End-of-life care

End-of-life care US Medical PG Question 1: A 52-year-old man presents to his physician with a chief concern of not feeling well. The patient states that since yesterday he has experienced nausea, vomiting, diarrhea, general muscle cramps, a runny nose, and aches and pains in his muscles and joints. The patient has a past medical history of obesity, chronic pulmonary disease, lower back pain, and fibromyalgia. His current medications include varenicline, oxycodone, and an albuterol inhaler. The patient is requesting antibiotics and a refill on his current medications at this visit. He works at a local public school and presented with a similar chief complaint a week ago, at which time he had his prescriptions refilled. You have also seen several of his coworkers this past week and sent them home with conservative measures. Which of the following is the best next step in management?

• A. Oseltamivir
• B. Azithromycin
• C. Metronidazole
• D. Methadone
• E. Supportive therapy (Correct Answer)

End-of-life care Explanation: ***Supportive therapy*** - The patient's symptoms (nausea, vomiting, diarrhea, myalgias, flu-like symptoms) are highly suggestive of a **viral illness**, given the recent similar presentations in his coworkers where conservative measures were sufficient. - Antibiotics are ineffective against viral infections, and the patient has no signs or symptoms indicating a bacterial infection, making **supportive care** (hydration, rest, symptomatic relief) the most appropriate management. *Oseltamivir* - This antiviral medication is primarily used for the treatment of **influenza**, typically within 48 hours of symptom onset. - While the patient's symptoms are flu-like, the timing (symptoms began yesterday, and he presented a week ago with similar complaints) and the general viral presentation among coworkers make targeted antiviral therapy less indicated without a confirmed influenza diagnosis. *Azithromycin* - **Azithromycin is an antibiotic** used to treat bacterial infections, particularly respiratory tract infections, skin infections, and some sexually transmitted infections. - There is no indication of a bacterial infection in this patient; therefore, administering an antibiotic would be inappropriate and contribute to **antibiotic resistance**. *Metronidazole* - **Metronidazole is an antibiotic** primarily used for anaerobic bacterial infections and parasitic infections (e.g., *Clostridium difficile*, *Giardia*). - The patient's symptoms do not suggest these specific types of infections, making its use unwarranted. *Methadone* - **Methadone is an opioid analgesic** and is also used in medication-assisted treatment for opioid use disorder. - Prescribing methadone for the patient's current symptoms or for **opioid pain management** without further assessment, considering his current oxycodone prescription and potential for drug-seeking behavior given his request for refills, is inappropriate and potentially harmful.

End-of-life care US Medical PG Question 2: A 72-year-old woman with metastatic ovarian cancer is brought to the physician by her son because she is in immense pain and cries all the time. On a 10-point scale, she rates the pain as an 8 to 9. One week ago, a decision to shift to palliative care was made after she failed to respond to 2 years of multiple chemotherapy regimens. She is now off chemotherapy drugs and has been in hospice care. Current medications include 2 mg morphine intravenously every 2 hours and 650 mg of acetaminophen every 4 to 6 hours. The son is concerned because he read online that increasing the dose of morphine would endanger her breathing. Which of the following is the most appropriate next step in management?

• A. Counsel patient and continue same opioid dose
• B. Increase dosage of morphine (Correct Answer)
• C. Change morphine to a non-opioid analgesic
• D. Initiate palliative radiotherapy
• E. Initiate cognitive behavioral therapy

