50 item Psychiatric Exam Answers and Rationales


CORRECT ANSWERS AND RATIONALE

1. 60 year old post CVA patient is taking TPA for his disease, the nurse understands that this is an example of what level of prevention?
C. Tertiary : The client already had stroke, TPA stands for TRANSPLASMINOGEN ACTIVATOR which are thrombolytics, dissolving clots formed in the vessels of the brain. We are just preventing COMPLICATIONS here.

2. A female client undergoes yearly mammography. This is a type of what level of prevention?
b. secondary : The client is never sick of anything but we are detecting the POSSIBILITY by giving yearly mammography. Remember that all kinds of tests, case findings and treatment belongs to the secondary level of prevention.

3. A Diabetic patient was amputated following an unexpected necrosis on the right leg, he sustained and undergone BKA. He then underwent therapy on how to use his new prosthetic leg. this is a type of what level of prevention?
c. tertiary : Tertiary prevention involves rehabilitation. Client is now being assisted to perform ADLs at his optimum functioning. Remember that all kinds of rehabilitatory and palliative management is included in tertiary prevention.

4. As a care provider, The nurse should do first:
d. Early recognition of the client’s needs. : we are talking about what should the nurse do first. ASSESSMENT involves early recognition of clients needs. A,B,C are all involve in the intervention phase of the nursing process.

5. As a manager, the nurse should:
d. Works together with the team. : As a nurse manager, you should be able to work with the team. A,B,C are not specific of a nurse manager. They can be done by an ordinary R.N.

6. the nurse shows a patient advocate role when
a. defend the patients right : An advocate role is shown when the nurse defends the rights of the client. Interceding in behalf of the patient should not be done by a nurse. Counter transference can develop in that case and we should avoid that. Only the family and the health attorney of the patient can intercede or speak for the patient.

7. which is the following is the most appropriate during the orientation phase ?
d. establishment of regular meeting of schedules : Orientation phase is synonymous with CONTRACT ESTABLISHMENT. Here, the nurse will establish regular meeting of schedule, agreements and giving the client information that there is a TERMINATION. Letter A and B assesses the client’s coping skills, which is in the working phase and so is letter B. In working phase, The nurse assesses the coping skills of the client and formulate plans and intervention to correct deficiencies. Although assessment is also made in the orientation phase, COPING SKILLS are assessed in the working phase.

8. preparing the client for the termination phase begins :
c. working : Telling the client that there is a TERMINATION PHASE should be in the ORIENTATION PHASE, however, in preparing the client for the TERMINATION, it should be done in the working phase. The nurse will start to lessen the number of meetings to prevent development of transference or counter transference.

9. a helping relationship is a process characterized by :
c. growth facilitating : In psychiatric nursing, The epitome of all nursing goal should focus on facilitating GROWTH of the client.

10. During the nurse patient interaction, the nurse assess the ff: to determine the patients coping strategy :
d. How does your problem affect your life? : this is the only question that determines the effects of the problem on the client and the ways she is dealing with it. Letter A can only be answered by FINE and close further communication. B is unrelated to coping strategies. Letter C, asking the client what do you think can help you right now is INAPPROPRIATE for the nurse to ask. The client is in the hospital because she needs help. If she knows something that can help her with her problem she shouldn’t be there.

11. As a counselor, the nurse performs which of the ff: task?
a. encourage client to express feelings and concerns : A counselor is much more of a listener than a speaker. She encourage the client to express feelings and concerns as to formulate necessary response and facilitate a channel to express anger, disappointments and frustrations.

12. Freud stresses out that the EGO
a. Distinguishes between things in the mind and things in the reality. : The ego is responsible for distinguishing what is REAL and what is NOT. It is the one that balances the ID and super ego. B and D is a characteristic of the SUPER EGO which is the CONTROLLER of instincts and drives and serve as our CONSCIENCE or the MORAL ARM. The ID is our DRIVES and INSTINCTS that is mediated by the EGO and controlled by the SUPER EGO.

