| Course | NURS 6910 Introduction to Palliative Care: Principles of Hospice and Palliative Care |
|---|---|
| Week | Week 4 |
| Paper type | Referral memo |
| Length | About 880 words, 5 pages |
| Format | Memo, APA 7 citations |
| School | Walden University |
| Program | Master of Science in Nursing (MSN) |
| Updated | September 2026 |
Free sample paper for NURS 6910 Week 4
Memorandum
To: Medical Director, Composite Primary Care Group
From: Nurse Lead for Chronic Illness Care
Date: Month Day, Year
Re: Proposed triggers for palliative care referral and for hospice discussion in patients with advanced illness
Purpose
This memo proposes two separate sets of triggers for our clinicians: one for when to offer palliative care and one for when to begin a conversation about hospice. Keeping the two apart should bring palliative support to patients months earlier than it arrives now, and keep hospice conversations for the patients who actually meet its rules.
Background
Our panel includes a growing number of patients with advanced chronic obstructive pulmonary disease, heart failure and dementia. In a review of recent deaths among these patients, most referrals to palliative care or hospice, when they happened at all, arrived in the final days of life, often from the hospital rather than from us. Clinicians describe hesitating because they are unsure whether a patient is "sick enough," and because raising palliative care feels like announcing that death is near. Both hesitations come from treating palliative care and hospice as one decision.
They are two decisions. Palliative care is based on need and may be provided alongside any treatment. Hospice is a Medicare benefit whose rules turn on prognosis and on the patient electing comfort-focused care in place of treatment meant to cure the terminal illness. Much of the work of palliative care can also be done by primary care clinicians themselves, with specialists reserved for complex needs (Quill & Abernethy, 2013).
Recommendation 1: Palliative Care Triggers
Our clinicians should offer palliative care, either by addressing needs themselves or by referring to the specialist team, when any of the following is present in a patient with advanced illness:
1. The clinician answers no to the surprise question, asked about the coming year: would a death within that time come as a surprise? The question is simple to use but performs only modestly as a stand-alone predictor, so it should open a closer look rather than settle anything on its own (Downar et al., 2017).
2. A lower Palliative Performance Scale score at a second visit than at the first; the scale grades a patient in 10 percent steps across walking, activity and evidence of disease, self-care, eating and drinking, and alertness (Anderson et al., 1996).
3. Two or more hospital admissions or emergency visits for the same condition within six months.
4. Symptoms that persist despite standard treatment, such as breathlessness, pain or fatigue.
5. Caregiver distress reported by the patient, the family or our staff.
6. A decision ahead that the patient finds hard, such as whether to start dialysis or accept a device.
Recommendation 2: Hospice Discussion Triggers
A hospice conversation belongs when both of the following are true:
1. The clinician believes the patient's prognosis is limited enough that physician certification of terminal illness is likely, which the hospice benefit requires (42 C.F.R. § 418.22). The hospice medical director and our clinician share this judgment; our memo does not set a number.
2. The patient's goals, as expressed in a prior conversation, have shifted toward comfort and away from treatment aimed at controlling the disease, or the patient asks about stopping treatment.
When only the first is true, the next step is a goals-of-care conversation, not a hospice referral. When only the second is true, the patient may benefit from palliative care while continuing to be followed.
What This Changes in Practice
Clinicians would stop waiting for hospice eligibility before offering help. A patient with heart failure admitted twice this winter, whose wife is exhausted, would be offered palliative support now, even if no one expects death this year. Clinicians would also stop mentioning hospice to patients who are not near its threshold, which frightens families and damages trust in later conversations.
The palliative team's capacity is limited, so primary care clinicians would address first-level needs themselves: basic symptom management, a conversation about goals and naming a health care proxy. Referral to the specialist team would be reserved for refractory symptoms, conflict about goals within a family or complex decisions (Quill & Abernethy, 2013).
Limits of the Triggers
The triggers are prompts for a conversation, not rules for who receives care. None of them predicts death accurately on its own, and none should be read to a patient as a forecast. Patients with dementia and heart failure in particular follow uneven courses, and a stable month can follow a hard one. The triggers also depend on clinicians recording what they notice; a caregiver's exhaustion that no one writes down will not prompt anything. Finally, some patients will decline palliative care even when it is offered early and explained well. The measure of success is that the offer is made in time, in words the patient understands, and that the decision is the patient's own. A patient who declines should be asked again at the next change in condition, because an answer given in a stable month often changes after the next admission.
Next Steps
I propose that we add the six palliative care triggers to the annual visit template for patients with advanced chronic disease, offer one lunch session on the surprise question and the Palliative Performance Scale, and review the timing of referrals after six months. I would be glad to present this proposal at the next clinical leadership meeting.
References
Anderson, F., Downing, G. M., Hill, J., Casorso, L., & Lerch, N. (1996). Palliative Performance Scale (PPS): A new tool. Journal of Palliative Care, 12(1), 5-11. https://doi.org/10.1177/082585979601200102
Downar, J., Goldman, R., Pinto, R., Englesakis, M., & Adhikari, N. K. J. (2017). The "surprise question" for predicting death in seriously ill patients: A systematic review and meta-analysis. Canadian Medical Association Journal, 189(13), E484-E493. https://doi.org/10.1503/cmaj.160775
Medicare Hospice Care: Certification of terminal illness, 42 C.F.R. § 418.22 (2024).