End-of-life care Explanation: ***Increase dosage of morphine*** - The patient is experiencing severe, **uncontrolled pain** (8-9/10), indicating her current morphine dose is inadequate. In palliative care, the goal is to provide maximum comfort, and **opioid dose escalation** is appropriate to achieve this. - While respiratory depression is a concern with opioids, in patients with chronic pain who are already on opioids, **tolerance to respiratory depressant effects** develops more quickly than tolerance to analgesic effects. Careful titration and monitoring can safely increase pain relief. *Counsel patient and continue same opioid dose* - The patient's pain is severe and unmanaged, so simply counseling her without addressing the **inadequate analgesia** would be inappropriate and unethical. - Continuing the same dose would perpetuate her suffering, as the current regimen is clearly **insufficient for pain control**. *Change morphine to a non-opioid analgesic* - For severe cancer pain (8-9/10), **non-opioid analgesics** alone are typically ineffective. - Switching to a non-opioid would likely lead to even poorer pain control and increased suffering, as opioids are the **cornerstone of severe cancer pain management**. *Initiate palliative radiotherapy* - While **radiotherapy** can be effective for localized pain caused by bone metastases, its onset of action is not immediate, and the primary issue here is urgent, **uncontrolled systemic pain**. - It is not an appropriate initial step for immediate pain relief in a patient already in hospice with widespread metastatic disease and severe current pain. *Initiate cognitive behavioral therapy* - **Cognitive behavioral therapy (CBT)** can be a useful adjunct in chronic pain management to help with coping strategies and psychological distress. - However, it does not directly address the severe, acute physical pain the patient is experiencing and is not a substitute for **pharmacological pain control** in this context.

End-of-life care US Medical PG Question 3: A 76-year-old woman is brought to the physician by her daughter for evaluation of progressive cognitive decline and a 1-year history of incontinence. She was diagnosed with dementia, Alzheimer type, 5 years ago. The daughter has noticed that in the past 2 years, her mother has had increasing word-finding difficulties and forgetfulness. She was previously independent but now lives with her daughter and requires assistance with all activities of daily living. Over the past year, she has had decreased appetite, poor oral intake, and sometimes regurgitates her food. During this time, she has had a 12-kg (26-lb) weight loss. She was treated twice for aspiration pneumonia and now her diet mainly consists of pureed food. She has no advance directives and her daughter says that when her mother was independent the patient mentioned that she would not want any resuscitation or life-sustaining measures if the need arose. The daughter wants to continue taking care of her mother but is concerned about her ability to do so. The patient has hypertension and hyperlipidemia. Current medications include amlodipine and atorvastatin. Vital signs are within normal limits. She appears malnourished but is well-groomed. The patient is oriented to self and recognizes her daughter by name, but she is unaware of the place or year. Mini-Mental State Examination score is 17/30. Physical and neurologic examinations show no other abnormalities. A complete blood count and serum concentrations of creatinine, urea nitrogen, TSH, and vitamin B12 levels are within the reference range. Her serum albumin is 3 g/dL. Urinalysis shows no abnormalities. Which of the following is the most appropriate next step in management?

• A. Prescribe oxycodone
• B. Short-term rehabilitation
• C. Home hospice care (Correct Answer)
• D. Inpatient palliative care
• E. Evaluation for alternative methods of feeding

End-of-life care Explanation: ***Home hospice care*** - This patient exhibits advanced **dementia** with significant decline in function, frequent aspiration events, and substantial **weight loss**, indicating a prognosis of less than six months. **Hospice care** focuses on comfort and dignity during the end-of-life stage. - The daughter's recollection of the patient's wishes to avoid life-sustaining measures, combined with the current medical complexity and poor prognosis, supports the transition to **hospice services** to manage symptoms and provide support to both the patient and family. *Prescribe oxycodone* - There is no mention of pain in the patient’s presentation; therefore, prescribing an **opioid** like oxycodone is not indicated and could cause adverse effects such as **sedation** and **constipation**, which would further complicate her care. - While patients with advanced dementia may experience pain, it must be assessed and confirmed before prescribing **analgesics**. *Short-term rehabilitation* - Given the patient's advanced dementia, severe functional decline, recurrent aspiration pneumonia, and malnourishment, **short-term rehabilitation** to improve functional status is unlikely to be effective. - The patient's underlying condition is progressive and irreversible, making restoration of independent function an unrealistic goal. *Inpatient palliative care* - While **palliative care** focuses on symptom management and quality of life, **inpatient palliative care** is typically reserved for patients with severe symptoms requiring constant medical attention that cannot be managed at home. - In this case, the patient's symptoms, while serious, appear amenable to management in a home setting with the comprehensive support offered by **hospice**. *Evaluation for alternative methods of feeding* - In advanced dementia, **percutaneous endoscopic gastrostomy (PEG) tube feeding** does not improve survival, reduce aspiration risk, or enhance quality of life. - Given the patient's advanced stage of disease and the recalled wishes to avoid life-sustaining measures, initiating **artificial feeding** would be contrary to comfort-focused care.