13. A 16 year old child is hospitalized, according to Erik Erikson, what is an appropriate intervention?
a. tell the friends to visit the child : The child is 16 years old, In the stage of IDENTITY VS. ROLE CONFUSION. The most significant persons in this group are the PEERS. B refers to children in the school age while C refers to the young adulthood stage of INTIMACY VS. ISOLATION. The child is not dying and the situation did not even talk about the child’s belief therefore, calling the priest is unnecessary.

14. NMS is characterized by :
c. Hypertension, hyperthermia, diaphoresis. : Neuroleptic malignant syndrome is a side effect of neuroleptics. This is characterized by fever, increase in blood pressure and warm, diaphoretic skin.

15. Which of the following drugs needs a WBC level checked regularly?
b. Clozaril : Clozapine is a dreaded aypical antipsychotic because it causes severe bone marrow depression, agranulocytosis, infection and sore throat. WBC count is important to assess if the clients immune function is severely impaired. The first presenting sign of agranulocytosis is SORE THROAT.

SITUATION : Angelo, an 18 year old out of school youth was caught shoplifting in a department store. He has history of being quarrelsome and involving physical fight with his friends. He has been out of jail for the past two years

16. Initially, The nurse identifies which of the ff: Nursing diagnosis:
b. impaired social interaction : There is no such nursing diagnosis as A , looking at C and D, they are much more compatible to schizophrenia which is not a characteristic of an ANTI SOCIAL P.D which is shown in the situation. Remember that Personality Disorder is FAR from Psychoses. When client exhibits altered thought process or sensory alteration, It is not anymore a personality disorder but rather, a sign and symptom of psychoses.

17. which of the ff: is not a characteristic of PD?
b. loss of cognitive functioning : As I said, symptoms of PD will never show alteration in cognitive functioning. They are much more of SOCIAL Disturbances rather than PSYCHOLOGICAL.

18. the most effective treatment modality for persons if anti social PD is
c. behavior therapy : The problem of the patient is his behavior. A is done for patient who has insomnia or severe anxiety. B is a therapy that promotes growth by providing a contact, either a person or an environment who will facilitate the growth of an individual. It is a humanistic psychotherapeutic model approach. D is done on clients who are in crisis like trauma, post traumatic disorders, raped or accidents.


19. Which of the following is not an example of alteration of perception?
b. flight of ideas : Flight of ideas is a condition in which patient talks continuously and then switching to unrelated topic. An example is “ Ang ganda ng bulaklak na ito no budek? Rose ito hindi ba? Kilala mo ba si jack yung boyfriend ni rose? Grabe yung barko no ang laki laki tapos lumubog lang. Dapat sana nag seaman ako eh, gusto kasi ng nanay ko. “. Loose association is somewhat similar but the switch in topic is more obvious and completely unrelated. Example “ Ang cute nung rabbit, paano si paul kasi tanga eh, papapatay ko yan kay albert. Ang ganda nung bag na binigay ni jenny, tanga nga lang yung aswang dun sa kanto. Pero bakit ka ba andito? Wala akong pagkain, Penge ako kotse aakyat ako everest.”

A,C,D are all alteration in perception. A refers to a person thinking that everyone is talking about him. C and D are all sensory alterations. The difference is that, in hallucination, there is no need for a stimuli. In illusion, a stimuli [ A phone cord ] is mistakenly identified by the client as something else [ Snake ]

20. The type of anxiety that leads to personality disorganization is :
d. panic : Panic is the only level of anxiety that leads to personality disorganization.

21. A client is admitted to the hospital. Twelve hours later the nurse observes hand tremors, hyperexicitability, tachycardia, diaphoresis and hypertension. The nurse suspects alcohol withdrawal. The nurse should ask the client:
a. at what time was your last drink taken? : This question will give the nurse idea WHEN will the withdrawal occur. Withdrawal occurs 5 to 10 hours after the last intake of alcohol. This is a crucial and mortality is very high during this period. Client will undergo delirium tremens, seizures and DEATH if not recognize earlier by the nurse. B is very judgmental, C is non specific, whether it is a beer or a wine It is still alcohol and has the same effects. D is a valuable question to determine the chronic effects of alcohol ingestion but asking letter A can broaden the line between life and death.

