Abstract
All physicians face end-of-life issues during their training and many continue to work in specialties where life and death are part of their daily duties. This chapter addresses a key challenge for physicians who work with older and critically ill patients.
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Appendices
Appendix A: Tables with Possible Answers to the Vignettes
Case Vignette 16.1: Mr. Kim
Learning Issue Table 16.1.1
Facts | Hypotheses | Information needed | Learning issues |
|---|---|---|---|
63-year-old Chinese man | Normal grief reaction | Does he meet DSM-5 criteria for major depression? | What are the stages of grief? |
80 pack-year smoking history | Major depressive episode | ||
Had not sought medical treatment in years | Adjustment reaction | ||
Has end-stage lung cancer | |||
Recommended treatment would be palliative chemotherapy | |||
Barely says a word during this discussion | |||
Nursing staff has witnessed him crying frequently in his room, barely touching his food |
Learning Issue Table 16.1.2
Facts | Hypotheses | Information needed | Learning issues |
|---|---|---|---|
Delayed seeking treatment because of concerns that it could be something bad | Grief reaction | Monitor for other mental status changes | How does the clinician differentiate grief and depression? |
Felt numb and was in disbelief | Rule out anxiety disorders, mood and anxiety disorders secondary to another medical condition, and delirium | What else is he worried about? | |
Sad and anxious, denies actual thoughts of wanting to hurt himself | How much pain does he have and how well is it controlled? | ||
Denies any feelings of hopelessness or worthlessness | |||
Recent weight loss, decreased energy, some difficulty sleeping due to lower back pain |
Learning Issue Table 16.1.3
Facts | Hypotheses | Information needed | Learning issues |
|---|---|---|---|
Afraid of what will happen to his body and his ability to function as he approaches death | Afraid of pain | What other goals may he have at the end of life? | What are common treatment goals at the end of life? |
Saw his father die (with pain) from gastric cancer | What is the AMA Code of Medical Ethics, Opinion 2.211, position on PAS? | ||
Saw a television special on Dr. Jack Kevorkian | |||
Important to have a dignified death |
Learning Issue Table 16.1.4
Facts | Hypotheses | Information needed | Learning issues |
|---|---|---|---|
Appears to have accepted his prognosis | What is the impact on the surviving spouse? | ||
Been married to his wife for 2 years | How can the physician determine whether spirituality and religion are relevant for the patient? | ||
They had plans to travel to Europe when he retired at age 65 | |||
He has not spoken to his three adult children for several years after a bitter divorce from their mother and would like to reconcile with them | |||
He worries about his wife, who also has multiple medical problems | |||
He has not attended church in years but would like to speak with the hospital chaplain |
Learning Issue Table 16.1.5–16.1.8
Facts | Hypotheses | Information needed | Learning issues |
|---|---|---|---|
Increasingly tachycardic and tachypneic | Family may have grief issues | What questions do the family members have? | How does the clinician engage family members in end-of-life discussions? |
Family members at the bedside are distressed | How does the physician address the family at the time of death? | ||
“He looks like he’s drowning. Can’t you do something?” | |||
Morphine given to make him feel better | |||
Progresses to complete unresponsiveness and asystole | |||
Family sobbing at the bedside |
Appendix B: Answers to Review Questions
Answers: 1. C, 2. F, 3. a—False. b—False
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Murayama-Sung, L., Ahmed, I. (2016). Death, Dying, and End-of-Life Care. In: Alicata, D., Jacobs, N., Guerrero, A., Piasecki, M. (eds) Problem-based Behavioral Science and Psychiatry. Springer, Cham. https://doi.org/10.1007/978-3-319-23669-8_16
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