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February 3, 2015 Issue

Death and Dying

The Institute of Medicine’s recent report, “Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life” offers an opportunity to evaluate the care we provide our patients with terminal illness and consider where we need to focus and improve. Plan a teaching session, or a few, around this important topic using any of a number of papers:

Medical Knowledge
Patient Care
Interpersonal and Communication Skills

Symptom Trends in the Last Year of Life From 1998 to 2010. A Cohort Study

Despite end-of-life care receiving increased attention in recent years, it is not known whether dying patients’ symptoms have improved. This cohort study describes changes in pain intensity and symptom prevalence reported by patients and their proxies during the last year of life from 1998 to 2010. Findings suggest that serious pain and other troubling symptoms remain prevalent among patients near the end-of-life.

Use this paper to:

  • Use a recent In the Clinic: Palliative Care to prepare a teaching session. Ask if your learners know the difference between palliative care and hospice care? Do they know in whom each should be considered, and when? How is the approach to pain management altered by its underlying cause? Which drugs work best for each cause? How about for nausea? Use the multiple-choice questions at the end to introduce topics for discussion. Sign in and enter your answers to earn CME credits.
  • The authors of this research study did not know the roles played by the proxies in patient care, nor whether the patients who died were enrolled in hospice care or for how long. How do these limitations affect what may be concluded? Does the study show that hospice programs are failing or doing inadequate jobs? What can we conclude? Why do your learners think it matters? Do they think we do a good job providing care to terminally ill patients?
  • Are your learners comfortable introducing hospice care to a patient? Do they think it hastens death? Divide your learners into pairs and pretend to explain what palliative and hospice care involve. Pretend to be patients asking questions.

Patient Care
Interpersonal and Communication Skills

Can the United States Buy Better Advance Care Planning?

Dying in America: A Constructive Step Forward and an Opportunity to Deepen Partnerships With Patients and Families

The Doctor: For Life and at the End-of-Life

Engaging Public Health in End-of-Life Issues: It Is Time to Step Up to the Plate

These commentaries discuss the need for constructive conversations with patients and families about advance care planning, reimbursement for such conversations, the need for physician engagements after patients enter palliative or hospice care, and why end-of-life care is an important public health issue.

Use these papers to:

  • Distribute a blank copy of an “advance care directive” to your learners. Ask them to think about how they would complete it for themselves. How would they want to be cared for at the end of their lives? What do they want done? What don’t they want done? Are they able to answer those questions? Is the answer, “it depends”?
  • How do your learners ask those questions of their patients? Do we know how to have those conversations? What if the answer is “it depends?” How can a physician still use this conversation to help plan appropriate and compassionate care?
  • Review your team’s patient list. Might any of the patients be amenable (or even appreciate?) joining your team for a discussion of how they have considered these issues?
  • Do your learners think we do a good job addressing the needs of dying patients?

Clinical Practice Points

Medical Knowledge
Patient Care

Platelet Transfusion: A Clinical Practice Guideline From the AABB

Platelet transfusions are administered to prevent or treat bleeding in patients with quantitative or qualitative platelet disorders. This guideline from AABB (formerly, the American Association of Blood Banks) makes recommendations for the transfusion of patients undergoing specific medical procedures and at specific degrees of thrombocytopenia.

Use this guideline to:

  • Start a teaching session with a multiple-choice question. We’ve provided one below.
  • Generate a differential diagnosis of thrombocytopenia in hospitalized patients with your learners.
  • Ask someone from your hematology or clinical pathology (blood bank) service to review how platelet products are collected, prepared, and ordered. What are the risks involved in their use? Is the risk for transfusion-related reactions and infection the same with the receipt of platelets and red blood cell products?
  • Review the guideline’s recommendations for platelet transfusion thresholds for central line placement, lumbar puncture, and other situations.

Medical Knowledge
Patient Care

Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older: United States, 2015

The ACIP presents the 2015 recommended immunization schedule for adults. Changes in the 2015 recommendations include the routine administration of the 13-valent pneumococcal conjugate vaccine (PCV13) in series with the 23-valent pneumococcal polysaccharide vaccine (PPSV23) for all adults aged 65 years or older.

