A 76-year-old man is brought to the hospital after having a stroke. Head CT is done in the emergency department and shows intracranial hemorrhage. Upon arrival to the ED he is verbally non-responsive and withdraws only to pain. He does not open his eyes. He is transferred to the medical ICU for further management and intubated for airway protection. During his second day in the ICU, his blood pressure is measured as 91/54 mmHg and pulse is 120/min. He is given fluids and antibiotics, but he progresses to renal failure and his mental status deteriorates. The physicians in the ICU ask the patient’s family what his wishes are for end-of-life care. His wife tells the team that she is durable power of attorney for the patient and provides appropriate documentation. She mentions that he did not have a living will, but she believes that he would want care withdrawn in this situation, and therefore asks the team to withdraw care at this point. The patient’s daughter vehemently disagrees and believes it is in the best interest of her father, the patient, to continue all care. Based on this information, what is the best course of action for the physician team?

Listen to the patient’s wife’s wishes and withdraw care

Call other family members and consult them for their opinions

Listen to the patient’s daughter’s wishes and continue all care

Compromise between the wife and daughter and withdraw the fluids and antibiotics but keep the patient intubated

Consult the hospital ethics committee and continue all care until a decision is reached

A 75-year-old woman with metastatic colon cancer comes to the physician requesting assistance in ending her life. She states: “I just can't take it anymore; the pain is unbearable. Please help me die.” Current medications include 10 mg oral hydrocodone every 12 hours. Her cancer has progressed despite chemotherapy and she is very frail. She lives alone and has no close family. Which of the following is the most appropriate initial action by the physician?

Increase her pain medication dose

Consult with the local ethics committee

Submit a referral to psychiatry

Submit a referral to hospice care

Initiate authorization of physician-assisted suicide

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?

Counsel patient and continue same opioid dose

Change morphine to a non-opioid analgesic

Initiate palliative radiotherapy

Initiate cognitive behavioral therapy

A 69-year-old man with aggressive metastatic cholangiocarcinoma presents after the second round of chemotherapy. He has suffered a great deal of pain from the metastasis to his spine, and he is experiencing side effects from the cytotoxic chemotherapy drugs. Imaging shows no change in the tumor mass and reveals the presence of several new metastatic lesions. The patient is not willing to undergo any more chemotherapy unless he gets something for pain that will “knock him out”. High-dose opioids would be effective, in his case, but carry a risk of bradypnea and sudden respiratory failure. Which of the following is the most appropriate next step in management?

Put him in a medically-induced coma during chemotherapy sessions

Continue another round of chemotherapy without opioids

Give a lower dose even though it has less efficacy

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?

Evaluation for alternative methods of feeding

A 28-year-old woman dies shortly after receiving a blood transfusion. Autopsy reveals widespread intravascular hemolysis and acute renal failure. Investigation reveals that she received type A blood, but her medical record indicates she was type O. In a malpractice lawsuit, which of the following elements must be proven?

Duty, breach, causation, and damages

A 57-year-old man presents to his oncologist to discuss management of small cell lung cancer. The patient is a lifelong smoker and was diagnosed with cancer 1 week ago. The patient states that the cancer was his fault for smoking and that there is "no hope now." He seems disinterested in discussing the treatment options and making a plan for treatment and followup. The patient says "he does not want any treatment" for his condition. Which of the following is the most appropriate response from the physician?

"It must be very challenging having received this diagnosis. I want to work with you to create a plan."

"You seem upset at the news of this diagnosis. I want you to go home and discuss this with your loved ones and come back when you feel ready to make a plan together for your care."

"It must be tough having received this diagnosis; however, new cancer therapies show increased efficacy and excellent outcomes."

"We are going to need to treat your lung cancer. I am here to help you throughout the process."

"I respect your decision and we will not administer any treatment. Let me know if I can help in any way."

