7.1 Crisis, Safety, and End-of-Life Planning

The current FNP-BC Test Content Outline places anticipatory guidance — including crisis management and end-of-life care — in Domain III Planning (29 scored items, 19% on both the current outline and the October 30, 2026 outline). Assessment finds the danger. Planning writes the next actions on a page the patient, a caregiver, or EMS can follow. Implementation (Chapter 18.3 for reporting; later system chapters for drugs) is the call, the injection, or the transfer. Do not wait for the ICU to invent a plan that belonged in clinic.

A safety plan is not a vibe and it is not a signed no-harm contract. It is a specific sequence: who stays, which lethal means leave the home, which number is called, which facility takes the transfer, and when you recontact.

Suicidal ideation: means restriction, 988, or the ED

Ask directly. Stratify passive thoughts versus active ideation, plan, intent, means, and rehearsal. Protective factors (children at home, a job to return to, religious prohibition) inform the plan; they do not cancel an unlocked firearm and a tonight-plan.

Build a written safety plan (the Stanley-Brown template is the common U.S. structure): personal warning signs; internal coping the patient can do alone; social settings that distract; people they can tell; professionals and agencies, including 988; means restriction; and reasons for living.

Means restriction is the highest-yield line. Firearms first: store the gun off-site with a trusted person, or lock the firearm and lock ammunition separately with the key out of the patient's hands. Remove leftover opioids and stockpiled medicines. Do not send a high-risk patient home to “think about” an unlocked cabinet.

988 (Suicide & Crisis Lifeline) is the right next step when the person can stay safe with support, needs a warm line, or needs help bridging to a same-day or next-day appointment. Put the number in writing. Emergency department or equivalent crisis evaluation now when there is intent plus a plan plus access to means, inability to keep safe, agitation or psychosis, a just-occurred attempt, intoxication that blocks assessment, or no capable adult who will stay. A teenager with a plan to use a parent's unlocked firearm tonight is not a 988-and-see-you-in-two-weeks case.

Do not treat a signed no-suicide contract as a plan. It has no evidence as a safety intervention and it is a common wrong answer. Document the risk, the means conversation, who is staying, the destination of any transfer, and a follow-up measured in hours to a day, not a routine three-month slot.

Intimate-partner violence: plan without forcing leaving

Leaving is often the most dangerous window. The FNP plan is not “you must leave today or I will not help you.” It is a safety plan the patient controls:

• A code word with a friend, coworker, or family member that means call 911
• A bag of documents and essentials (IDs, medications, cash, keys, court papers, a spare phone) stored outside the home
• Where to go (trusted person, shelter, public place with witnesses)
• How to call 911 versus the National Domestic Violence Hotline (1-800-799-7233)
• Safer rooms if violence escalates (avoid kitchens and bathrooms — hard surfaces and weapons)

Do not send take-home IPV pamphlets if a partner could find them. Offer numbers the patient can memorize, review resources on a clinic screen, or print at a safe site. Document injuries in the patient's words and on a body map. Competent adult IPV is not automatically a mandated report in every state; injuries to a child and elder or dependent-adult abuse often are. State law determines reporter details; ANCC tests the recognition and the next action, not a 50-state statute list.

Child and elder abuse: report-and-protect

Reasonable suspicion of child abuse or neglect, or of elder or dependent-adult abuse, moves you from ordinary guidance to a report-and-protect plan. Which hotline and whether the first call is oral then written are Implementation details later. Planning facts you need now:

• The threshold is reasonable suspicion, not courtroom proof
• You are not the investigator; do not interrogate the alleged perpetrator in the exam room
• Treat injuries, photograph per clinic policy, and decide whether the patient can go home today
• Notify the designated child protective or adult protective agency as state law requires
• State law determines reporter details; ANCC tests the recognition and the next action

A 3-year-old with patterned burns and a changing story is not watchful waiting until the next well visit. An 84-year-old with unexplained bruises, missed medicines, and a new “friend” who controls the bank card is an APS-planning case, not only a vitamin D refill.

Anaphylaxis action plan

Anyone with anaphylaxis leaves with a written plan and a current epinephrine auto-injector they can demonstrate. Use epinephrine at the first signs of anaphylaxis (two systems, or a known allergen plus respiratory or cardiovascular involvement). Call 911 after epinephrine even if the person looks better. A second dose may be given in 5–15 minutes if symptoms persist. Antihistamines and albuterol are adjuncts, not substitutes. Add medical-alert identification and allergist referral for a first or unexplained episode. Choose the device dose by current weight (commonly 0.15 mg versus 0.3 mg — read the product in front of you).

Asthma, COPD, hypoglycemia, and seizure plans

Asthma. Green / yellow / red zones by symptoms and, if used, peak flow. GINA 2025/2026: every adolescent and adult needs ICS-containing therapy; Track 1 ICS-formoterol as anti-inflammatory reliever (AIR) or maintenance-and-reliever (MART) is preferred; SABA-only is not a plan. Yellow: step up the written ICS-containing regimen. Red — speaks in words, silent chest, cyanosis, collapsing peak flow, or no response — is ED now.

COPD. A GOLD-style plan names usual inhalers, how this patient recognizes an exacerbation (more dyspnea, more sputum volume or purulence), when to start a pre-agreed steroid and/or antibiotic, and when to seek emergency care (confusion, accessory muscles, cyanosis, falling saturations).

Hypoglycemia. For insulin or a sulfonylurea: rule of 15 — about 15 g of fast carbohydrate, recheck in 15 minutes, repeat if still low, then a snack if the next meal is not immediate. Unconscious or seizing: glucagon (intranasal or injectable) and 911. Teach a household member. Same-day clinic contact for unexplained or recurrent lows or a driving event.

Seizure rescue. Time the event. For known epilepsy, a written plan usually authorizes a rescue benzodiazepine when a convulsion lasts about 5 minutes, or sooner for clusters as neurology specified. Community options include diazepam rectal gel, diazepam nasal spray, and midazolam nasal spray. Call 911 for a first seizure, ongoing convulsion at 5 minutes, a second seizure before recovery, injury, pregnancy, water immersion, or difficulty breathing. The FNP writes and refills the rescue plan; neurology owns drug-resistant epilepsy, pregnancy with epilepsy, and first-seizure workups that are not straightforward.

Advance directives, POLST, palliative, hospice

Chapter 6.3 started the conversation while the patient could still choose. This section writes the orders.

Palliative care is not hospice. Palliative care can start at diagnosis. Hospice is a time-limited, comfort-focused benefit. Comfort-focused primary care — stopping a non-beneficial statin in a dying week, treating dyspnea, calling the family — does not require a hospice nurse in the room.

The FNP initiates advance-care planning, proxy completion, POLST in appropriate patients, primary palliative symptom plans, and hospice referral when criteria are met. Specialty or the hospice team owns refractory symptoms, pediatric end-of-life, contested capacity, and family conflict that needs ethics. Do not invent a statute that every healthy midlife adult must sign a POLST. Do not invent a national mandated-reporter script that ignores state law.

Vignette. A 67-year-old with GOLD E COPD, insulin-treated type 2 diabetes, and newly disclosed suicidal ideation without a plan, after his brother's funeral, also cares for a grandchild with peanut anaphylaxis. Tonight's plan is not “follow up PRN.” It is a written COPD action plan, a hypoglycemia and glucagon plan, an anaphylaxis plan for the adult who watches the child, a suicide safety plan with means counseling and 988, a next-day mental-health contact, and — because hospitalizations are stacking — an advance-directive and POLST conversation plus a palliative-care offer. That is crisis, safety, and end-of-life Planning.