22. client with a history of schizophrenia has been admitted for suicidal ideation. The client states "God is telling me to kill myself right now." The nurse's best response is:
a. I understand that god’s voice are real to you, But I don’t hear anything. I will stay with you. : The nurse should first ACKNOWLEDGE that the voices are real to the patient and then, PRESENT REALITY by telling the patient that you do not hear anything. The third part of the nursing intervention in hallucination is LESSENING THE STIMULI by either staying with the patient or removing the patient from a highly stimulating place.
Telling the client that the voices is part of his illness is not therapeutic. People with schizophrenia do not think that they are ILL. Letter C and D disregards the client’s concern and therefore, not therapeutic.

23. In assessing a client's suicide potential, which statement by the client would give the nurse the HIGHEST cause for concern?
c. I’ve thought about taking pills and alcohol till I pass out : This is the only statement of the client that contains a specific and technical plan. B,D are all indicative of suicidal ideation but it contains no specific plans to carry out the objective. Letter A admits the client thinks of hurting himself, but not doing it because it scares him, therefore, it is not indicative of suicidal ideation.

24. A client with paranoid schizophrenia has persecutory delusions and auditory hallucinations and is extremely agitated. He has been given a PRN dose of Thorazine IM. Which of the following would indicate to the nurse that the medication is having the desired effect?
c. Stops pacing and sits with the nurse : Thorazine is a neuroleptic. Desired effect evolve on controlling the client’s psychoses. Letter A is the side effect of the drug, which is not desired. B and D indicates that the drug is not effective in controlling the client’s agitation, restlessness and disorders of perception.

25. A client who was wandering aimlessly around the streets acting inappropriately and appeared disheveled and unkempt was admitted to a psychiatric unit and is experiencing auditory and visual hallucinations. The nurse would develop a plan of care based on:
c. schizophrenia : When disorders of perception and thoughts came in, The only feasible diagnosis a doctor can make is among the choices is schizophrenia. A,B and D can occur in normal individuals without altering their perceptions. Schizophrenia is characterized by disorders of thoughts, hallucination, delusion, illusion and disorganization.

26. A decision is made to not hospitalize a client with obsessive-compulsive disorder. Of the following abilities the client has demonstrated, the one that probably most influenced the decision not to hospitalize him is his ability to:
c. Perform activities of daily living : If a client can do ADLs , there is no reason for that client to be hospitalized.

27. A client is admitted to the inpatient psychiatric unit. He is unshaven, has body odor, and has spots on his shirt and pants. He moves slowly, gazes at the floor, and has a flat affect. The nurse's highest priority in assessing the client on admission would be to ask him:
b. If he is thinking about hurting himself : The client shows typical sign and symptoms of DEPRESSION. Moving slowly, gazes on the floor, blank stares and showing flat affect. The highest priority among depressed client is assessing any suicide plans or ideation for the nurse to establish a no suicide contract early on or, in any case client do not participate in a no suicide contract, a 24 hour continuous monitoring is established.

28. The nurse should know that the normal therapeutic level of lithium is :
a. .6 to .12 meq/L : According to brunner and suddarths MS nursing, The normal therapeutic level of lithium is .6 to 1.2 meq/L. Some books will say .5 to 1.5 meq/L.

29. The patient complaint of vomiting, diarrhea and restlessness after taking lithane. The nurse’s initial intervention is :
a. Recognize that this is a sign of toxicity and withhold the next medication. : The nurse should recognize that this is an early s/s of lithium toxicity. Taking the clients vital signs will not confirm diarrhea, vomiting or restlessness. Notifying the physician is unnecessary at this point and the physician will likely to withhold the medication.

30. The client is taking TOFRANIL. The nurse should closely monitor the patient for :
c. Increase Intra Ocular Pressure : Tofranil is a neuroleptic. It is well known that this is the antipsychotic that increases the IOP and contraindicated in patients with glaucoma. Hypertension is not specific with TOFRANIL. All neuroleptics can cause NMS or the neuroleptic malignant syndrome.

31. A client was hospitalized with major depression with suicidal ideation for 1 week. He is taking venlafaxine (Effexor), 75 mg three times a day, and is planning to return to work. The nurse asks the client if he is experiencing thoughts of self-harm. The client responds, "I hardly think about it anymore and wouldn't do anything to hurt myself." The nurse judges:
c. The depression to be improving and the suicidal ideation to be lessening. : too obvious, no need to rationalize.

