Professional Practice - Exam 3 (Cumulative Set)

Terms in this set (278)

What are 10 limitations of health care directives?

1. Comprehension of pt, surrogate, or physician in doubt

2. Questionable validity of surrogate

3. Time since execution of HCD

4. Too much or too little information

5. Doesn't apply to the clinical situation

6. Invalid surrogate: HCD and surrogate in conflict

7. Conflict w/ moral beliefs of provider

8. Futility

9. Can't find AD in EHR

10. Lack of education for pts and providers alike

Who determines "Benefits and Burdens"?

Who determines "Effectiveness"?

What is the proportionality equation for Futility?

(Effectiveness + Benefits) / Burdens

What 2 communication models are commonly used but are not optimal?

Informative model

Paternalistic model

What is the deliberative model of communication?

Provider helps pt choose the best health-related values that can be clinically realized; provider acts as teacher/friend engaging in dialogue on what course of action would be best

In the delibeartive model of communication, the provider aims at ___________________, and ultimately coercion is avoided

Moral persuasion

Persuasion is ethically (obligatory/reprehensible) within a clinical context

True or false: Respecting autonomy means that we as providers are solely allowing the person/patient to select his/her preferred course of action

What does STICC stand for (in re: to the protocol)?

Situation
Tx
Intent
Context
Calibrate

What is the four step process for analyzing the values in our lives?

1. Identify key values
2. Understand those key values
3. Articulate key values
4. Promote values

What is the best way to promote your values?

by living them

not by telling and asking others to adopt them

In medicine, there is an intersection between what 2 values?

-Religious Values
-Values in Medicine

Can patients refuse treatment for religious or moral reasons?

What is the relationship like between religion and health?

Generally good, because religion promotes:
-Healthy lifestyle
-Opposes self-indulgent and self-destructive behavior
-Encourages moral behavior
-Provides social support
-Provides ethical value system
-Promotes spiritual growth

What are the three key application areas of the expectations of healing and curing in medicine?

1. Expectations among all stakeholders
2. Expectations in medicine
3. Prayer and other religious practices

True or false:

There is A LOT of evidence to support that religion is effective in healing.

FALSE

There is LITTLE evidence to support its effectiveness in healing

Religion is not simply a set of beliefs, but also a set of ________________.

In a 1993 letter from AAPA President William H. Marquart to President of the AMA John L. Clowe MD conveyed that some of the values of PAs at the time were what? (3)

1. Do not seek independent practice
2. Do not seek direct reimbursement from 3rd party payers
3. Do not seek federal preemption of state practice acts

the last 2 have changed since 1993

The ability to ________________ your values forces you to a better understanding of them as well as opens them up for evaluation by others.

Ethical dilemmas are often because of conflicts between ____________

Moral philosophy relies on which of the following?
-Emotions
-Logic
-Superstition
-Chance

What is "The Hope/Goal Switch"?

Taking the hope that the patient/patient's family has and switching it to hope for a realistic goal (e.g. the afterlife w/ no pain or suffering)

From the 4 principles of health care ethics, what are the 3 results?

informed consent
confidentiality
concept of negligence

What is beneficence?

promoting the well-being of others

What is nonmaleficence?

do no harm deliberately

Giving patients choices promotes which of the 4 principles of health care ethics?

respect for autonomy

Equal treatment and allocation of scarce resources promote which of the 4 principles of health care ethics?

Which two principles of health care ethics often conflict?

autonomy and beneficence

What are the four constant and essential components of ethical decision making?

agent: person faced w/ making choice and the focus of responsibility

choice: agents are always presented with a choice

consequences: all choices will have some anticipated consequence, and should be verbalized to the pt

context: the setting must be considered with deliberation of an ethical dilemma or discussion

Pts are vulnerable by illness or injury. The capacity to act as _________ of their community must be considered.

What types of ethical theories are employed when making ethical decision making? (5)

virtue ethics
deontology or formalism
consequentialism and utilitarianism
casuistry
narrative

The emphasis of virtue ethics is what?

the moral character of the agent

In virtue ethics, _______________ are not enough. The agent must also be able to _____________ that which we see as being good.

intention

accomplish

What is the criticism for virtue ethics?

That it treats moral virtue as only sufficient, rather than a necessary condition for the ethical decisions being made

Deontology focuses more on the _______________, not the ______________.

action itself

agent

What is deontology?