Quill, T. E., & Abernethy, A. P. (2013). Generalist plus specialist palliative care: Creating a more sustainable model. New England Journal of Medicine, 368(13), 1173-1175. https://doi.org/10.1056/NEJMp1215620
What the NURS 6910 Week 4 instructions ask for
Week 4 in this course commonly asks you to write guidance for colleagues on identifying patients who need palliative care or hospice, and to explain eligibility and referral processes. A memo of two or three pages is a common format. Keep palliative care need and hospice eligibility on separate lists, because mixing them is the problem most practices have. Choose triggers clinicians can observe in an ordinary visit, and cite a source for each. Describe hospice eligibility accurately in general terms, avoiding figures you cannot support. Explain who handles which needs, generalists or specialists. State what the triggers cannot do. Finish with concrete next steps and a date to review whether referrals have moved earlier.
Inside the NURS 6910 Week 4 example
A two-sentence purpose opens the memo. The background describes the practice's patients with lung disease, heart failure and dementia and the late referrals prompting the change, citing Quill and Abernethy on generalist and specialist palliative care. The first recommendation lists six palliative care triggers, citing Downar and colleagues' review of the surprise question and Anderson and colleagues on the Palliative Performance Scale. The second lists two conditions for a hospice conversation, citing the certification rule. A section on what changes in practice gives a heart failure example. A limits section explains why the triggers are prompts rather than rules. Next steps propose a template change, a lunch session and a review.
Where the marks sit in the NURS 6910 Week 4 rubric
Referral memos are typically graded on accuracy, practicality and clarity. Accuracy carries weight because eligibility is easy to misstate, so hospice rules should be described correctly and palliative care should never be tied to prognosis. Practicality is judged by whether clinicians could use the triggers in a busy visit. Evidence earns credit when each trigger has a source and its limits are acknowledged, as with the surprise question's modest predictive accuracy. Clarity credit goes to a memo with a purpose statement, numbered recommendations and a clear request. Audience fit matters: a medical director wants the change and the reason, not a literature review. APA citations and professional format complete the criteria for most sections.
NURS 6910 Week 4 help from the desk
Referral memos lose marks by folding palliative care and hospice into one list, which tells clinicians to wait for a terminal prognosis before offering any help. Another loss is presenting the surprise question as a reliable predictor. Some memos quote hospice eligibility figures that are wrong or out of context. Others ask for everything and give the director nothing specific to approve. Separate the two thresholds, choose observable triggers with sources, describe eligibility accurately, assign roles and propose small next steps with a review date. The desk can draft a memo for the practice and patient population your prompt describes. Keep the memo short enough that a busy reader finishes it.
Get a NURS 6910 Week 4 example written to your instructions
Let the desk know who your Week 4 memo is addressed to and which illnesses or setting the prompt specifies, then add the rubric. The memo arrives formatted as a memo, headers and all, within 24-48 hours, free for a first sample. State or payer details are drawn only from sources your course provides.
More NURS 6910 papers and MSN samples
- NURS 6910 Week 1: Discussion post
- NURS 6910 Week 2: Concept comparison paper
- NURS 6910 Week 3: Models of care analysis
- NURS 6910 Week 5: Goals of care plan
- NURS 6910 Week 6: Communication case
- NURS 6910 Week 7: Family assessment
- NURS 6910 Week 8: Discussion post
- NURS 6910 Week 9: Spiritual and cultural assessment
- NURS 6910 Week 10: Palliative Case Analysis
- NURS 6910 Week 11: Reflection
- NURS 6730 Week 4: Workforce plan
- NURS 6720 Week 4: Intervention selection paper
- DNRS 6501 Week 4: Evidence appraisal
- NURS 6710 Week 4: Community assessment
NURS 6910 Week 4 questions, answered
What is the surprise question?
A single prognostic prompt a clinician asks about a patient: would I be surprised if this person died within a stated period? An answer of no flags someone who may benefit from palliative care. The memo uses it as one trigger among several and notes its known limits as a stand-alone predictor, so your paper does not overstate what one question can do.
Why not recommend hospice for every advanced illness?
Because hospice has eligibility rules and palliative care does not work that way. Many patients with advanced disease have needs that palliative care can meet for a long time before a limited prognosis applies, and some never meet hospice criteria at all. Treating the two as one pathway delays support for the many and frightens families who were never near hospice.
Does the memo need citations?
Yes, though fewer than an essay and placed differently. Each trigger carries one source in a short parenthetical, and a reference list sits after the closing line. Your course may accept a memo with footnotes or a brief works-cited block instead; the example follows APA because Walden defaults to it, and switches format if the prompt asks for another.
Where can I find a free NURS 6910 Week 4 sample paper?
The whole referral memo, both trigger lists, the limits section and next steps, is free to read here. A memo for the practice your prompt describes can be requested.
What triggers does the NURS 6910 Week 4 memo list for palliative care?
A no to the surprise question, a falling Palliative Performance Scale score, repeated admissions, persistent symptoms, caregiver distress and a hard decision ahead, such as dialysis or a device.