32. The client is taking sertraline (Zoloft), 50 mg q AM. The nurse includes which of the following in the teaching plan about Zoloft?
a. Zoloft causes erectile dysfunction in men : When you take zoloft, mag zozoloft ka nalang sa buhay. Because it causes erectile dysfuntion and decrease libido. Letter B and C are specific of TCAs. Zoloft will exert its effects as early as 1 week.

33. After 3 days of taking haloperidol, the client shows an inability to sit still, is restless and fidgety, and paces around the unit. Of the following extrapyramidal adverse reactions, the client is showing signs of:
b. Akathisia : The client shows sign of motor restlessness, which is specific for Akathisia or MAKATI SYA.

34. After 10 days of lithium therapy, the client's lithium level is 1.0 mEq/L. The nurse knows that this value indicates which of the following?
b. An anticipated therapeutic blood level of the drug.

35. When caring for a client receiving haloperidol (Haldol), the nurse would assess for which of the following?
b. Extrapyramidal symptoms : Haldol is a neuroleptic, Specific to these neuroleptics are the EPS. The client will likely be hypotensive than hypertensive because neuroleptics causes postural hypotension, The client will complaint of dry mouth due to its anticholinergic properties. Dizziness and drowsiness are side effects of neuroleptics but not oversedation.

36. A client is brought to the hospital’s emergency room by a friend, who states, "I guess he had some bad junk (heroin) today." In assessing the client, the nurse would likely find which of the following symptoms?
c. Decreased respirations, constricted pupils, and pallor. : Heroin is a narcotic. Together with morphine, meperidine, codeine and opiods, they are DEPRESSANTS and will cause decrease respiration, constricted pupils and pallor due to vasoconstriction.


37. The client has been taking the monoamine oxidase inhibitor (MAOI) phenelzine (Nardil), 10 mg bid. The physician orders a selective serotonin reuptake inhibitor (SSRI), paroxetine (Paxil), 20 mg given every morning. The nurse:
b. Questions the physician about the order : 2 anti depressants cannot be given at the same time unless the other one is tapered while the other one is given gradually.

38. Which of the following client statements about clozapine (Clozaril) indicates that the client needs additional teaching?
d. "I need to call my doctor whenever I notice that I have a fever or sore throat." : Clozapine causes AGRANULOCYTOSIS and bone marrow depression. Early s/s includes fever and sore throat. The medication is to be withheld this time or the patient might develop severe infection leading to death.

39. A client has been taking lithium carbonate (Lithane) for hyperactivity, as prescribed by his physician. While the client is taking this drug, the nurse should ensure that he has an adequate intake of:
a. Sodium : The levels of lithium in the body are dependent on sodium. The higher the sodium, The lower the levels of lithium. Clients should have an adequate intake of sodium to prevent sudden increase in the levels of lithium leading to toxicity and death.

40. The client has been taking clomipramine (Anafranil) for his obsessive-compulsive disorder. He tells the nurse, "I'm not really better, and I've been taking the medication faithfully for the past 3 days just like it says on this prescription bottle." Which of the following actions would the nurse do first?
a. Tell the client to continue taking the medication as prescribed because it takes 5 to 10 weeks for a full therapeutic effect. : Anafranil is an anti depressant, effects are noticeable within 1 to 2 weeks.

41. The nurse judges correctly that a client is experiencing an adverse effect from amitriptyline hydrochloride (Elavil) when the client demonstrates:
d. Urinary retention : Elavil is an TC antidepressant. It should not cause insomnia. Hypertension are specific of MAOI anti depressants when tyramine is ingested. Due to the anticholinergic s/e of TCAs, Urinary retention is an adverse effect.

42. Which of the following health status assessments must be completed before the client starts taking imipramine (Tofranil)?
a. Electrocardiogram (ECG). : Aside from tonometry or IOP measurement, Client should undergo regular ECG schedule. Most TCAs causse tachycardias and ECG changes, an ECG should be done before the client takes the medication.

