End-of-Life Issues — MCQs
As per Mental Healthcare Act, an individual with a known psychotic disorder on treatment and is not a minor, can decide the caretaker and the course of treatment. This is called:
In an accident case, after the arrival of medical team, all should be done in early management except;
Leading questions are permitted only in-
Electroconvulsive therapy is not useful in which of the following conditions?
The Confusion Assessment Method (CAM) is used for which of the following?
Which of the following is not a diagnostic criteria for declaring brainstem death?
A woman died within 5 years of marriage under suspicious circumstances. Her parents complained that her in-laws used to frequently demand dowry. Under which of the following sections can a magistrate authorize an autopsy of the case?
A moribund patient who has little chance of survival but is submitted to surgery as a last resort belongs to ASA class-
Which of the following antidepressants can be safely used in elderly depression?
"Sundowning" is seen in which of the following conditions?
End-of-Life Issues Indian Medical PG Practice Questions and MCQs
Question 1: As per Mental Healthcare Act, an individual with a known psychotic disorder on treatment and is not a minor, can decide the caretaker and the course of treatment. This is called:
- A. Future directive
- B. Treatment directive
- C. Advance directive (Correct Answer)
- D. Mental will
Explanation: ***Advance directive*** - An **advance directive** allows individuals with mental illness who are not minors to make decisions about their future care, including appointing a caretaker and outlining treatment preferences, while they are still capable. - This legal document ensures that a person's wishes regarding their mental health treatment are respected even if they later lose the capacity to make those decisions. *Future directive* - While "future directive" might seem semantically similar, it is not the specific legal or medical term used in the context of the **Mental Healthcare Act** for outlining future treatment choices. - This term is less precise and does not carry the same legal weight or established definition as "advance directive." *Treatment directive* - "Treatment directive" specifically refers to choices about treatment, but it doesn't encompass the full scope of appointing a **caretaker** or the broader legal framework of an advance directive under the act. - It's a more general term that might be used to describe instructions for current or future treatment, but it's not the legally recognized term for comprehensive pre-planned care in mental health. *Mental will* - "Mental will" is not a recognized legal or medical term under the **Mental Healthcare Act** or generally in healthcare planning. - The concept of a "will" typically applies to the distribution of property after death, not to ongoing healthcare decisions or the appointment of caretakers for mental health.
Question 2: In an accident case, after the arrival of medical team, all should be done in early management except;
- A. Glasgow coma scale
- B. Check BP (Correct Answer)
- C. Stabilization of cervical vertebrae
- D. Check Respiration
Explanation: ***Check BP*** - In the **immediate/early management** of trauma (primary survey), while circulation assessment is crucial, the **initial assessment of circulation** focuses on: - **Pulse rate and quality** (radial, carotid) - **Capillary refill time** - **Skin color and temperature** - **Active hemorrhage control** - **Formal blood pressure measurement** with a cuff, while important, is typically recorded during or after these rapid initial assessments, as it takes more time to obtain an accurate reading. - In the context of this question, among the four options listed, BP measurement is relatively less immediate compared to the other life-saving priorities (airway protection, breathing assessment, C-spine stabilization, and GCS). - **Note:** This is a nuanced distinction - BP is assessed during primary survey, but the other three options have more immediate life-threatening implications if not addressed. *Glasgow coma scale* - **GCS assessment** is part of the **"D" (Disability)** step in the ATLS primary survey. - It is performed early to assess neurological status and level of consciousness. - GCS <8 indicates need for **definitive airway protection** (intubation). - This is a critical early assessment that guides immediate management decisions. *Stabilization of cervical vertebrae* - **C-spine immobilization** is part of the **"A" (Airway)** step - "Airway with cervical spine protection." - It is performed **simultaneously** with airway assessment using a **rigid cervical collar**. - This is the **first priority** in trauma management to prevent secondary spinal cord injury. - All trauma patients should be assumed to have C-spine injury until proven otherwise. *Check Respiration* - **Respiratory assessment** is part of the **"B" (Breathing)** step in the ATLS primary survey. - This involves checking: - **Respiratory rate and pattern** - **Chest wall movement** - **Air entry bilaterally** - **Signs of tension pneumothorax or flail chest** - This is an immediate life-saving priority and must be assessed early.
