discharge and readmission. Retrieved
from https://www.uptodate.com/contents/hospital-discharge-

and-readmission#H8
Sponsler, K.C. (2017). Care transitions at hospital discharge.
S.C. McKean, J.J., Ross, D.D. Dressler, D.B. Scheurer
(Eds). The
Principles and Practice of Hospital Medicine 2nd edition (pp.
90-96). Mcgrawhill education.

Q 1 a providers obligation is to do no harm. healing the patient

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