43. A client comes to the outpatient mental health clinic 2 days after being discharged from the hospital. The client was given a 1-week supply of clozapine (Clozaril). The nurse reviews information about clozapine with the client. Which client statement indicates an accurate understanding of the nurse's teaching about this medication?
b."I need to keep my appointment here at the hospital this week for a blood test." : Regular blood check up is required for patients taking clozaril. As frequent as every 2 weeks. Clozapine can cause bone marrow depression, therefore, frequent blood counts are necessary.

44. The client is taking risperidone (Risperdal) to treat the positive and negative symptoms of schizophrenia. Which of the following negative symptoms will improve?.
d. Asocial behaviour and anergia : A,B and C are all positive symptoms of schizophrenia. Negative symptoms includes anhedonia, anergia, associative looseness and Asocial behavior.

45. The nurse would teach the client taking tranylcypromine sulfate (Parnate) to avoid which food because of its high tyramine content?
b. Aged cheeses. : This is high in tyramine, and therefore, removed from patients diet to prevent hypertensive crisis.

46. Which of the following clinical manifestations would alert the nurse to lithium toxicity?
d.Anorexia with nausea and vomiting.

47. The client with depression has been hospitalized for 3 days on the psychiatric unit. This is the second hospitalization during the past year. The physician orders a different drug, tranylcypromine sulfate (Parnate), when the client does not respond positively to a tricyclic antidepressant. Which of the following reactions should the client be cautioned about if her diet includes foods containing tryaminetyramine?
d. Hypertensive crisis.

48. After the nurse has taught the client who is being discharged on lithium (Eskalith) about the drug, which of the following client statements would indicate that the teaching has been successful?
c. "I'll call my doctor right away for any vomiting, severe hand tremors, or muscle weakness." : This is a sign of light lithium toxicity. Increasing fluid intake will cause dilutional decrease of lithium level. Restriction of sodium will cause dilutional increase in lithium level.

49. A nurse is caring for a client with Parkinson's disease who has been taking carbidopa/levodopa (Sinemet) for a year. Which of the following adverse reactions will the nurse monitor the client for?
c. hypotension : Hypotension, dizziness and lethargy are side effects of anti parkinson drugs like levodopa and carbidopa.

50. A client is taking fluoxetine hydrochloride (Prozac) for treatment of depression. The client asks the nurse when the maximum therapeutic response occurs. The nurse's best response is that the maximum therapeutic response for fluoxetine hydrochloride may occur in the:
c. Third week : A and B are similar, therefore , removed them first. Recognizing that most antidepressants exerts their effects within 2-3 weeks will lead you to letter C.

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PSYCHIATRIC NURSING
1. 60 year old post CVA patient is taking TPA for his disease, the nurse understands that this is an example of what level of prevention?

a. primary

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The Manila Bulletin reports on how the WHO is working with countries that have high rates of migrating health workers to maintain and expand the health workforce in areas with the greatest need, expecially low-income rural communities.

According to a WHO statement, "62 percent of nurses and 76 percent of doctors work in towns, while half of the population lives in rural areas. This is a major challenge to the provision of health services. To improve this situation WHO is disseminating strategies to help countries encourage health workers to live and work in remote and rural areas," the newspaper reports (Luci, 7/10).

In May, at the World Health Assembly, member countries agreed to a voluntary code, known as the WHO Global Code of Practice on the International Recruitment of Health Personnel, to reduce the negative effects of the recruitment of health workers from developing countries facing an acute shortage of medical professionals (Kaiser Daily Global Health Policy report, 5/24).

A WHO fact sheet outlines the positive and negative outcomes that result from health worker migration. "When significant numbers of doctors and nurses leave, the countries that financed their education lose the return on their investment. When a country has a fragile health system, the loss of its health workforce can bring the whole system close to collapse, with the consequences measured in lives lost."
On the other hand, "[E]ach year, migration generates billions of dollars in remittances (the money sent back to home countries by migrants) to low-income countries and has been associated with a decline in poverty. Health workers also may return and bring significant skills and expertise back to their home countries," according to the WHO.