A system of ethical decision making based on moral rules and unchanging principles (a guide to truth exists)

"there is a moral litmus test"

What is a common criticism of deontology?

no rule as to how to approach when two rules are at odds with each other

no way to "rank" the rules

Consequentialism focuses on what aspect of ethical decision making? What is the main principle of this theory?

the consequence :)

good actions produce good consequences, and bad actions produce bad consequences

According to consequentialism/utilitarianism, what is the correct action?

the result that maximizes the most good for the most number

What are some common criticisms of consequentialism/utilitarianism?

we must know what consequences to pursue and be able to predict them

consequences may not be applied to individuals equally (degree)

What is casuistry?

employs analogical reasoning to resolve difficult cases and proceeds on the basis of comparing one case with another

considers the degrees of similarities between the cases or issues

means to an end.....

ANY action is justifiable according to which ethical decision making theory?

utilitarianism/consequentialism

What aspect of modern medicine primarily utilizes utilitarianism/consequentialism?

when resources are scarce (triage)

What is a criticism of casuistry?

it cannot achieve a consensus on controversial issues

Casuistry is commonly utilized in what non-medical field? What is it called?

law/supreme court

precedence

What is the main focus of the narrative theory of ethical decision making?

the context of the case

What do proponents of the narrative theory of ethical decision making argue is its strong point?

it allows for deeper penetration and insight into the human moral drama involved with illness

What is a criticism of narrative ethics?

there is an inherent difficulty with knowing both how to interpret and how to complete a narrative

What or who's point of view should be adopted for interpretation?

What is the best form of decision making with your patient? As evidenced by:

greater trust and loyalty
greater satisfaction with their healthcare
better clinical outcomes

SHARED DECISION MAKING

What specific court case established self-determination as a groundwork for consent?

Schloendorff v New York Hospital 1914

"Every human being of adult years and of sound mind has a right to determine what shall be done with his body."

What is the psychological significance of self-determination?

Personal autonomy is self rule free from ..... (2)

controlling interference by others

limitations of understanding preventing meaningful choice

Autonomy is not simply an ideal, but a ________________.

professional obligation

What are some obligations that must accompany autonomy? (5)

telling pts the truth

respecting patient's privacy

securing confidential information

obtaining consent

help pts making important (INFORMED) decisions

What is paternalism in medicine?

overriding or ignoring preferences of pts in order to benefit them or enhance their welfare

How do practitioners justify paternalism in medical care?

they judge beneficence over autonomy

Informed consent and refusal was adopted in what decade?

What are some elements of fully informed consent? (9)

must be in layman's terms

diagnosis and recommended procedure/tx

nature of recommended procedure/tx

risk and benefits of procedure/tx

alternatives, including doing nothing, and their risks and benefits

likelihood that anticipated risks or benefits will be realized

identity, credentials, and experience of those performing the procedure or providing the tx

cost of the procedure/tx

ALWAYS DOCUMENT W/ PT'S SIGNATURE ON A FORM

Who can determine competency?

What does it mean to determine a pt's capacity?

to determine the person's ability to make rational decisions (NOT the decision in question)

the pt may be incompetent in other areas of their life but competent in others

Determination of capacity is NOT a _____________.

What are some important elements of capacity? (3)

The agent has to:

-have a set of goals and values
-be able to communicate
-be able to compare the impact of alternative outcomes w/ respect to their goals and values

Are health care professionals ever permitted to say "no" to pts?

Are health care professionals ALWAYS permitted to say "no" to pts?

YES --> esp. if conflicts w/ beneficence, futile actions, etc.

NO

What are the 5 "do not's" of nonmaleficence?

DO NOT:

kill
cause pain
incapacitate
offend
deprive others of the goods of life

What is the result when due care is not taken?

What are the 4 legal elements of negligence?

You must have a duty to the pt.
You must have breached that duty.
The patient must have experienced harm.
That harm must be caused by the breach.

What are two types of negligence?

Intentional: imposing risks of harm that are unreasonable

Unintentional: carelessly imposing risks of harm

Are obligations of nonmaleficence or beneficence more stringent? Why?

nonmaleficence

beneficence requires taking an action, whereas nonmaleficence requires intentionally refraining from an action that will harm someone.

What are the three categories that most types of professional misbehavior fit into?

