End-of-life care Practice Questions

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?

Accepted Answer

Supportive therapy

Answer

Oseltamivir

Answer

Azithromycin

Answer

Metronidazole

Answer

Methadone

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?

Accepted Answer

Increase dosage of morphine

Answer

Counsel patient and continue same opioid dose

Answer

Change morphine to a non-opioid analgesic

Answer

Initiate palliative radiotherapy

Answer

Initiate cognitive behavioral therapy

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?

Accepted Answer

Home hospice care

Answer

Prescribe oxycodone

Answer

Short-term rehabilitation

Answer

Inpatient palliative care

Answer

Evaluation for alternative methods of feeding

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?

Accepted Answer

The durable medical power of attorney’s decision should be followed.

Answer

Withdraw the life support since the patient’s chances of recovery are very low

Answer

Contact other family members to get their input for the patient

Answer

Act according to the patient’s living will

Answer

Follow the daughter’s decision for the patient

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?

Accepted Answer

At this visit

Answer

Once she enters hospice

Answer

Now that she is ill, speaking about advance directives is no longer an option

Answer

Only if her curative surgical and medical treatment fails

Answer

Only if she initiates the conversation

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?

Accepted Answer

“What is causing your blood pressure to be elevated?”

Answer

“Have you been taking your medications as prescribed?”

Answer

“Would you like us to consider trying a different medication for your blood pressure?”

Answer

“You are taking your medications as prescribed, aren’t you?”

Answer

“Why are you not taking your medication?”

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?

Accepted Answer

"Can you tell me more about the symptoms you have been experiencing?"

Answer

"Does the diarrhea typically precede the constipation, or vice-versa?"

Answer

"Is the diarrhea foul-smelling?"

Answer

"Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"

Answer

"Are the symptoms worse in the morning or at night?"

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?

Accepted Answer

Documentation of her decision prior to treatment is required

Answer

There are reasons to believe that she may not have decision-making capacity

Answer

Endoscopic treatment may be performed without further action

Answer

Her sister must sign the consent form

Answer

Her decision to have an endoscopy is not voluntary

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?

Accepted Answer

Two patient identifiers at every patient encounter by any healthcare provider

Answer

Two patient identifiers at every nurse-patient encounter

Answer

A patient’s medical identification number at every encounter by any healthcare provider

Answer

Two patient identifiers at every physician-patient encounter

Answer

A patient’s medical identification number at every physician-patient encounter

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?

Accepted Answer

Perform a needle thoracostomy

Answer

Obtain a chest x-ray

Answer

Perform an endotracheal intubation

Answer

Apply a cervical collar

Answer

Perform an open reduction of the tibia fracture

End-of-life care

Study Resources

Lessons

Questions

Flashcards

Lessons

Advance directives

DNR/DNAR orders

POLST paradigm

Palliative care principles

Hospice eligibility and services

Pain management at end of life

Symptom management at end of life

Cultural and spiritual aspects

Ethical dilemmas in end-of-life care

Family conferences

Bereavement support

Healthcare provider self-care

Futility and medical judgment

Practice Questions

Flashcards

About End-of-life care for USMLE

Lessons in End-of-life care

Master End-of-life care