End-of-life care US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for End-of-life care. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
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**.
More End-of-life care US Medical PG questions available in the OnCourse app. Practice MCQs, flashcards, and get detailed explanations.