End-of-life care US Medical PG Question 4: An 85-year-old man with terminal stage colon cancer formally designates his best friend as his medical durable power of attorney. After several courses of chemotherapy and surgical intervention, the patient’s condition does not improve, and he soon develops respiratory failure. He is then placed on a ventilator in a comatose condition. His friend with the medical power of attorney tells the care provider that the patient would not want to be on life support. The patient’s daughter disputes this and says that her father needs to keep receiving care, in case there should be any possibility of recovery. Additionally, there is a copy of the patient’s living will in the medical record which states that, if necessary, he should be placed on life support until full recovery. Which of the following is the most appropriate course of action?

• A. Withdraw the life support since the patient’s chances of recovery are very low
• B. Contact other family members to get their input for the patient
• C. Act according to the patient’s living will
• D. The durable medical power of attorney’s decision should be followed. (Correct Answer)
• E. Follow the daughter’s decision for the patient

End-of-life care Explanation: ***The durable medical power of attorney's decision should be followed*** - The patient designated his friend as his **durable power of attorney for healthcare (DPOA)**, giving him legal authority to make medical decisions when the patient cannot communicate. - While the living will states life support "until full recovery," the patient has **terminal stage colon cancer** - full recovery is **medically impossible**. The living will's condition cannot be fulfilled. - When advance directive language is ambiguous or cannot be applied to actual clinical circumstances, the **DPOA's interpretive authority** is essential. The DPOA is expected to apply the patient's values to the real situation. - The DPOA states the patient would not want to be on life support - this reflects the patient's **values and wishes** as understood by his chosen decision-maker, applied to the actual terminal situation. - This honors both **patient autonomy** (through his chosen proxy) and the reality that advance directives cannot anticipate every clinical scenario. *Act according to the patient's living will* - While a living will expresses patient wishes, it states life support should continue "**until full recovery**" - but the patient has terminal cancer with no possibility of recovery. - Literal adherence to an advance directive whose conditions are **medically impossible** does not serve the patient's true interests or autonomy. - Living wills and DPOAs work **together** - the DPOA interprets and applies the living will to actual circumstances, especially when literal application is impossible or the situation wasn't anticipated. *Withdraw the life support since the patient's chances of recovery are very low* - While this may align with the DPOA's interpretation of the patient's wishes, unilateral physician decision-making without following the proper **decision-making hierarchy** is inappropriate. - The physician should work **with the DPOA** rather than make independent decisions about life support withdrawal. *Contact other family members to get their input for the patient* - The patient **legally designated** his friend as DPOA, indicating his trust in this person's judgment over family members. - While family input can be valuable, seeking additional opinions when there is a **legally appointed decision-maker** undermines the patient's explicit choice. - The daughter has no legal standing to override the DPOA's decisions. *Follow the daughter's decision for the patient* - The daughter was **not designated** as the healthcare decision-maker; the friend was explicitly chosen as DPOA. - Following the daughter's wishes would **violate** the patient's autonomous choice of decision-maker. - Family relationship alone does not override a formal DPOA designation.

End-of-life care US Medical PG Question 5: A 68-year-old woman was recently diagnosed with pancreatic cancer. At what point should her physician initiate a discussion with her regarding advance directive planning?