A 32-year-old man comes to the emergency department because of recurrent episodes of vomiting for 1 day. He has had over 15 episodes of bilious vomiting. During this period he has had cramping abdominal pain but has not had a bowel movement or passed flatus. He does not have fever or diarrhea. He was diagnosed with Crohn disease at the age of 28 years which has been well controlled with oral mesalamine. He underwent a partial small bowel resection for midgut volvulus at birth. His other medications include vitamin B12, folic acid, loperamide, ferrous sulfate, and vitamin D3. He appears uncomfortable and his lips are parched. His temperature is 37.1°C (99.3°F), pulse is 103/min, and blood pressure is 104/70 mm Hg. The abdomen is distended, tympanitic, and tender to palpation over the periumbilical area and the right lower quadrant. Rectal examination is unremarkable. A CT scan of the abdomen shows multiple dilated loops of small bowel with a transition zone in the mid to distal ileum. After 24 hours of conservative management with IV fluid resuscitation, nasogastric bowel decompression, promethazine, and analgesia, his condition does not improve and a laparotomy is scheduled. During the laparotomy, two discrete strictures are noted in the mid-ileum, around 20 cm apart. Which of the following is the most appropriate next step in management?

Strictureplasty of individual strictures

Small bowel resection with ileostomy

Abdominal closure and start palliative care

Small bowel resection and primary anastomosis

Palliative care principles for USMLE Step 3: High-Yield Patient Safety Lessons

Palliative Care Principles - The Comfort Crew

Focuses on improving quality of life for patients and families facing serious illness.
Core goal: Prevent and relieve suffering through a multidisciplinary approach.
📌 COMFORT Mnemonic:
- Communication: Open, honest discussions.
- Orientation: Aligning care with patient goals.
- Management: Aggressive symptom control (pain, dyspnea).
- Family: Involving and supporting loved ones.
- Openness: Addressing emotional & spiritual needs.
- Respect: Upholding patient autonomy.
- Team: Interdisciplinary collaboration.

⭐ Palliative care is not limited to end-of-life; it can be initiated at any stage of a serious illness, alongside curative treatment.

Symptom Control - The Relief Squad

Core Goal: Alleviate distressing symptoms to improve quality of life, regardless of prognosis.
Pain Management:
- Opioids are the cornerstone (e.g., morphine, fentanyl). Start low, go slow.
- Titrate to effect; no ceiling dose for pain relief.
- Adjuvants: NSAIDs, corticosteroids, antidepressants (for neuropathic pain).
Dyspnea (Shortness of Breath):
- Opioids (low-dose oral or parenteral morphine) are first-line.
- Supplemental O₂ only if hypoxic (SpO₂ < 90%).
- Anxiolytics (benzodiazepines) can reduce associated anxiety.
Constipation:
- 📌 Mush & Push: Prophylaxis is key with opioids. Use a stimulant (Senna - "push") + softener (Docusate - "mush").

⭐ High-Yield: Opioids are the primary treatment for the sensation of dyspnea in terminally ill patients, even if they are not hypoxic.

Communication & Ethics - The Guidance Guild

Core Goal: Align care with patient values, preferences, and goals. Focus on quality of life and symptom control, not just curative treatment.
Advance Care Planning:
- Advance Directives: Legal documents (Living Will, Healthcare Proxy) specifying future medical wishes.
- DNR/DNI: Orders to withhold CPR or intubation. Must be documented.
- POLST/MOLST: Physician/Medical Orders for Life-Sustaining Treatment; converts wishes into actionable medical orders.
Breaking Bad News (📌 SPIKES): A structured approach to difficult conversations.

⭐ The principle of double effect is key. Administering escalating doses of morphine for pain control in a terminally ill patient is ethically sound, even if it may hasten death. The intent is to relieve suffering, not to cause death.

High‑Yield Points - ⚡ Biggest Takeaways

Palliative care aims to improve quality of life for patients and families facing serious illness, at any stage.

It can be provided concurrently with curative treatment; it is not solely for the end-of-life.

The core focus is comprehensive symptom management, including pain, dyspnea, nausea, and anxiety.

Care involves an interdisciplinary team to address physical, psychosocial, and spiritual needs.

Hospice is a form of palliative care for patients with a prognosis of <6 months who are no longer seeking curative therapy.

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