"the three m's"

boundary violations (me)
misrepresentation
financial infractions (money)

What are the six elements of professionalism?

altruism
accountability
excellence
duty
honor and integrity
respect for others

What are the seven challenges to the six elements of professionalism?

abuse of power
arrogance
greed
misrepresentation
impairment
lack of conscientiousness
conflict of interest

What is the pyramid for professional practice?

What is civility and what are the four elements of it?

Civility is the behavioral expression of underlying ethical integrity.

Tolerance
Respect
Proper conduct
Diplomacy

What is professionalism?

the more specialized development of ethical and civil behavior, above and beyond what is expected from the nonprofessional

Professional organization as reference, service to the public, and a sense of calling are all elements of what part of professionalism?

Specialized knowledge and skill, unique socialization of student members, licensure/certification, professional applications, governance by peers, social prestige, vital service to society, code of ethics, autonomy, equivalence of members, and special relationship with clients are all elements of what part of professionalism?

".... the unexamined life _____________________."

is not worth living

-Socrates

What is emotional intelligence?

the ability to monitor one's own emotions and guide one's thoughts and actions in a healthy manner

What are the 5 domains of emotional intelligence?

Knowing one's own emotions
Managing one's own emotions
Motivating oneself
Recognizing emotions in others
Handing relationships

The inability to notice our true feelings results in what?

The inability to notice our true feelings leaves us at their mercy

What are the 4 principles of health care ethics?

respect for autonomy
beneficence
nonmaleficence
justice

The Tuskegee Syphilis Trials is a landmark case for which biomedical ethical principle?

The Dax Cowart case is a landmark case for which biomedical ethics principle?

Respect for autonomy

The Nancy Cruzan and Karen Quinlan cases are landmark cases for which biomedical ethics principles?

Beneficence and non-maleficence

Which ethical theory focuses primarily on the AGENT of ethical decision making?

Virtue theory of ethics

Which ethical theory focuses primarily on the ACTION of ethical decision making?

Deontology/formalism

Which ethical theory focuses primarily on the OUTCOME of ethical decision making?

Consequentialism/utilitarianism

Which ethical theories focus primarily on the CONTEXT of ethical decision making?

Casuistry and Narrative ethics

The ethical principle of respect for autonomy has what two essential components?

Liberty: independence from outside influences

Agency: capacity for decision-making

Is there a difference in withholding treatment you never started vs treatments that have never been started?

Are obligations of nonmaleficence or beneficence more stringent? Why?

nonmaleficence

b/c it requires intentionally refraining from an action that will harm someone vs. taking an action to help someone

Is the provision of assisted ventilation and dialysis the same as the provision of nutrition and hydration (MN&H)? What are two arguments for "yes" and three arguments for "no"?

Yes because:
-no morally relevant difference exists between the various life-sustaining technologies
-the right to refuse medical treatment for oneself or others is not contingent on the type of treatment

No because:
-MN&H is necessary for the pt's comfort
-MN&H symbolize the essence of care and compassion
-not doing so will progress to adverse consequences. Society will not be able to limit decisions to legitimate cases.

What is the rule of double effect?

A single act may have two foreseen effects, one that is good and another is that is not

A distinction is made between clearly intended effects and merely foreseen effects

What is the main conflict present in the Karen Ann Quinlan case in 1975-6?

the pt's family wanted to discontinue mechanical ventilation in their daughter in PVS but PCP and hospital refused

What was the ultimate outcome of the Karen Ann Quinlan case? What impact has this had on the field of medical ethics? (2)

NJ supreme court determined that the pt's father could serve as her guardian and as such could have mechanical ventilation discontinued, based on a right to privacy

-developed necessity for formal ethics committees in hospitals, nursing homes, etc. to protect health care workers from prosecution
-allowed people to refuse "extraordinary" means of treatment when doing so would end life

What is the main conflict present in the Nancy Beth Cruzan case in 1983?

pt's family wanted to withdraw feeding tube from Nancy, who was in PVS. There was debate within the court system and the medical community about whether or not this was ethical.

What is considered the first "right to die" case?

Nancy Cruzan case

What was the ultimate result of the Nancy Cruzan case? What was the main impact it had on medical practice?

after many years, feeding tube was removed when it was determined that Nancy had told a friend during life that she would not want to live by artificial means

the establishment of advanced directives (living wills)

What is the main conflict present in the Tuskegee Syphilis Study in 1930?