• A. Once she enters hospice
• B. Now that she is ill, speaking about advance directives is no longer an option
• C. Only if her curative surgical and medical treatment fails
• D. Only if she initiates the conversation
• E. At this visit (Correct Answer)

End-of-life care Explanation: ***At this visit*** - Advance care planning should ideally be initiated as soon as a **serious illness** like pancreatic cancer is diagnosed, while the patient still has the capacity to make informed decisions. - This allows the patient to clearly state their **wishes** for future medical care and designate a **surrogate decision-maker**. *Once she enters hospice* - Delaying discussions until hospice care often means the patient's condition has significantly deteriorated, potentially impacting their ability to actively participate in **decision-making**. - While advance directives are crucial for hospice patients, starting earlier ensures their preferences guide all stages of their care, not just the end-of-life phase. *Now that she is ill, speaking about advance directives is no longer an option* - This statement is incorrect as illness is often the **catalyst** for initiating advance care planning, not a barrier. - Patients often appreciate the opportunity to discuss their wishes, especially when facing a serious diagnosis, to maintain a sense of **control** and ensure their autonomy. *Only if her curative surgical and medical treatment fails* - Waiting until treatment failure is too late as the patient's condition may have worsened to a point where they are no longer able to engage in **meaningful discussions** or have decreased mental capacity. - Advance care planning is about preparing for potential future scenarios, not just reacting to immediate failures; it provides a framework for care regardless of **treatment outcomes**. *Only if she initiates the conversation* - While patient initiation is ideal, it is the physician's responsibility to bring up these important discussions, especially with a new diagnosis of a serious illness like **pancreatic cancer**. - Many patients may not know about advance directives or feel comfortable initiating such a sensitive conversation, so the physician should proactively offer the **opportunity**.

End-of-life care US Medical PG Question 6: A 56-year-old man presents to the family medicine office since he has been having difficulty keeping his blood pressure under control for the past month. He has a significant medical history of hypertension, coronary artery disease, and diabetes mellitus. He has a prescription for losartan, atenolol, and metformin. The blood pressure is 178/100 mm Hg, the heart rate is 92/min, and the respiratory rate is 16/min. The physical examination is positive for a grade II holosystolic murmur at the left sternal border. He also has diminished sensation in his toes. Which of the following statements is the most effective means of communication between the doctor and the patient?

• A. “What is causing your blood pressure to be elevated?” (Correct Answer)
• B. “Have you been taking your medications as prescribed?”
• C. “Would you like us to consider trying a different medication for your blood pressure?”
• D. “You are taking your medications as prescribed, aren’t you?”
• E. “Why are you not taking your medication?”

End-of-life care Explanation: ***“What is causing your blood pressure to be elevated?”*** - This is an **open-ended question** that encourages the patient to share their perspective, concerns, and potential reasons for the elevated blood pressure, fostering a **patient-centered approach**. - It allows the physician to understand the patient's individual circumstances, medication adherence, lifestyle factors, or other contributing issues without being judgmental or leading. *“Have you been taking your medications as prescribed?”* - This is a **closed-ended question** that primarily elicits a "yes" or "no" answer, providing limited insight into the patient's actual adherence and the underlying reasons for non-adherence. - While important, phrasing it this way might make the patient feel interrogated or judged, potentially hindering honest communication. *“Would you like us to consider trying a different medication for your blood pressure?”* - This question prematurely jumps to a solution without fully understanding the cause of the elevated blood pressure and the patient's perspective. - It bypasses the crucial step of investigating potential reasons for poor blood pressure control, which could include non-adherence, lifestyle factors, or secondary hypertension, rather than necessarily a medication efficacy issue. *“You are taking your medications as prescribed, aren’t you?”* - This is a **leading question** that implies an expectation and can make the patient feel pressured to answer affirmatively, even if they are not consistently taking their medication. - Such phrasing can create a defensive environment and discourage the patient from openly discussing adherence challenges. *“Why are you not taking your medication?”* - This is a **direct and accusatory question** that implies blame and can immediately put the patient on the defensive, making them less likely to be honest or forthcoming about their medication habits. - It fails to create a supportive or collaborative atmosphere, which is essential for effective patient-physician communication.

End-of-life care US Medical PG Question 7: A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?