The WHO factsheet highlights the 10 countries with the "highest expatriation rates for doctors," notes several ways countries of origin and destination countries can work to reduce the migration of health workers and highlights key pieces of the voluntary code on health workers (July 2010).
This information was reprinted from globalhealth.kff.org with kind permission from the Henry J. Kaiser Family Foundation. You can view the entire Kaiser Daily Global Health Policy Report, search the archives and sign up for email delivery at globalhealth.kff.org.

© Henry J. Kaiser Family Foundation. All rights reserved.

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The Australian Nursing Federation has welcomed the announcement that the Royal College of Nursing, Australia will administer the new national nursing scholarship scheme.

The federal government has committed to more than $100 million funding over four years for undergraduate and postgraduate study, clinical placements and continuing professional development for nursing and allied health professionals in the Nursing and Allied Health Scholarship and Support Scheme.

ANF federal secretary Lee Thomas congratulated the RCNA in being appointed administrator of the nursing and midwifery scholarships. "Nursing and midwifery are highly skilled professions that require rigorous education and preparation for practice. This is recognition that the RCNA has shown commitment to the high standards of educational requirements required by the professions which ultimately affects the quality care provided to the community."

Ms Thomas said the federal government had shown commitment to the advancement of nursing and midwifery education and practice with the scheme. "The federal government has placed an emphasis on further education and training of nurses and midwives and expanded and advanced practice."

Source:
Australian Nursing Federation

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In 20 years, approximately 72 million older adults will reside in the United States, almost double the current number, according to the U.S. Administration on Aging. Potential issues are compounded by the projected shortage of health care workers needed to provide elder care. As part of the solution, an interdisciplinary team of University of Missouri researchers is refining electronic health record (EHR) technology to more efficiently meet increasing health care demands.


The MU researchers are developing an EHR system that encompasses standard health assessments and those obtained through new technologies. The goal is to increase efficiency and accuracy, improve patient outcomes and reduce costs for long-term care.

"As the use of emerging technologies increases along with the older population, maintaining complete and accurate patient information can be overwhelming," said Marilyn Rantz, professor in the MU Sinclair School of Nursing. "A comprehensive system that encompasses all measures, old and new, is the key to enhanced and efficient clinical decision making."

The EHR is being tested at TigerPlace, an independent senior-living facility that helps residents age in place. According to the researchers' initial findings, use of the EHR system can enhance nursing care coordination and advance technology use and clinical research.

"New technologies to passively monitor older adults' health are being developed and are increasingly commercially available," Rantz said. "The challenge remains to integrate clinical information systems with passive monitoring data, especially in long-term care and home health settings, in order to improve clinical decision making and ensure patient records are complete."

Effective EHR systems display data in ways that are meaningful and quickly assessable for clinicians, Rantz said. With access to comprehensive data, clinicians can make more informed clinical decisions, better perform risk assessments and provide risk-reducing interventions.

The study, "Developing a Comprehensive Electronic Health Care Records to Enhance Nursing Care Coordination, Use of Technology and Research," was published in the Journal of Gerontological Nursing. The research was supported by the U.S. Administration on Aging and the National Science Foundation. Project collaborators included researchers from the MU Sinclair School of Nursing, University Hospital, School of Medicine and the College of Engineering.



Source:
Emily Martin
University of Missouri-Columbia

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Research conducted at the University of Granada revealed that emotions play an important role when health professionals have to certify that a patient is in terminal stage. To the purpose of this research, a qualitative study was undertaken with a sample of 42 participants. Participants were thoroughly interviewed, with the aim of analyzing the approach and language employed by health professionals treating terminally-ill patients


Physicians who have to decide whether an illness is terminal think that "there are not valid and adequate criteria for certifying that an illness is terminal". This is the conclusion drawn from a pioneer study conducted at the University of Granada, and recently published in the Journal of Clinical and Health Psychology (IJCHP).

For the purpose of this study, 42 health professionals were thoroughly interviewed. Of this group, 21 were physicians and 21 were nurses working with terminally-ill patients in hospitals in the province of Granada. Of the 42 participants, 22 were women and 20 were men with ages between 23 and 52. Of the participants, 17 worked in community health centers, 18 worked in public hospitals, 4 in combined units and 3 worked in private health centers.

