Psiquiatria Paliativa Flashcards
29.1.
Which of the following is a feature of the stages of death and
dying as described by Dr Kübler-Ross?
A. All the stages are thought to occur in everybody
B. Depression and possibly suicidal ideation can occur
C. Most people do not reach the phase of acceptance
D. Shock and denial are experienced by all
E. The stages are typically followed in order
29.1. B. Depression and possibly suicidal ideation can
occur
The stages of death and dying, as identified by Elizabeth Kübler-Ross
include the following: 1. Shock and Denial, 2. Anger, 3. Bargaining, 4.
Depression, and 5. Acceptance. In the stage of depression, patients
can show clinical signs of a major depressive disorder including
withdrawal, psychomotor retardation, and suicidal ideation. It
should be noted that a dying patient rarely follows these stages in
order and that not all patients experience all five stages
29.2.
Approximately 75% of those who die in late adolescence do so
from which of the following causes?
A. Accidents, homicides, and suicides
B. Blood and skin cancers
C. Brain tumors
D. Eating disorders
E. Heart disease and metabolic disorders
29.2. A. Accidents, homicides, and suicides
Almost half of the children who die between 1 to 14 years old, and
nearly 75% of those who die in late adolescence and early adulthood
do so from a combination of accidents, homicides, and suicides.
29.3.
A patient is suffering from an incurable brain tumor. The
patient feels significant guilt for dying and views the treatment
as a punishment and struggles with feelings of rejection from
the family. A person with this attitude surrounding death is
most likely to be in which of the following age groups?
A. Preschool
B. Elementary school
C. Early adolescence
D. Late adolescence
E. Elderly
29.3. A. Preschool
At the preschool age, the preoperational stage of cognitive
development predominates. Preschoolers still see death as
incomplete and reversible. Separation from the primary caregiver is
the main fear. Terminally ill children often feel guilty and
responsible for their own death and don’t relate treatment to the
illness and view it as punishment and feel family separation as
rejection. School-aged children in the concrete operational cognitive
stage can realize the finality of death but see it as something that
happens to older people. Adolescents often struggle with loss of
independence and fears of abandonment by friends. Teenagers are
capable and should typically be involved in all decision-making
processes surrounding their deaths. Adults have various fears
including losing control, being a burden to others, pain, fear of
afterlife, etc. Late-aged adults often can accept death.
29.4.
Which of the following symptoms is the most lasting
manifestation of grief after spousal bereavement?
A. Decreased appetite
B. Guilt
C. Loneliness
D. Suicidal thoughts
E. Worthlessness
29.4. C. Loneliness
The most lasting manifestation of grief, especially after spousal
bereavement, is loneliness. Typically, it can last for up to many years.
Grief often becomes circumscribed throughout time and reemerges
when specific triggers are present. The other symptoms listed are
indicative of a major depressive disorder, which if present, would
typically resolve with treatment.
29.5.
Which symptom is more commonly found in a major
depressive disorder compared to bereavement?
A. Dysphoria with thoughts of the deceased
B. Onset within the first 2 months of the loss
C. Psychomotor retardation
D. Symptoms lasting for 1 month
E. Transient functional impairment
29.5. C. Psychomotor retardation
Symptoms associated with a major depressive disorder, as opposed
to bereavement include classic DSM-5 symptoms such as guilt,
worthlessness, suicidal ideation, or psychomotor retardation.
Dysphoria independent of thoughts of the deceased is typical for a
major depressive disorder and the depression causes clinically
significant impairment and distress. With bereavement, the
functional impairment is transient and mild, with symptoms lasting
for less than 2 months, and the onset is within the first 2 months of
the loss
29.6.
Bereavement has been shown to exacerbate which of the
following symptoms in both sexes?
A. Accidents
B. Alcohol consumption
C. Death
D. Ischemic heart disease
E. Suicide
29.6. B. Alcohol consumption
An increased mortality rate is seen after bereavement, especially for
men. Higher mortality rates for men are due to an increased risk of
death by suicide. Accidents, ischemic heart disease, and some
infectious diseases are also more common among men. In both
sexes, increased alcohol consumption, smoking, and use of over-thecounter
(OTC) medications can be exacerbated
29.7.
Which is a distinguishing feature of grief compared to
depression after a loss of a loved one?
A. Enduring low mood
B. Positive emotions
C. Protracted course
D. Social withdrawal
E. Trouble going to wor
29.7. B. Positive emotions
Grief involves both positive and negative emotions. Grief is fluid and
gradually lessens over time as the negative feelings lessen and
positive ones take their place. With grief, the person can eventually
find comfort in memories of their loved one and can resume a
satisfying life. Major depressive disorder consists of a protracted
course, with enduring low mood and impairment in work and social
functioning
29.8.
Which medication is commonly prescribed and may be useful
in some forms of grief?