• A. "Does the diarrhea typically precede the constipation, or vice-versa?"
• B. "Is the diarrhea foul-smelling?"
• C. "Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"
• D. "Are the symptoms worse in the morning or at night?"
• E. "Can you tell me more about the symptoms you have been experiencing?" (Correct Answer)

End-of-life care Explanation: ***Can you tell me more about the symptoms you have been experiencing?*** - This **open-ended question** encourages the patient to provide a **comprehensive narrative** of their symptoms, including details about onset, frequency, duration, alleviating/aggravating factors, and associated symptoms, which is crucial for diagnosis. - In a patient presenting with vague, intermittent symptoms like alternating constipation and diarrhea, allowing them to elaborate freely can reveal important clues that might not be captured by more targeted questions. *Does the diarrhea typically precede the constipation, or vice-versa?* - While knowing the sequence of symptoms can be helpful in understanding the **pattern of bowel dysfunction**, it is a very specific question that might overlook other important aspects of the patient's experience. - It prematurely narrows the focus without first obtaining a broad understanding of the patient's overall symptomatic picture. *Is the diarrhea foul-smelling?* - Foul-smelling diarrhea can indicate **malabsorption** or **bacterial overgrowth**, which are important to consider in some gastrointestinal conditions. - However, this is a **specific symptom inquiry** that should follow a more general exploration of the patient's symptoms, as it may not be relevant if other crucial details are missed. *Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life* - Quantifying pain intensity is useful for assessing the **severity of discomfort** and monitoring changes over time. - However, for a patient with intermittent rather than acute, severe pain, understanding the **character, location, and triggers** of the pain is often more diagnostically valuable than just a numerical rating initially. *Are the symptoms worse in the morning or at night?* - Diurnal variation can be relevant in certain conditions, such as inflammatory bowel diseases where nocturnal symptoms might be more concerning, or functional disorders whose symptoms might be stress-related. - This is another **specific question** that should come after gathering a more complete initial picture of the patient's symptoms to ensure no key information is overlooked.

End-of-life care US Medical PG Question 8: A 32-year-old woman is brought to the emergency department by her husband because of an episode of hematemesis 2 hours ago. She has had dyspepsia for 2 years. Her medications include occasional ibuprofen for headaches. After initial stabilization, the risks and benefits of upper endoscopy and alternative treatments, including no therapy, are explained thoroughly. She shows a good understanding of her condition and an appreciation of endoscopic treatment and its complications. She decides that she wants to have an endoscopy to find the source of bleeding and appropriately manage the ulcer. Her medical records show advance directives that she signed 3 years ago; her sister, who is a nurse, has a durable power of attorney. Regarding obtaining informed consent, which of the following is the most accurate conclusion for providing endoscopic treatment for this patient?

• A. There are reasons to believe that she may not have decision-making capacity
• B. Endoscopic treatment may be performed without further action
• C. Her sister must sign the consent form
• D. Documentation of her decision prior to treatment is required (Correct Answer)
• E. Her decision to have an endoscopy is not voluntary

End-of-life care Explanation: **Documentation of her decision prior to treatment is required** - The patient has been fully informed, understands her condition, and has expressed a clear desire for the procedure, demonstrating **decision-making capacity**. - To ensure ethical and legal compliance, her **informed consent** must be accurately documented in her medical record before any invasive treatment, including endoscopy, is performed. *There are reasons to believe that she may not have decision-making capacity* - The patient has clearly demonstrated **understanding of her condition, treatment options, and potential complications**, which indicates preserved decision-making capacity. - Despite the acute medical situation, her ability to articulate her preference after a thorough discussion confirms her competence for informed consent. *Endoscopic treatment may be performed without further action* - While the patient has consented verbally, this does not negate the need for proper **documentation of informed consent** before initiating the procedure. - Legally and ethically, a verbal agreement alone is insufficient; a signed consent form or detailed chart note confirming her understanding and decision is essential. *Her sister must sign the consent form* - Her sister, holding a **durable power of attorney**, would only be authorized to make medical decisions if the patient were deemed to lack **decision-making capacity**. - Since the patient clearly demonstrates the ability to make her own medical decisions, her sister's consent is not required and would override the patient's autonomy. *Her decision to have an endoscopy is not voluntary* - The scenario explicitly states that the risks and benefits were **thoroughly explained**, and she shows a "good understanding" and "appreciation of endoscopic treatment." - Her decision to "want to have an endoscopy" despite knowing the alternatives suggests a **voluntary and informed choice**, not coercion.