Question 3: Leading questions are permitted only in-
- A. Re-examination
- B. Examination in chief
- C. Dying declaration
- D. Cross examination (Correct Answer)
Explanation: ***Cross examination*** - **Leading questions** are questions that suggest the answer the examiner wishes to elicit. They are generally permitted in **cross-examination** to challenge the witness's testimony and probe for inconsistencies. - The purpose of cross-examination is to test the **veracity** and **accuracy** of the evidence given by the witness during direct examination. *Re-examination* - **Re-examination** follows cross-examination and is conducted by the party who called the witness, but it is limited to explaining or clarifying matters raised during cross-examination. - **Leading questions** are generally not allowed during re-examination, as its purpose is to rehabilitate the witness, not introduce new evidence or suggest answers. *Examination in chief* - **Examination in chief** (or direct examination) is when a lawyer questions their own witness to elicit factual information relevant to their case. - **Leading questions** are typically prohibited during examination in chief to ensure that the testimony is the witness's own and not influenced by the lawyer. *Dying declaration* - A **dying declaration** is a statement made by a person who is conscious and believes death is imminent, regarding the cause and circumstances of their impending death. - It is an exception to the **hearsay rule** and is usually recorded as a statement, not as a process involving direct questioning where leading questions would be applied in a court setting.
Question 4: Electroconvulsive therapy is not useful in which of the following conditions?
- A. Panic attacks (Correct Answer)
- B. Depression
- C. Seizures
- D. Delirium
Explanation: ***Panic attacks*** - ECT has **no established role** in the treatment of panic disorder or panic attacks. - **First-line treatments** include SSRIs, benzodiazepines, and cognitive behavioral therapy (CBT). - ECT is not indicated for **anxiety-predominant disorders** and there is no evidence supporting its use in panic attacks. *Depression* - ECT is a **highly effective** treatment for **severe major depression**, particularly: - **Treatment-resistant depression** (failed multiple antidepressant trials) - **Psychotic depression** (depression with psychotic features) - **Severe melancholic or catatonic depression** - Depression with **high suicide risk** requiring rapid response - ECT is considered one of the most effective treatments in psychiatry for severe depression. *Seizures* - ECT **induces controlled therapeutic seizures** to achieve psychiatric benefits, but it is **not a treatment for epilepsy** or seizure disorders. - The therapeutic effect in psychiatric conditions is mediated through the induced seizure and its neurobiological effects. - ECT does **not treat or prevent epileptic seizures**; patients with epilepsy can safely receive ECT with appropriate precautions. *Delirium* - ECT can be used in **highly selected cases** of refractory delirium, particularly: - Delirium with **severe agitation** unresponsive to medical management - Delirium in the context of **catatonia** - While not a first-line treatment, ECT **has documented efficacy** in specific refractory cases of delirium when conventional treatments have failed.
Question 5: The Confusion Assessment Method (CAM) is used for which of the following?
- A. Schizophrenia
- B. Delirium (Correct Answer)
- C. Dementia
- D. Depression
Explanation: ***Delirium*** - The Confusion Assessment Method (CAM) is a widely used and highly sensitive and specific tool for the rapid identification of **delirium**. - It assesses for acute onset and fluctuating course, inattention, disorganized thinking, and altered level of consciousness. *Schizophrenia* - Schizophrenia is a chronic mental health disorder primarily characterized by **psychosis**, including hallucinations, delusions, and disorganized thought. - While patients with schizophrenia can experience cognitive difficulties, specialized scales like the Positive and Negative Syndrome Scale (PANSS) are used, not the CAM. *Dementia* - Dementia is a gradual and progressive decline in cognitive function, including memory, thinking, and reasoning, severe enough to interfere with daily life. - Tools like the mini-mental state examination (MMSE) or Montreal Cognitive Assessment (MoCA) are used for screening and assessing dementia, not the CAM. *Depression* - Depression is a mood disorder characterized by persistent sadness, loss of interest, and other emotional and physical symptoms. - Assessment tools like the Hamilton Depression Rating Scale (HDRS) or Patient Health Questionnaire-9 (PHQ-9) are used for depression.
Question 6: Which of the following is not a diagnostic criteria for declaring brainstem death?