A. An atypical antipsychotic
B. A mild sedative
C. A narcotic
D. A selective serotonin–norepinephrine reuptake inhibitor
E. A selective serotonin reuptake inhibitor
29.8. B. A mild sedative
Most people don’t end up seeing a psychiatrist for grief, as it is
accepted as a normal reaction. However, the most common request
for help with grief often involves a request for sleeping medication
from a primary care doctor. A mild sedative might be helpful in
certain situations. However, antidepressant medication, antianxiety
agents, and narcotics are not indicted and can interfere with the
normal grief process.
29.9.
Which criterion is part of the Endicott Substitution Criteria
for depression in those experiencing advanced disease?
A. Anhedonia
B. Changes in appetite
C. Increased energy
D. Suicidal ideation
E. Worthlessness
29.9. B. Changes in appetite
The Endicott Substitution Criteria can help diagnose depression in
those with advanced disease. The criteria have been found to
perform as well as the DSM criteria. The physical/somatic symptoms
listed include changes in appetite or weight, sleep disturbances,
fatigue, loss of energy, and memory and concentration deficits.
Psychological symptoms include tearfulness, despair, withdrawal,
self-pity, a lack of mood reactivity, etc.
29.10.
Which of the following is a distinguishing factor between a
persistent vegetative state versus brain death?
A. Absence of respiration
B. Absence of wave formations on electroencephalography
C. Lack of reflex eye movements
D. Mild to moderate response to medical intervention
E. Smiling, frowning, and yawning can be noted
29.10. E. Smiling, frowning, and yawning can be noted
A persistent vegetative state is a condition in which no awareness
exists of the self or environment and is associated with severe
neurologic damage. Brainstem or hypothalamic autonomic functions
permit survival and various cranial nerves, and spinal reflexes are
preserved, and patients can even smile, frown, or yawn and sleep–
wake cycles can return. No meaningful response to a stimulant or
receptive or expressive language is possible, and medical treatment
proves no benefits to patients in persistent vegetative states. Brain
death is accepted criterion for death and involves a loss of all higher
and lower brain stem functions, respiration, and no brain waves are
seen on electroencephalographies (EEGs).
29.11.
Use of which of the following pain-relieving drugs in end-oflife
care can help minimize the risk of psychotoxicity leading
to delirium?
A. Hydromorphone
B. Levorphanol
C. Meperidine
D. Methadone
E. Morphine
29.11. A. Hydromorphone
Opioids can cause delirium and hallucinations. Psychotoxicity can
occur when these drugs or metabolites accumulate because the
duration of the analgesics is shorter than their plasma half-lives.
Morphine, levorphanol, and methadone are drugs that can
accumulate easily whereas hydromorphone has a half-life close to its
analgesic duration. Meperidine’s active metabolite, normeperidine,
can accumulate in the body.
29.12.
Arguments for euthanasia revolve around which of the
following ethical principles?
A. Autonomy
B. Beneficence
C. Justice
D. Loyalty
E. Nonmaleficence
29.12. A. Autonomy
Most medical, religious, and legal groups in the United States are
against active euthanasia and it is considered illegal. Those in
support of euthanasia argue the ethical principle of autonomy and a
right to a dignified death. Passive euthanasia, a patient requesting
the withdrawal of life-sustaining treatment, should be abided by if
the patient is competent.
29.13.
In addition to depression and an incurable medical
condition, which of the following factors is part of the triad
that exists in almost every case in patients asking to be put to
death?
A. A cancer diagnosis
B. Alzheimer disease
C. Fear of losing bodily functions
D. Intolerable pain
E. Religious reasons
29.13. D. Intolerable pain
In almost every case in which a patient asks to be put to death, the
triad of depression, an incurable medical condition, and intolerable
pain exists. Every effort should be made to provide treatment with
antidepressants or stimulants, opioids for pain control, along with
therapy and spiritual counseling and family support.
29.14.
Which safeguard has been put in place as a part of Oregon’s
Assisted Suicide Law?
A. The doctors and pharmacists must abide by the Death with
Dignity Act
B. The patient must make two witnessed written requests at
least 1 month apart
C. The patient must complete at least 3 months of counseling
with a licensed provider
D. The next of kin must be notified of the patient’s decision by
the doctor and patient together
E. Two doctors must confirm the patient is terminally ill and
acting of their own free will
29.14. E. Two doctors must confirm the patient is
terminally ill and acting of their own free will
In 1994, Oregon was the first state to pass the legalization of
physician-assisted suicide, known as the Death with Dignity Act.
Washington, Montana, and Vermont have also since made it legal.
Oregon’s physician-assisted suicide laws include that two doctors
must agree the patient is terminally ill and acting of their own free
will and that the patient is capable of making health care decisions
and can change their mind at any time. The patient must make one
written request and two spoken ones. While the doctor must ask the
patient to tell the next of kin, the patient can decide not to. Other
parts of the Law include the person must live in Oregon. Pharmacists
must be told of the medication’s use. It should be noted that all
health care providers are not under any obligation to participate in
the act.