End-of-life care US Medical PG Question 9: A 72-year-old woman is brought to the emergency department with dyspnea for 2 days. She is on regular hemodialysis at 3 sessions a week but missed her last session due to an unexpected trip. She has a history of congestive heart failure. After urgent hemodialysis, the patient’s dyspnea does not improve as expected. The cardiologist is consulted. After evaluation of the patient, he notes in the patient’s electronic record: “the patient does not have a chronic heart condition and a cardiac cause of dyspnea is unlikely.” The following morning, the nurse finds the cardiologist’s notes about the patient not having congestive heart failure odd. The patient had a clear history of congestive heart failure with an ejection fraction of 35%. After further investigation, the nurse realizes that the cardiologist evaluated the patient’s roommate. She is an elderly woman with a similar first name. She is also on chronic hemodialysis. To prevent similar future errors, the most appropriate strategy is to use which of the following?

• A. Two patient identifiers at every nurse-patient encounter
• B. A patient’s medical identification number at every encounter by any healthcare provider
• C. Two patient identifiers at every patient encounter by any healthcare provider (Correct Answer)
• D. Two patient identifiers at every physician-patient encounter
• E. A patient’s medical identification number at every physician-patient encounter

End-of-life care Explanation: ***Two patient identifiers at every patient encounter by any healthcare provider*** - This strategy ensures that **all healthcare providers**, not just nurses or physicians, verify the patient's identity using at least **two distinct identifiers** before any interaction, greatly reducing the risk of mix-ups. - This comprehensive approach prevents errors like the one described, where a cardiologist evaluated the wrong patient due to similar names and circumstances, ensuring **patient safety** and appropriate care delivery. *Two patient identifiers at every nurse-patient encounter* - While important, limiting identification to nurse-patient encounters would **miss opportunities for error by other healthcare providers**, such as physicians, technicians, or pharmacists. - The scenario explicitly states the error was made by a **cardiologist**, indicating that relying solely on nurses for identification is insufficient. *A patient’s medical identification number at every encounter by any healthcare provider* - Although the **medical identification number** is a valid identifier, relying on a *single* identifier still carries a risk, especially if typed or read incorrectly. - **Two distinct identifiers** (e.g., name and date of birth, or name and medical record number) are the **gold standard** to minimize errors. *Two patient identifiers at every physician-patient encounter* - This option, while improving physician encounters, **fails to cover interactions with other crucial healthcare team members** (e.g., nurses, phlebotomists, imaging technicians) where patient misidentification can still occur. - A comprehensive patient safety strategy must extend beyond physician interactions to **all points of care**. *A patient’s medical identification number at every physician-patient encounter* - This option combines the weaknesses of using only a **single identifier** and limiting the scope to **only physician encounters**, leaving multiple vulnerabilities for patient misidentification throughout the healthcare process. - The **Joint Commission's National Patient Safety Goals** explicitly recommend using at least **two patient identifiers**.

End-of-life care US Medical PG Question 10: A 25-year-old man is admitted to the emergency department because of an episode of acute psychosis with suicidal ideation. He has no history of serious illness and currently takes no medications. Despite appropriate safety precautions, he manages to leave the examination room unattended. Shortly afterward, he is found lying outside the emergency department. A visitor reports that she saw the patient climbing up the facade of the hospital building. He does not respond to questions but points to his head when asked about pain. His pulse is 131/min, respirations are 22/min, and blood pressure is 95/61 mm Hg. Physical examination shows a 1-cm head laceration and an open fracture of the right tibia. He opens his eyes spontaneously. Pupils are equal, round, and reactive to light. Breath sounds are decreased over the right lung field, and the upper right hemithorax is hyperresonant to percussion. Which of the following is the most appropriate next step in management?