- A. A positive apnea test
- B. Lack of cerebromotor response to pain in all extremities
- C. Absence of brainstem reflexes
- D. Absence of stretch reflex from all extremities is essential (Correct Answer)
Explanation: ***Absence of stretch reflex from all extremities is essential*** - While loss of **deep tendon reflexes** may occur in brain death, it is not a specific diagnostic criterion for brainstem death. [1] - The stretch reflex primarily indicates the integrity of the **spinal reflex arc**, which can persist even in brainstem death. *A positive apnea test* - A **positive apnea test** (no spontaneous respirations despite CO2 rising to a critical level) is a crucial criterion for declaring brainstem death, indicating irreversible cessation of brainstem respiratory control. [1], [2] - It demonstrates the absence of the **medullary respiratory center's function**. *Lack of cerebromotor response to pain in all extremities* - The absence of any **motor response** to noxious stimuli in the cranial nerve distribution or in the limbs, mediated by brainstem pathways, is a key component of brainstem death criteria. [1], [2] - This specifically excludes **spinal reflexes**, which may still be present. *Absence of brainstem reflexes* - This is a fundamental criterion, encompassing the absence of **pupillary light reflexes**, **oculocephalic reflexes** (doll's eyes), **oculovestibular reflexes** (caloric reflexes), **corneal reflexes**, **gag reflex**, and **cough reflex**. [1], [2] - Their absence indicates complete and irreversible loss of **brainstem function**, which is prerequisite for brainstem death.
Question 7: A woman died within 5 years of marriage under suspicious circumstances. Her parents complained that her in-laws used to frequently demand dowry. Under which of the following sections can a magistrate authorize an autopsy of the case?
- A. Section 302 IPC
- B. Section 174 Cr Pc
- C. Section 304 IPC
- D. Section 176 Cr Pc (Correct Answer)
Explanation: ***Section 176 Cr PC*** - This section empowers a **Magistrate to hold an inquiry into the cause of death** in cases of suspicious circumstances, including deaths within seven years of marriage where dowry harassment is alleged. - The magistrate can **order a post-mortem examination** or even a second post-mortem if there are doubts about the initial findings, making it the appropriate section for **magisterial authorization** of autopsy. - In dowry death cases, Section 176 provides judicial oversight and ensures an independent inquiry beyond police investigation. *Section 174 Cr PC* - This section deals with **police inquiry** and report on suicide and suspicious deaths, empowering the **police officer** (not magistrate) to investigate and order an autopsy. - While Section 174 is used for initial police investigation in suspicious deaths, the question specifically asks about **magistrate authorization**, which falls under Section 176. - Section 174 is the procedural provision for police-initiated investigation, whereas magisterial inquiry requires Section 176. *Section 304 IPC* - This section pertains to **punishment for culpable homicide not amounting to murder**. It is a substantive penal provision, not a procedural law. - It deals with the legal consequence of an act after investigation and trial, not with the investigative procedure for conducting an autopsy. - Charges under Section 304 IPC may result from findings after the autopsy, but it doesn't authorize the autopsy itself. *Section 302 IPC* - This section specifies the **punishment for murder**. Like Section 304 IPC, it is substantive criminal law defining a crime and its penalty. - It would be invoked *after* the investigation reveals evidence of murder, not during the initial phase of ordering an autopsy for a suspicious death. - An autopsy authorized under Cr PC sections might lead to charges under Section 302 IPC, but it doesn't authorize the autopsy procedure.
Question 8: A moribund patient who has little chance of survival but is submitted to surgery as a last resort belongs to ASA class-
- A. II
- B. V (Correct Answer)
- C. VI
- D. IV
Explanation: ***V*** - An ASA Physical Status **Class V** patient is defined as a **moribund patient** who is not expected to survive without the operation, often with a high risk of mortality within 24 hours even with surgery. - The description of a patient with "**little chance of survival** but submitted to surgery as a last resort" perfectly matches this classification. *II* - ASA Class II describes a patient with a **mild systemic disease** that is well-controlled and does not limit activity, such as well-controlled hypertension or diabetes. - This patient's condition is far more severe than what is classified as ASA Class II. *VI* - ASA Class VI is reserved for a **declared brain-dead patient** whose organs are being removed for donor purposes. - While the patient is moribund, they are not brain dead, and the surgery is for their own survival, not organ donation. *IV* - ASA Class IV describes a patient with a **severe systemic disease** that is a constant threat to life, such as unstable angina or severe cardiac disease. - While severe, Class IV patients generally have a better chance of survival than the patient described, who is already considered moribund and unlikely to survive without the surgery.