For 30-40 years, nearly 400 black males from AL were studied for the effects of syphilis, and they were denied treatment (penicillin) for many years, even after it became widely used as a cure. Many of these patients suffered or died and many other people became infected as a result (including wives and newborns).

NO INFORMED CONSENT WAS OBTAINED. BENEFICENCE WAS DENIED AND THE PRINCIPLE OF NONMALIFENCE WAS NOT UPHELD.

What are the two types of consent?

informed consent

implied consent

Which type of hematoma is described below?

Typically lentiform (lens-shaped, biconcave) and do not cross sutures

extradural (epidural) hematoma

Which type of hematoma is described below?

Typically crescentic (crescent-moon shaped). More extensive and with deep margin paralleling the cortical margin of the adjacent brain. They cross sutures.

subdural hematoma

Which type of hematoma is pictured on the other side of this card? The answer is at the bottom of this side of the card and spelled backwards.

LARUDBUS

Which type of hematoma is pictured on the other side of this card? The answer is at the bottom of this side of the card and spelled backwards.

LARUDIPE

What is the main conflict present in the Juanita case?

PA disagrees with the attending physician about whether or not to inform a patient about her critical diagnosis or to inform the pt's family and let them decide whether or not to tell the pt. The doctor says to inform the pt's family, not the pt. The PA wants to inform the pt herself.

What are the three parties involved in the patient-PA relationship? Where must the focus always be?

patient (sick or injured and seeking your help)
PA
supervising physician

focus must always be on the patient and their needs

Which type of consent fits the following criteria:

-Rooted in respecting a person's dignity.
-Pt must have adequate reasoning faculties.
-Pt must be in possession of relevant facts.

informed consent

Which type of consent fits the following criteria:

-Not expressly granted by a person.
-Implicitly granted by a person through actions and the facts and circumstances of a particular situation.

implied consent

What do Pellegrino and Thomas believe is most central to medicine?

the relationship between the patient and the health-care professional

What are 5 general, non-medical things that sick patients may struggle with as part of their illness? (hint: many of them include the word "loss")

loss of routine

loss of control/autonomy to illness and healthcare system

loss of income

anxiety over losing job, future income, relationships

loss of identity

No matter how trivial the illness or injury, _______________ exists.

We fail when we answer anger with _________, indifference with ___________, and silence with __________.

anger, indifference, silence :)

Pellegrino and Thomas proffer that healing entails restoring the person to ________________, which involves both ___________ and ____________ factors.

wholeness

emotional, physical

PAs must respect their limitations, just as anyone should. If in doubt, you must discuss with your supervising physician because what can happen if you do not? (4)

You are not serving the pt.

You put yourself at risk.

You put your supervising physician at risk.

You are a terrible team member.

What is the difference between healing and curing?

healing: relieve suffering

curing: removing/relieving illness

Regardless of the knowledge disparity present between patients and caregivers, the pt must retain _________ to make decisions.

An ethical person is someone who has ______________ that facilitate human flourishing, which help to bring about human __________.

Ultimately becoming virtuous involves what, according to Aristotle?

Who famously said "...what we think, we become..."?

Margaret Thatcher

Unconscious patients have lost ________________. Thus consent is ____________.

autonomy

implied

What a reasonable person would consent to in the defined situation

What type of consent is this?

implied consent

What are some times when the responsibility to recognize situations that are dangerous to the patient's health and well-being is increased?

when the pt is:

-unconscious
-incapacitated
-at risk of being ignored or otherwise mistreated

IOM report in 2007 showed at least 380,000 to 450,000 patient lives are lost each year due to what?

preventable medical errors in hospital

According to Clemets, the "ethic of justice" begins with an assumption of what? It emphasizes notions of what?

human separateness

choice and will in understanding our moral obligations

According to Clemets, the "ethic of care" begins with an assumption of what? It emphasizes notions of what?

human connectedness

recognizing rather than choosing our obligations to others

According to Clemets, "the ethic of justice takes ________________ as its starting point, while the ethic of care takes ________________ as its starting point.

freedom

obligations

What novel by Ralph Ellison in 1952 describes the struggles of a black man in search of his identity in an overtly racist society? What populations can relate to this man's feelings of invisibility, especially in disparities in health care?

Invisible Man

poor, elderly, non-white, disabled

What landmark report in 2003 found that racial and ethnic disparities in health care DO exist and that many sources, including health care systems, healthcare providers, patients and utilization managers, are all contributors? SHOCKER....

Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care

Refers to integrated patterns of human behavior, which includes the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups.

Implies having the capacity to function effectively as an individual and organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities.

culturally competent care

What approach to culturally competent healthcare failed?

efforts focused on learning specifics about individual cultures

All human decisions and judgements, to some extent or another, have reference to a ________________.

What are the three types of stereotypical actions? What are the differences?

Prejudice: attitudes

Bias: preferences

Discriminatory practice: actions

The tendency to assign to others positive or negative feelings and attitudes associated with significant persons in the patient's early life

transference

A reaction from the clinician to the patient, reflecting a reaction to the patient's behavior or the clinician's own inner needs and conflicts.

countertransference

Preconceived judgements made without adequate evidence and are not easily alterable by contrary evidence

Prejudices prevent what? (2)

objective discussion or decision making

Satel wants us to remember that we are supposed to use our ___________________ appropriately, not simply treat everyone the same. However, deliberately ___________________ in biomedical research can lead to inferior or improper treatment.

discriminatory skills

ignoring race

Treating everybody the same has what consequences?

devalues individuals

strips them of their unique individual characteristics

When the skill of discrimination is no longer used in the patient's best interest, we have crossed the line from _________________ to ____________.

What should you ask yourself when that happens?

beneficence to maleficence

".... and this benefits the patient how?"

What is the difference between stereotypes and generalizations?

Stereotypes: subjectively categorize those affected as alike, rendering the patient's individual uniqueness as invisible

Generalizations: indicates an objective awareness of cultural norms; serves as a starting point and allows the clinician to factor in individual characteristics

What happens when we fall prey to our biases? (5)

We are less of clinicians
We are less of a person
Mistakes are made
Patients are harmed
We are harmed

Overdose deaths involving prescription opioids have _______________ since 1999.

What are the three transmembrane neurotransmitter receptors activated by opioids?

What term refers to both natural and synthetic substances that act at one of the 3 main opioid receptors?

Feedback from the _____________ _________ to the Ventral tegmental area (VTA) normally helps us overcome drives to obtain pleasure

Prefrontal Cortex

3 Options for Opioid Use Disorder Tx

1. Residential and drug-free approaches
2. Agonist/Partial agonist maintenance
3. Antagonist therapy

What are the 3 indications for Buprenorphine?

1. Opioid Detox
2. Opioid Maintenance
3. Pain Management

What are the 3 immediate objectives of methadone maintenance?

1. Suppress signs and symptoms of opioid withdrawal
2. Extinguish opioid drug craving
3. Block the reinforcing effects of illicit drugs

What is an OTP?

Opioid Treatment Program

With repeated exposure to opioids, more ___________________ is released. If the opioid is then taken away, jitters, anxiety, muscle cramps, and diarrhea can occur.

Abuse of what other substances is pertinent to know about in your pt presenting for opioid use disorder?

alcohol and benzodiazepines

Which partial agonist would you use for MAT in a pregnant pt?

subutex (buprenorphine only)

Which MAT agent is described below:

-blocks effects of other opiates
-relieves cravings to use other opiates
-allows "normal" function

What is the MAT agent of choice for a pt w/ high-risk environment for relapse that needs help getting through the initial hurdle of withdrawal?

What are the two MAT agents that are antagonists?

naltrexone and naloxone

Naltrexone can pose major problems for which major organ?

Noncompliance is a major issue with which group of MAT agents?

antagonists (naltrexone and naloxone)

Use of naltrexone or naloxone puts pts who are noncompliant at major risk for what?

death from overdose due to decrease in tolerance w/ receptor blockage

What is a main side effect of methadone at doses >100mg?

QTc prolongation

What are some relative contraindications for buprenorphine use? (5)

-severe opioid addiction
-previous tx for opioid use disorders w/ frequent relapse
-psychiatric comorbidities
-high-risk environment for relapse
-poor support system

YOU SHOULD USE METHADONE FOR THESE PTS.

In stable pts w/ high motivation and good support system, what opioid use disorder treatment may be a good first option?

residential and drug-free

Conditions of what body system are important to know about in your pt presenting for opioid use disorder?

heart problems or family hx of heart problems

Upon ingesting an opioid, signals in the ______________ result in the release of ______________ in the brain, causing feelings of pleasure.

ventral tegmental area (VTA)
dopamine

Describe the effects of activation of mu receptors in both the CNS and PNS.