This study revealed interesting findings. The answers given by the professionals interviewed revealed that the diagnosing of terminal illness in their daily work differs depending on the type of health centre - primary or specialized care - and the type of professional - physician or nurse.



Use of euphemisms

Concretely, those professionals working in community health centers - both physicians and nurses - use and record "terminal illness" diagnosis to define the clinical condition of their patients. On the other hand, the answers provided by professionals working in public hospitals differ significantly: while nurses use euphemisms or synonyms rather than "terminal illness" diagnosis, physicians use this diagnosis in professional circles and, although they are aware of this circumstance, they avoid using it in their medical reports.

This research conducted at the University of Granada reveals that health professionals have difficulties in certifying terminal illnesses. The question emerges on whether such situation could be preventing palliative care from being provided to a significant number of terminal patients. This means that many terminal patients are being deprived from professional assistance aimed at helping them in facing the end of their lives, and at providing them an acceptable quality of life. Additionally, professionals have a distorted view of the role and purpose of palliative assistance, since they are emotionally conditioned by a diagnosis that - in our society - is associated to a "death sentence".

This study was co-authored by María Paz García Caro, Francisco Cruz Quintana, Jacqueline Schmidt Río Valle, Antonio Muñoz Vinuesa, Rafael Montoya Juárez, Diego Prados Peña y Miguel C. Botella López from the University of Granada, and Atthanasios Pappous, from the University of Kent, United Kingdom.


Patients with cancer


For a deeper understanding of the difficulties that a diagnosis of "terminal illness" involves and its consequences, health professionals were asked what illnesses get diagnosed as "terminal" and when such diagnosis is disclosed. For most physicians and nurses, "terminal illness" diagnosis is associated only to patients with cancer. However, a significant number of professionals working in community health centers also associate this diagnosis to patients with an advanced stage of some chronic and/or degenerative non-cancerous illness.

As regards terminal diagnosis, it is mostly associated to patients in preagony or agony phase. This opinion is shared by most professionals working both in hospitals and in community health centers.

The study emphasizes the fact that, although the criteria and references for diagnosing a terminal illness - at least in oncological cases - were defined 20 years ago, such diagnosis is still employed in a very restrictive way. Diagnosis of a terminal illness involves a change of treatment, and when patients in terminal stage are not diagnosed as such, they and their families are deprived from the special care and assistance they need.

Similarly, the study remarks the lack of studies on the emotional charge suffered by health professionals treating terminal patients. This study states that this is a key factor when explaining the restrictive use of terminal illness diagnosis, especially in hospitals.

The research conducted at the University of Granada emphasizes the need to improve professional training of care providers in diagnosing a terminal illness, especially in chronic and degenerative illnesses in advanced stages. Additionally, the study remarks the need of further research for determining the scientific parameters on which terminal diagnosis must be based.



Source:
María Paz García Caro
University of Granada

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More than one third of US doctors who responded to a survey did not agree it was their responsibility to report colleagues who were incompetent or impaired, for instance due to substance abuse or a mental health disorder.

You can read about the research behind these findings online: they were published on 14 July in JAMA, Journal of the American Medical Association.

Lead study investigator, Dr Catherine DesRoches, of the Mongan Institute for Health Policy at Massachusetts General Hospital (MGH) in Boston, told the press that their findings question the ability of medical profession to regulate itself when it comes to dealing with incompetent or impaired doctors:

"Since physicians themselves are the primary mechanism for detecting such colleagues, understanding their beliefs and experiences surrounding this issue is essential. This is clearly an area where the profession of medicine needs to be concerned," she urged.

The survey also revealed that many doctors felt unprepared to deal with or report impaired or incompetent colleagues.

Studies show that compared to the number expected, far fewer reports of incompetence among doctors actually occur, in spite of increasing attention in the media and professional circles, and the fact many states and professional bodies like the American Medical Association require that health professionals report colleagues whose ability to practise is impaired.

DesRoches, who is also an associate professor of Medicine at Harvard Medical School, and colleagues designed a new study to investigate doctors' experiences, views and beliefs about colleagues who are impaired or incompetent to practise medicine, including the extent to which they felt obliged to report, their preparedness to do so, and actions they took.