• A. Obtain a chest x-ray
• B. Perform a needle thoracostomy (Correct Answer)
• C. Perform an endotracheal intubation
• D. Apply a cervical collar
• E. Perform an open reduction of the tibia fracture

End-of-life care Explanation: ***Perform a needle thoracostomy*** - The patient presents with **clinical signs of tension pneumothorax**: hypotension (95/61 mm Hg), tachycardia (131/min), decreased breath sounds, and hyperresonance over the right hemithorax following significant trauma from a fall. - According to **ATLS (Advanced Trauma Life Support) principles**, the primary survey follows the **ABC priority**: Airway, Breathing, Circulation. A **tension pneumothorax is an immediately life-threatening condition** that compromises both breathing and circulation (obstructive shock). - **Needle thoracostomy (needle decompression)** is the immediate, life-saving intervention for tension pneumothorax and must be performed **before** or concurrent with other interventions. This takes precedence over spinal immobilization when there is an immediate life threat. - The clinical presentation strongly suggests tension physiology requiring immediate decompression; waiting for imaging would be inappropriate and potentially fatal. *Apply a cervical collar* - While **cervical spine protection** is important in this polytrauma patient with head injury and fall mechanism, it does **not take precedence over treating immediately life-threatening conditions** like tension pneumothorax. - C-spine can be protected with **manual in-line stabilization** during the needle thoracostomy procedure. - Modern trauma protocols emphasize that **life threats to airway, breathing, and circulation must be addressed immediately**, even if it requires brief spinal movement with appropriate precautions. *Obtain a chest x-ray* - **Tension pneumothorax is a clinical diagnosis** that requires immediate intervention without waiting for imaging confirmation. - The combination of hypotension, tachycardia, decreased breath sounds, and hyperresonance in a trauma patient is sufficient to warrant emergent needle decompression. - Delaying treatment for imaging in a hemodynamically unstable patient would be dangerous and violates patient safety principles. *Perform an endotracheal intubation* - While the patient has a **GCS of approximately 10** (eyes open spontaneously = 4, no verbal response = 1-2, localizes pain = 5-6), intubation is not the immediate priority. - The **tension pneumothorax must be decompressed first** before attempting intubation, as positive pressure ventilation could worsen the tension pneumothorax and cause cardiovascular collapse. - If intubation is needed, it should occur after needle decompression. *Perform an open reduction of the tibia fracture* - While the open tibia fracture requires urgent surgical management, it is **not immediately life-threatening** in the same timeframe as tension pneumothorax. - According to ATLS principles, **life-threatening injuries are addressed before limb-threatening injuries**. - The fracture should be stabilized temporarily, and definitive surgical management can occur after the patient is hemodynamically stable.

End-of-life care Flashcard 1 of 6

Question: What type of disease prevention is identifying patients at risk of unnecessary treatment?_____

Answer: Quaternary

End-of-life care Flashcard 2 of 6

Question: Patients typically get exposed to _____ radiation via nuclear reactor accidents or radiotherapy

Answer: Ionizing

End-of-life care Flashcard 3 of 6

Question: What must be used in all patients treated with cisplatin?_____

Answer: IV saline

End-of-life care Flashcard 4 of 6

Question: What are three common types of advance directives? (medical law)

Answer: 1 - oral advance directive (often informal) 2 - written advance directive (formal living will) 3 - medical power of attorney

End-of-life care Flashcard 5 of 6

Question: advance directive (medical law)

Answer: instructions given by a patient in anticipation of the need to make a medical decision in the future (state-specific)

End-of-life care Flashcard 6 of 6

Question: When is an extremely important time to re-address advanced care planning for end-of-life issues? _____

Answer: Hospital admission

Extra Information:  https://onlinemeded.org?ref=anki