CNS: respiratory depression, analgesia, euphoria, and miosis

PNS: cough suppression and opioid-induced constipation

Gay/Lesbian: Coming out
Transgender: _______________

LGB adolescents are (more/less) likely to get pregnant compared to heterosexual adolescents

Heterosexual adolescent males are (more/less) likely to have an eating disorder compared to Gay/Bisexual adolescent males

20% of people w/ HIV are between the ages of:

sexual and gender minority

lesbian, gay, bisexual, and transgender

Define the following:

Sex
Sexual orientation
Gender

Sex: determined by chromosomes
Sexual orientation: preferences about who to engage in sexual activity with
Gender: determined by how society interprets your behaviors

An umbrella term encompassing many different gender communities generally referring to a person whose gender identity or expression differs from the sex assigned to them at birth

What are some other terms for transgender? (7)

gender variant
gender non-conforming
transsexual
drag king/queen
gender different
crossdresser
genderqueer

_____________________ does not equal ______________________ which does not equal ____________________.

behavior
identity
orientation

Who waged anti-homosexual witch hunts in the 1950's?

Senator McCarthy

What was the birth of the modern gay rights movement?

stonewall riots in 1969

Who was the first openly gay politician elected to office in CA in 1977?

In what decade ddi the AIDS epidemic explode?

The "Don't Ask, Don't Tell" policy was enforced during what time frame?

What year did legalization of gay marriage start?

In the DSM-IV, gender identity disorder is termed as what?

gender dysphoria

Which 3 states have targeted religious exemption laws for same-sex marriage?

What show depicted the first lesbian couple of a kid's show?

"Good Luck Charlie" in 2014

The number of gay and lesbian couples that are raising children has ______________ in the past decade.

_______% of SGM couples are raising kids, and ___________% of heterosexual couples are raising kids.

Who raises more adopted or fostered children - SGM couples of heterosexual couples?

SGM couples

How should you refer to the "father" of a baby in a lesbian couple if you are unsure? (i.e. in when you are trying to get medical history pertinent to the child)

sperm donor

OR JUST ASK

For SGMs, having children is an ______________ with medical and legal issues (as well as associated costs).

intentional activity

Compare the societal expectation for having a family for SGM couples vs. heterosexual couples.

the societal expectation is LESS for SGM couples

What are three options for SGM couples to have children?

Donor insemination
IVF (in vitro insemination)
IUI (intrauterine insemination)

What is the cost of just getting pregnant for an SGM couple?

Lesbian couples who have a baby may be at a higher risk for __________________.

post-partum depression

A large portion of XY infants born with _______________ (raised as females) requesting reassignment in late childhood and adolescence.

cloacal exstrophy

When should you start considering gender reassignment surgery for a young child/adolescent?

When they verbalize that they ARE a gender other than their sex (e.g. "I AM a boy" in an XX child)

True or false:

Gender reassignment surgery should be avoided in babies.

True or false:

Overall, adjustment of children is not related to parental sexual orientation.

What are the three types of stigma that can experienced by children in same-sex families?

Subtle (perceived stigma)
Experienced rejection
Homophobic bullying

In 2014, it was determined that deaths related to opioid overdoses were highest in what age group?

What term refers to a subclass of opioids consisting of alkaloid compounds that occur naturally in the opium poppy, including morphine, thebaine, and codeine?

Fentanyl, tramadol, and methadone are what type of opioids?

synthetic opioids

Oxycodone, hydrocodone, and buprenorphine are what type of opioids?

semi-synthetic opioids

How does DSM 5 describe opioid use disorder?

a problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following in a 12-mo period:

1. More use than intended
2. Craving for the substance
3. Unsuccessful efforts to cut down
4. Spends excessive time in acquisition
5. Activities given up b/c of use
6. Uses despite negative effects
7. Failure to fulfill major role obligations
8. Recurrent use in hazardous situations
9. Continued use despite consistent social or interpersonal problems
10. Tolerance
11. Withdrawal

What two terms were removed from the definition of opioid use disorder in DSM 5 that were included in DSM IV?

"abuse" and "dependence"

What are the three agents that are agonists or partial agonists for MAT?

buprenorphine or buprenorphine/naloxone

methadone

naltrexone

Which MAT agent has the longest half-life of all the opioids?

