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Professional Practice - Exam 3 (Cumulative Set)
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Gravity
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"?
The patient
Who determines "Effectiveness"?
The provider
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
Obligatory
True or false: Respecting autonomy means that we as providers are solely allowing the person/patient to select his/her preferred course of action
FALSE
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?
Yes
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 ________________.
pretenses
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.
articulate
Ethical dilemmas are often because of conflicts between ____________
Values
Moral philosophy relies on which of the following?
-Emotions
-Logic
-Superstition
-Chance
Logic
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?
justice
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.
full agents
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?
control
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?
1970's
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?
a judge
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 _____________.
diagnosis
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?
negligence
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?
attitude
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?
structure
".... 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?
Justice
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.
suffering
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.
autonomy
An ethical person is someone who has ______________ that facilitate human flourishing, which help to bring about human __________.
virtues
good
Ultimately becoming virtuous involves what, according to Aristotle?
habituation
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.
culture
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 ________________.
stereotype
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
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.
quadrupled
What are the three transmembrane neurotransmitter receptors activated by opioids?
mu
kappa
delta
What term refers to both natural and synthetic substances that act at one of the 3 main opioid receptors?
Opioid
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.
noradrenaline
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
buprenorphine
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?
methadone
What are the two MAT agents that are antagonists?
naltrexone and naloxone
Naltrexone can pose major problems for which major organ?
the liber
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: _______________
Passing
LGB adolescents are (more/less) likely to get pregnant compared to heterosexual adolescents
More
Heterosexual adolescent males are (more/less) likely to have an eating disorder compared to Gay/Bisexual adolescent males
Less
20% of people w/ HIV are between the ages of:
15-24
What is SGM?
sexual and gender minority
What is LGBT?
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
transgender
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?
Harvey Milk
In what decade ddi the AIDS epidemic explode?
1980's
The "Don't Ask, Don't Tell" policy was enforced during what time frame?
1994-2011
What year did legalization of gay marriage start?
2004
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?
KS
MS
NC
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.
doubled
_______% of SGM couples are raising kids, and ___________% of heterosexual couples are raising kids.
16%
39%
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?
$10-30K
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
True or false:
Overall, adjustment of children is not related to parental sexual orientation.
TRUE
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?
25 to 54 y/o
What term refers to a subclass of opioids consisting of alkaloid compounds that occur naturally in the opium poppy, including morphine, thebaine, and codeine?
opiates
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?
buprenorphine
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
naltrexone
Which MAT agent requires completed withdrawal from opioids and requires highly motivated pts?
naltrexone
What is the median age when gay men, lesbians, and bisexual individuals first thought they were something other than straight or heterosexual?
12
What is the median age when gay men, lesbians, and bisexual individuals were SURE they were not straight or heterosexual?
17
What is the median age when gay men, lesbians, and bisexual individuals first told a close friend or family member that they were LGBT?
20
What is the mean age that transgender individuals "pass"?
42
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?
20-40%
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
TRUE!
Smoking and alcohol use are higher in SGM or heterosexual individuals?
SGM
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?
transgender
What percentage of SGM parents don't disclose their sexual orientation to their child's health care provider?
25%
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?
<3 cm
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?
tongue
pharynx
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?
S
etting
P
erception
I
nvitation
K
nowledge
E
mpathy
S
trategy 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
futility
True or false:
It is medically indefensible to let any patient die in pain.
TRUTH!
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!!
H
ungry
A
ngry
L
ate for another event
T
ired
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.
20-25%
A complicating factor of end of life considerations is the "illusion of ____________."
choice
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
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.
"Incompetent"
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?
California
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)
shunt
Q-V
A normal person breaths by (positive/negative) pressure ventilation.
negative
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?
Flow
Ventilator trigger thresholds do not take into account _________________.
auto-PEEP
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.
Rise time
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.
CPAP
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.
poor
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.
increased
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