Questions & explanations
1. Compare existential distress with depression in a palliative patient. How would you tell them apart?
Existential distress is about worries over life's meaning, death, and loss of purpose, while depression is a medical condition with symptoms like low mood, loss of interest, and changes in sleep or appetite. A patient with existential distress may still enjoy time with family but feel troubled by big questions. A depressed patient may have a constant low mood that does not improve with good news. The team can tell them apart by asking about the patient's thoughts and feelings. For example, if a patient says, 'I don't see the point of living,' it could be either, so the team explores further. Both can occur together, and treatment may include counseling, spiritual care, and sometimes antidepressants.
2. Compare a conflict based on different religious beliefs versus a conflict based on different understanding of medical facts.
A religious conflict might involve a family believing that only God should decide when someone dies, so they reject stopping treatment. The doctor should respect this belief and explore if there are religious leaders who can help. For example, a priest might explain that stopping treatment is not 'playing God' if it is allowing natural death. A fact-based conflict, on the other hand, might involve a family thinking the patient will recover because they saw a similar case on TV. The doctor should provide clear, simple explanations of the patient's condition and prognosis. Both conflicts require empathy, but the first needs spiritual support, while the second needs education.
3. What is a seizure?
A seizure is a sudden burst of electrical activity in the brain that can cause shaking, staring, or confusion. In advanced illness, seizures may happen because of the disease itself, like a brain tumor, or from other problems like low sodium or infection. The goal of treatment is to stop seizures while avoiding side effects that make the patient uncomfortable. Doctors choose antiepileptic drugs (medicines that prevent seizures) based on the patient's other medicines and organ function. For example, levetiracetam is often used because it has few drug interactions. Sometimes, if a patient cannot take oral medicines, doctors give injectable options like lorazepam.
4. Compare botulinum toxin injections with oral baclofen for treating spasticity in a child's leg muscles.
Botulinum toxin (Botox) is injected directly into tight muscles, where it blocks nerve signals that cause contraction. It works for about 3-6 months and is best for spasticity in specific muscles, like the calf or thigh. It does not cause whole-body side effects. Oral baclofen affects the whole body and can cause drowsiness and weakness, but it treats spasticity in many muscles at once. Botox is often used when only a few muscles are tight, while baclofen is used for widespread spasticity. Botox requires repeated injections, while baclofen is taken daily. Both can be used together for better control. The choice depends on the child's specific needs and goals.
5. How do you manage seizures in a patient who cannot swallow pills?
For patients who cannot swallow, doctors use liquid or injectable forms of antiepileptic drugs. Levetiracetam comes in a liquid that can be given through a feeding tube or by mouth if the patient can still swallow a little. If the patient cannot take anything by mouth, intravenous (IV, into a vein) levetiracetam or lorazepam can be given. For a seizure that is happening right now, a fast-acting medicine like midazolam or lorazepam is given under the tongue, into the cheek, or through a vein. The goal is to stop the seizure quickly and keep the patient comfortable. The choice depends on what is available and the patient's care setting, like home or hospital.
6. How can doctors prevent seizures from happening again in a child at the end of life, and what medicines are used?
To prevent seizures, doctors may start a continuous infusion of a medicine like midazolam or give a long-acting medicine like levetiracetam. Levetiracetam can be given by injection or through a feeding tube and has few drug interactions. Another option is phenobarbital, which is very effective but can cause deep sedation. The choice depends on the child's condition and what medicines are available. The goal is to keep the child seizure-free without causing too much drowsiness if the child is still awake. For children who are already unconscious, deeper sedation may be acceptable. The family is taught how to give rescue medicines if a seizure breaks through.
7. What is a POLST form and how is it different from a living will?
POLST stands for Physician Orders for Life-Sustaining Treatment. It is a medical order form signed by a doctor that tells emergency workers and hospital staff exactly what treatments a patient wants, like CPR, feeding tubes, or breathing machines. A living will is a legal document written by the patient that describes general wishes, but it is not a doctor's order. POLST is meant for seriously ill patients and travels with them across care settings, like from home to hospital. For example, a POLST might say 'Do Not Resuscitate' (no CPR), while a living will might say 'I do not want life support if I am terminal.' POLST is more specific and actionable.
8. Compare the side effects of morphine and methadone when used for pain in children, and explain why a doctor might choose one over the other.
Morphine commonly causes constipation, nausea, and itching, and it can make a child sleepy. Methadone is a long-acting opioid that can cause similar side effects but also has a risk of heart rhythm problems (QT prolongation) and takes longer to reach steady levels. A doctor might choose morphine for quick pain relief after surgery because it works fast and is easy to adjust. They might choose methadone for chronic cancer pain that is not well controlled with other opioids, because methadone does not cause tolerance as quickly and can be given less often. However, methadone requires careful monitoring due to its long half-life and risk of accumulation.
9. Compare capacity assessment for a simple decision (e.g., taking an antibiotic) versus a complex decision (e.g., choosing between hospice and aggressive treatment).
For a simple decision like taking an antibiotic, capacity requires understanding that the antibiotic fights infection and agreeing to take it. The patient can say, 'I have an infection, and this medicine will help.' For a complex decision like hospice versus aggressive treatment, the patient must understand the prognosis, the goals of each option, and the trade-offs. For example, they need to grasp that hospice focuses on comfort but does not try to cure. The doctor asks more questions, like, 'What is the difference between hospice and continuing chemo?' The threshold for capacity is higher for complex decisions because the consequences are greater.
10. Compare the dual process model with the stage theory of grief (e.g., Kübler-Ross).
The stage theory says people go through fixed stages like denial, anger, bargaining, depression, and acceptance. The dual process model is different: it says grief is not linear but a dynamic back-and-forth. For example, a person might feel acceptance one day and anger the next. The dual process model focuses on coping strategies rather than emotional stages. It also emphasizes that both facing the loss and avoiding it are normal. Stage theory is more about emotional reactions, while dual process is about how people manage those reactions and life changes. Many experts now prefer the dual process model because it fits real-life grief better.
11. What should a doctor do if a patient with dementia says they want to stop dialysis, but the family disagrees?
First, the doctor must assess if the patient has capacity for this decision. Dementia patients may have lucid moments. If the patient can understand, appreciate, reason, and communicate consistently, their wish should be respected. The doctor can ask the patient to explain their reasoning, like, 'Why do you want to stop?' If the patient says, 'I feel tired and it's not helping,' that shows appreciation. The doctor then explains to the family that the patient's decision is valid. If the patient lacks capacity, the doctor looks at advance directives or involves a surrogate decision-maker. Ethics consultation may help if conflict persists.
12. Compare the use of midazolam and diazepam for stopping seizures in a child at the end of life.
Both midazolam and diazepam are benzodiazepines that stop seizures quickly. Midazolam is often preferred because it can be given under the tongue (buccal) or into the nose (intranasal), which is easy and fast. It also has a short action, so it can be given as a continuous infusion to prevent seizures. Diazepam is usually given rectally (gel) or intravenously, which may be less convenient. Midazolam causes less irritation to veins and has a lower risk of building up in the body. Diazepam lasts longer, which can be good for prevention but may cause more sleepiness. Both are effective, but midazolam is often chosen for ease of use at home.