What is the half-life of methadone? How often is it dosed?

15-36 hours (average of about 24 hrs)

dosed once daily

Which agent is described below:

-mu-opioid antagonist
-50 mg daily PO dosing
-started preferably >7 days after last opioid use
-once tolerated, may consider monthly vivitrol IM injections
-side effects include liver toxicity and GI effects

Which MAT agent requires completed withdrawal from opioids and requires highly motivated pts?

What is the median age when gay men, lesbians, and bisexual individuals first thought they were something other than straight or heterosexual?

What is the median age when gay men, lesbians, and bisexual individuals were SURE they were not straight or heterosexual?

What is the median age when gay men, lesbians, and bisexual individuals first told a close friend or family member that they were LGBT?

What is the mean age that transgender individuals "pass"?

What are the three most common problems faced by most SGM youth?

non-accepting familites

school/bullying problems

fear of being out or open

What are the three most common problems faced by most non-SGM youth?

class/exams/grades

college/career

financial pressures related to college or job

What percentage of homeless youth or SGM?

True or false:

LGB adolescents (7-12 graders) are:
-more likely to have had sex
-been responsible for or gotten pregnant
-reported 2+ sexual partners
-1st intercourse before age 14

Smoking and alcohol use are higher in SGM or heterosexual individuals?

Body image and eating disorders are more common in _________________ while obesity is more common in _______________.

gay men

lesbians

Who has the greatest fear of being treated differently or being refused medical service: LGB, transgender, or HIV+ patients?

What percentage of SGM parents don't disclose their sexual orientation to their child's health care provider?

Healthy People 2010 established a public health agenda with the goals of eliminating health disparities and improving the overall health of all Americans by what means? (4)

- promoting health
-preventing illness
-preventing disability
-preventing premature death

According to ACCP standards, what is the PRIMARY thing to avoid when ventilating a patient? (i.e. primary goal of mechanical ventilation)

iatrogenic lung injury

According to ACCP standards, what are the 5 clinical objectives of ventilation?

Reverse:
1. Hypoxemia
2. Respiratory acidosis
3. Atelectasis (or prevent)
4. Respiratory muscle fatigue
5. Respiratory distress

What are some interfaces of non invasive ventilation (NIV)? (5)

1. Full face masks
2. Mouthpiece
3. Cannulas
4. Nasal pillows
5. Mouth seals

What are the three T's of mechanical ventilation?

Target
Trigger
Termination

A TMJ of ____________ is representative of a difficult intubation?

What are you looking for on CXR after ET tube placement? (2)

1. To see how far down the trachea the ET tube is
2. Look for PNX

Mallampati score takes into account what two anatomical things?

According to Gawande, the remaining time alive in a terminally ill patient should be ________________.

the remaining time alive is the best it can be.

What is the SPIKES protocol for delivering bad news?

Setting
Perception
Invitation
Knowledge
Empathy
Strategy and summary

What are the five stages of grief?

Denial
Anger
Bargaining
Depression
Acceptance

The following are facts from what case:

-Parents ask court to remove feeding tube
-MO supreme court revered the lower court
-US supreme court upheld state supreme court but found that a competent person could refuse treatment while incompetent persons could not
-2 years later, Jasper county, MO granted the family permission to remove NG tube

Nancy Cruzan case

Ineffective care that provides no benefit to the patient

True or false:

It is medically indefensible to let any patient die in pain.

An _____________________ is needed for optimal care of the dying patient.

experienced team

Do not deliver sensitive news to patients or their loved ones if you are ..... (4)

HALT - Don't do it!!

Hungry
Angry
Late for another event
Tired

To be of maximum help to your patients when it comes to complex ethical problems near the end of life, you must think about what?

your own attitudes toward dying and death

Only __________ of the population dies suddenly; the rest die more slowly.

A complicating factor of end of life considerations is the "illusion of ____________."

True or false:

Each competent patient has the right, at any time, to accept or refuse any form of medical treatment or testing. Therapy can be refused, even if it might prolong life.

True or false:

Medical professionals have a legal or moral duty to prescribe procedures or treatments that simply prolong the process of dying.

FALSE!

They do NOT have a legal or moral duty to do so.