They used data from a 2009 nationally representative survey that included a section on beliefs and behaviors regarding impaired or incompetent colleagues.

The survey covered doctors in anesthesiology, cardiology, family practice, general surgery, internal medicine, pediatrics, and psychiatry. From 2,938 eligible US doctors invited to complete the survey, 1,891 responded (64.4 per cent).

The survey asked respondents to rate the extent to which they agreed or disagreed with the statement:

"Physicians should report all instances of significantly impaired or incompetent colleagues."

It also asked them to say how prepared they felt to deal with such a situation, and whether they had had direct knowledge of an impaired or incompetent colleague in the past three years.

If they answered yes to having direct knowledge of such a case or cases, the survey then asked them to say whether they had reported the most recent case, and if they had failed to report any cases within the last three years, what reasons did they have.

The results showed that:
64 per cent (1,120 respondents) agreed that doctors should always report impaired or incompetent colleagues.

69 per cent (1,208) said they felt prepared to deal effectively with impaired colleagues in their medical practice.

17 per cent (309) had direct personal knowledge of a colleague who was incompetent to practise medicine in their hospital, group, or practice.

Of these, 67 per cent (204) reported the colleague.

Psychiatrists and anesthesiologists were the most likely to say they felt prepared to deal with impaired or incompetent colleagues, while pediatricians were the least likely.

Underrepresented minorities and graduates of non-US medical schools were less likely than their counterparts to say they would report impaired or incompetent colleagues, while doctors working in hospitals or medical schools were the most likely.

The most frequently stated reason for taking no action was the belief that someone else was alreading dealing with it (19 per cent of respondents, 58), followed by the belief that nothing would happen (15 per cent, 46) and fear of retribution (12 per cent, 36).
The researchers concluded that:

"Overall, physicians support the professional commitment to report all instances of impaired or incompetent colleagues in their medical practice to a relevant authority; however, when faced with these situations, many do not report."

Co-author Dr John A. Fromson, associate director of Postgraduate Medical Education in the Psychiatry department at MGH, and assistant clinical professor at Harvard Medical School, said:

"This study underscores the need for the medical profession to educate its members on their reporting obligations to ensure safe and competent care to patients."

"Those obligations include referring colleagues to physician health programs that can guide and monitor their recovery from substance use and mental disorders," he added.

Senior author Dr Eric G. Campbell, research director for the Mongan Institute, said these results imply the current system is failing: many doctors are either afraid to use it or don't believe it will work.

"Improvements to the system need to include helping physicians understand their professional responsibility to report impaired and incompetent colleagues, enhancing protections for reporting physicians and providing confidential feedback about outcomes," said Campbell, who is also an associate professor of Medicine at Harvard Medical School.

In an accompanying editorial, Dr Matthew Wynia, director of the Institute for Ethics at the American Medical Association, called for better protection for doctors who report colleagues, and more education on how to do so.

One successful story of a doctor who was reported was that of Dr. A. Clark Gaither. 21 years ago, while on a training residency, he found himself reported by a colleague, he does not know who, who said he had smelled alcohol on his breath. Gaither told the Associated Press he wished he knew who had reported him, because:

"I'd like to give them a big ol' hug and thank them for saving my life."

Altogether in Gaither's case, it took that report, three confrontations with supervisors and temporary loss of his tranining licence, to get him into residential rehab with the help of the North Carolina Physicians Health Program. He eventually finished his residency and became a family doctor.

Now 55 he has not touched a drop in 20 years, and runs a free mobile clinic for the uninsured in North Carolina.

Gaither, who speaks freely about his experience, said doctors worry that their colleagues will lose their licenses and livelihoods if they are reported, but he urges them to do it, because reporting is a first step in getting them the help they need, which is preferable to them losing everything, as he was in danger of.

"Physicians' Perceptions, Preparedness for Reporting, and Experiences Related to Impaired and Incompetent Colleagues."
Catherine M. DesRoches, Sowmya R. Rao, John A. Fromson, Robert J. Birnbaum, Lisa Iezzoni, Christine Vogeli, and Eric G. Campbell.
JAMA, 304 (2):187-193, published online 14 July 2010.
DOI:10.1001/jama.2010.921

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