Question 9: Which of the following antidepressants can be safely used in elderly depression?
- A. Trazodone
- B. Mianserin (Correct Answer)
- C. Fluoxetine
- D. Phenelzine
Explanation: In geriatric psychiatry, the choice of antidepressant is dictated by the side-effect profile, specifically the risk of anticholinergic effects, sedation, and cardiovascular complications. **Why Mianserin is correct:** Mianserin is a tetracyclic antidepressant (TeCA) that is frequently preferred in the elderly because it lacks significant **anticholinergic side effects** (which cause confusion, urinary retention, and glaucoma) and has minimal **cardiotoxicity**. It is particularly useful in elderly patients with insomnia or agitation due to its sedative properties, but it does not typically cause the severe orthostatic hypotension seen with older TCAs. **Analysis of Incorrect Options:** * **Fluoxetine (Option C):** While SSRIs are first-line for the elderly, Fluoxetine has a very **long half-life** (and active metabolites) which can lead to accumulation and prolonged side effects (like hyponatremia/SIADH or agitation) in patients with age-related renal or hepatic decline. Sertraline is generally preferred over Fluoxetine in this age group. * **Trazodone (Option A):** Though used for sleep, it is notorious for causing significant **orthostatic hypotension** in the elderly, increasing the risk of falls and hip fractures. * **Phenelzine (Option D):** As a non-selective MAOI, it requires strict dietary restrictions and carries a high risk of **hypertensive crisis** and drug-drug interactions, making it unsafe for the polypharmacy often seen in geriatric patients. **NEET-PG High-Yield Pearls:** * **Drug of Choice:** SSRIs (specifically **Sertraline** or **Escitalopram**) are generally the first-line treatment for elderly depression. * **Mianserin Risk:** Always monitor for **agranulocytosis** (rare but serious). * **Avoid:** Tertiary amines (Amitriptyline, Imipramine) due to high anticholinergic activity. * **Key Concern:** Always check for **hyponatremia** (SIADH) when starting an SSRI in an elderly patient.
Question 10: "Sundowning" is seen in which of the following conditions?
- A. Night blindness
- B. Parkinsonism
- C. Delirium (Correct Answer)
- D. Solar urticaria
Explanation: **Explanation:** **Sundowning** refers to a clinical phenomenon characterized by the emergence or worsening of neuropsychiatric symptoms—such as agitation, confusion, anxiety, and aggressiveness—specifically during the late afternoon or evening hours. **Why Delirium is the Correct Answer:** Sundowning is most commonly associated with **Delirium** and **Dementia** (particularly Alzheimer’s disease). It occurs due to a combination of factors: the loss of daylight (fading circadian cues), sensory deprivation in low light, and accumulated fatigue throughout the day. In patients with pre-existing cognitive impairment, the brain's ability to process environmental stimuli diminishes as light levels drop, leading to acute disorientation and behavioral disturbances. **Analysis of Incorrect Options:** * **A. Night blindness:** This is a physiological inability to see in low light (often due to Vitamin A deficiency) and does not involve the cognitive or behavioral agitation seen in sundowning. * **B. Parkinsonism:** While Parkinson’s patients may experience sleep disturbances or dementia-related confusion, sundowning is not a hallmark feature of the motor syndrome itself. * **D. Solar urticaria:** This is a physical dermatological condition (hives) triggered by exposure to ultraviolet radiation, the opposite of the "diminishing light" trigger of sundowning. **High-Yield Clinical Pearls for NEET-PG:** * **Management:** The first step in managing sundowning is optimizing the environment (e.g., keeping the room well-lit during the evening, reducing noise, and maintaining a strict routine). * **Differential:** Always rule out a "Medical Delirium" (UTI, electrolyte imbalance) if sundowning symptoms appear suddenly. * **Pharmacology:** If behavioral interventions fail, low-dose atypical antipsychotics (like Quetiapine) or Melatonin may be considered, though they are secondary to environmental modification.
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