What are some groups that are at high risk of having their autonomy compromised or even disregarded when it comes to end of life considerations? (5)

-elderly
-mentally or physically disabled
-poor, esp. w/ no health insurance
-homeless
-residents in skilled nursing facilities (SNF)

_________________ is a legal term that implies an absolute and unchanging condition.

The ability to choose, having considered the pros and cons, and understood the possible consequences of actions. In some patients, it may be partial and vary over time as their mental condition changes.

decision-making capacity

In which state are the terms "incompetent" and "lacking capacity" interchangeable?

What is it called when a patient's proxy follows the patient's expressed wishes before decisional capacity is lost rather than deciding on his or her own what to do for the patient?

substituted judgement

What are some indications for non-invasive ventilation? (4)

OSA (obstructive sleep apnea)
OH (obesity hypoventilation)
Neuromuscular dz
Acute respiratory failure (hypoxemic/hypercapnic)

What is ventilation without perfusion referred to as? (i.e. part of inhaled air does not participate in gas exchange, such as in a PE)

dead space

V-Q

What is perfusion without ventilation referred to as? (i.e. pulmonary vasculature pump blood to an area that is not receiving oxygen, such as s/p pneumonectomy)

A normal person breaths by (positive/negative) pressure ventilation.

What are the four possible triggers of mechanical ventilation? (4)

timer
pressure
flow
neural

Is flow or pressure triggering for mechanical ventilation thought to be more sensitive?

Ventilator trigger thresholds do not take into account _________________.

What does NAVA mean?

neural-adjustment ventilatory assist

What is VIDD? How soon can it occur?

ventilator-induced diaphragm dysfunction due to over-assistance w/ mechanical ventilation (MV)

can occur 18-69 hours after complete diaphragmatic inactivity during MV

Refers to the time required by the ventilator to achieve the preset pressure.

What are a few ventilator modes that I think we need to know, but who really knows? (5)

Volume Control (VC)
Pressure Control (PC)
Pressure support (PS)
Volume support (VS)
Neural-Adjustment Ventilatory Assist (NAVA)

_____________ is functionally similar to PEEP.

What are four criteria for ventilator discontinuance?

1. Mental ability to maintain patent airway
2. Resolution or resolving of process that required MV initially
3. Decreased need for inotropic support
4. Able to tolerate 30 min spontaneous breathing trial w/ no detrimental change in hemodynamics or pulmonary mechanics

Negative inspiratory force (NIF) of _______ to _______ is indicative that the pt is ok to extubate (even though a normal person has a NIF of -120 to -150).

-30 to -35

(indicator of how well the pt will be able to cough after extubation)

What is the most accurate predictor of a successful extubation?

RSBI (rapid shallow breathing index) < 105

Dynamic compliance takes into account peak pressure, while static compliance takes into account __________ pressure. Which is a more relevant reflection of alveolar pressure?

plateau

static compliance

What is meant by compliance of the lung?

"stiffness" or elastance of alveoli

decreased compliance w/ ARDS, hemothorax, pulmonary fibrosis, PE, etc.

_____________________ are implicated as one of the primary causes of ventilator induced lung injury (VILI) and increased mortality w/ ARDS.

high plateau pressures

High peak and high plateau pressures are indicative of _______________ lung compliance.

Reduced thoracic wall compliance, abdominal distention or edema, obesity, and other mechanical abnormalities can cause _____________ plateau pressures and ________________ compliance.

increased

decreased

Non-cardiogenic pulmonary edema

ARDS (acute respiratory distress syndrome)

What is the most common cause of death in a pt w/ ARDS?

MSOF (multi-system organ failure)

What are the three primary ways to harm the lung?

1. Repetitive opening and closing
2. Strain-tidal volume
3. FiO2/PaO2

Putting the patient in what position improves the outcome for pt's w/ severe ARDS?

PRONE (they should also be sedated if they are in this position)

What is the equation for RSBI? (rapid shallow breathing index)

RSBI = RR/VT (in liters)

Mode of ventilation should be chosen based on what two criteria?

optimal patient/machine synchrony

acid-base and oxygenation goals met

High ______________________ is one of the primary causes of ventilator induced lung injury

plateau pressures

Plateau pressure is used as a surrogate for __________________.

alveoli pressure

High peak pressure + high plateau pressure = ____________ lung compliance. What are some causes? (3)

poor

-abdominal distension
-edema
0obesity

High peak pressure + normal/slight elevated plateau pressure = _______________ resistance.

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