Use this paper to:

  • Ask your learners how they review a patient’s immunizations. Are they sure their patients are up-to-date?
  • Review the recommendations for pneumococcal vaccination. Use Figure 3 and Table 2 to review when and in what sequence PCV13 and PPSV23 are recommended. Teach and provide care by reviewing each of the patients on your team’s service, or those being seen that day in clinic. Which patients should receive vaccine, and when?
  • Do your learners know the contraindications and precautions to the administration of certain vaccines noted in Table 1?

Medical Knowledge
Patient Care
In the Clinic:


This eminently practical and concise review answers key questions that your residents need to know to help their patients with perimenopausal symptoms.

Use this review to:

  • Ask your learners the differential diagnosis of abnormal uterine bleeding in perimenopausal women. When is testing indicated, and what tests should be obtained? How is it treated?
  • What effective hormonal and nonhormonal therapies are available to treat moderate to severe vasomotor symptoms? Which complementary and alternative therapies are effective?
  • When should combined hormonal contraceptives be considered? What are the risks?
  • Use the already prepared teaching slides and multiple-choice questions. Log on to enter your answers to earn CME credit.


A 48-year-old woman is evaluated in the emergency department for a severe headache that developed about 6 hours ago. She describes the headache as “the worst headache of her life,” and her family, who has accompanied her, notes she is now confused, and her speech is slurred. She has a history of myelodysplasia for which she has never required treatment, as well as poorly controlled hypertension. Medications are enalapril and amlodipine.

On physical examination, temperature is 36.4 °C (97.6 °F), blood pressure is 168/84 mm Hg, pulse rate is 66/min, and respiration rate is 18/min. The patient is confused. Her speech is slurred, and she has left-sided weakness. There is no lymphadenopathy or splenomegaly.

Laboratory studies:

Hemoglobin 10.3 g/dL (103 g/L)
Leukocyte count 4500/μL (4.5 × 109/L) with 63% neutrophils and 36% lymphocytes
Mean corpuscular volume 106 fL
Platelet count 32,000/μL (32 × 109/L)

The prothrombin time, activated partial thromboplastin time, and liver chemistry values are normal.

A CT scan of the head shows an intracerebral bleed with extravasation of blood into the ventricular system.

Which of the following is the most appropriate minimum platelet threshold for this patient?

A. 30,000/μL (30 × 109/L)
B. 50,000/μL (50 × 109/L)
C. 100,000/μL (100 × 109/L)
D. 150,000/μL (150 × 109/L)

Correct Answer
C. 100,000/μL (100 × 109/L)

Key Point
Platelet transfusion to maintain the platelet count at 100,000/μL (100 × 109/L) for the first few days after central nervous system bleeding or immediately prior to and after a planned central nervous system surgery is recommended.

Educational Objective
Manage the transfusion requirements in a patient with thrombocytopenia and intracranial hemorrhaging.

The most appropriate transfusion strategy is to maintain the platelet count at a level of 100,000/μL (100 × 109/L). This patient has life-threatening intracranial bleeding. The bleeding source is most likely due to hypertensive vasculopathy, and the patient is at risk for continued intracerebral bleeding because of her myelodysplasia-associated thrombocytopenia. Although no randomized trials exist, expert opinion and guidelines generally recommend maintaining the platelet count at a level greater than 100,000/μL (100 × 109/L) for the first few days after central nervous system bleeding or immediately prior to and after planned central nervous system surgery.

A platelet count of 30,000/μL (30 × 109/L) would not be high enough in this patient with intracranial bleeding.

A platelet count of 50,000/μL (50 × 109/L) is generally recommended for nonneurosurgical procedures or non-central nervous system bleeding, but transfusion to achieve a higher platelet count is recommended in this patient with intracranial hemorrhaging.

Guidelines do not suggest any additional benefit to maintaining a minimum platelet count greater than 100,000/μL (100 × 109/L).

Slichter SJ. Evidence-Based Platelet Transfusion Guidelines. Hematology Am Soc Hematol Educ Program. 2007:172-178. Review. PMID: 18024626

This question is derived from MKSAP® 16, the Medical Knowledge Self-Assessment Program.

From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Program Director in Internal Medicine, Thomas Jefferson University.


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