End-of-life care and bereavement: DipIMC practice questions
PHEM curriculum unit 2.13 · Theme 2: Providing Pre-hospital Emergency Medical Care
The DipIMC is blueprinted against phase 1 of the UK Pre-hospital Emergency Medicine (PHEM) curriculum. This page covers unit 2.13, Provide end-of-life care and immediate management of bereavement.
Below are 3 free practice questions from the DipIMC.Ninja bank, in the Part A single best answer format. Every answer names the textbook page, guideline or statute it was written from, so you can check it rather than take it on trust. The bank holds 11 questions on this unit.
Question 1 · Law, Ethics & Human Factors · Moderate
A district nurse calls an ambulance to a 74-year-old man with metastatic lung cancer who is in the last days of life at home. He is in severe pain, unable to swallow, and has never taken opioids. No anticipatory medicines have been prescribed and the palliative care team cannot attend for several hours. Respiratory rate 18, oxygen saturation (SpO2) 96% on air, blood pressure 98/60. Under the JRCALC end-of-life morphine guidance, which is the most appropriate initial dose and route of ambulance-service morphine?
A1 mg subcutaneously
B2.5 mg subcutaneously
C5 mg subcutaneously
D10 mg subcutaneously
E10 mg intravenously
Show answer
Answer: B
2.5 mg subcutaneously
JRCALC's end-of-life pain table makes the subcutaneous route the preferred route for pain at the end of life, given undiluted (intramuscular is an alternative). For an opioid-naive adult, or one whose opioid tolerance is unknown, the dose is 2.5 mg (0.25 ml of 10 mg in 1 ml), maximum 2.5 mg, with any repeat only on senior clinical advice. The reduced 1 mg dose is for an opioid-naive patient who also has severe respiratory compromise, which a respiratory rate of 18 with normal saturations does not represent. The 5 mg figure belongs to the oral end-of-life table, for patients who can swallow. 10 mg subcutaneously is the non-end-of-life adult subcutaneous or intramuscular dose, and 10 mg intravenously is the standard adult intravenous initial dose outside end-of-life care. Ambulance-issue morphine is used at the end of life only when the patient's own medicine has not been prescribed, is not available or has run out; discussion with a senior clinician is encouraged. In the dying phase morphine may be given with caution at a systolic pressure of 90 mmHg or less, after checking for prior opioid use.
Where this comes from
JRCALC Clinical Guidelines — Morphine sulfateJRCALC / AACE·Indications specific to adults at the end of life“Morphine sulfate — indications specific to adults at the end of life”
JRCALC Clinical Guidelines — Morphine sulfateJRCALC / AACE·Table 4, pain end of life, subcutaneous/intramuscular“Morphine sulfate — Table 4 end of life SC/IM: opioid naive row”
JRCALC Clinical Guidelines — Morphine sulfateJRCALC / AACE·Table 4, pain end of life, subcutaneous/intramuscular“Morphine sulfate — Table 4 end of life SC/IM: severe respiratory compromise row”
JRCALC Clinical Guidelines — Morphine sulfateJRCALC / AACE·Table 5, pain end of life, oral“Morphine sulfate — Table 5 end of life oral: opioid naive row”
JRCALC Clinical Guidelines — Morphine sulfateJRCALC / AACE·Tables 1 and 2, IV/IO and SC/IM (not end of life)“Morphine sulfate — Tables 1–2 (not end of life): adult ≥50 kg rows”
JRCALC Clinical Guidelines — Morphine sulfateJRCALC / AACE·End of life cautions“Morphine sulfate — end of life cautions”
law-098 · Law, Ethics & Human Factors · Medical · Moderate · v3
Question 2 · Law, Ethics & Human Factors · Hard
A 68-year-old woman receiving palliative care at home has a subcutaneous syringe driver of morphine. Her husband reports that a second driver was set up in error this morning. She is now unrousable and cyanosed, with a respiratory rate of 5 breaths per minute and a palpable pulse. Applying the JRCALC naloxone guidance for patients at the end of life, which is the most appropriate management?
AWithhold naloxone from a palliative-care patient, and ventilate her with a bag-valve-mask instead
BGive naloxone 400 micrograms intravenously, repeated every 3 minutes until she is fully awake and talking
CGive naloxone 1.8 mg by intranasal spray, repeated after 3 minutes, aiming for total opioid reversal
DGive naloxone 40 micrograms intramuscularly every 2 minutes, from 400 micrograms in 10 ml, until rate is 8
EGive naloxone 40 micrograms intravenously every 2 minutes, from 400 micrograms in 10 ml, until rate is 8
Show answer
Answer: E
Give naloxone 40 micrograms intravenously every 2 minutes, from 400 micrograms in 10 ml, until rate is 8
JRCALC says naloxone is not routinely used in palliative care, because patients on regular opioids can be physically dependent, but it is indicated where the clinician suspects opioid-induced toxicity from intentional or unintentional overdose. The aim is to reverse life-threatening respiratory depression only — a respiratory rate below 8 with the patient unconscious and/or cyanosed — not to restore full consciousness. A duplicated driver with a rate of 5 in an unrousable, cyanosed patient meets that test, so withholding naloxone is wrong. The end-of-life table directs: draw 400 micrograms into a 10 ml syringe, dilute to 10 ml with sodium chloride 0.9% (40 micrograms in 1 ml), give 40 micrograms by slow intravenous (IV) bolus, flush, and repeat every two minutes until the respiratory rate is above 8. If IV access cannot be gained the intramuscular (IM) route is used undiluted, following the standard IM table — so a diluted IM dose is wrong. The standard adult IV dose, the nasal spray, and the aim of total reversal belong to other patient groups; JRCALC reserves standard respiratory-depression dosing for a palliative patient who is not in the end stages of life.
Where this comes from
JRCALC Clinical Guidelines — Naloxone hydrochlorideJRCALC / AACE·Table 7, IV, end of life“Naloxone hydrochloride — Table 7 IV, opiate overdose (end of life)”
JRCALC Clinical Guidelines — Naloxone hydrochlorideJRCALC / AACE·Table 7, IV, end of life: IM route if no IV access“Naloxone hydrochloride — Table 7 end of life: IM route if no IV access”
JRCALC Clinical Guidelines — Naloxone hydrochlorideJRCALC / AACE·Table 2, IV, 400 micrograms in 1 ml“Naloxone hydrochloride — Table 2 IV: ≥12 years to adult row”
JRCALC Clinical Guidelines — Morphine sulfateJRCALC / AACE·Special precautions: naloxone at the end of life“Morphine sulfate — special precautions: end of life naloxone note”
law-099 · Law, Ethics & Human Factors · Medical · Hard · v3
Question 3 · Law, Ethics & Human Factors · Easy
A paramedic crew are called to a 90-year-old woman found in bed by her carer at 08:00, last seen well at 22:00. She is cold, pale and pulseless. Which of the following findings would, on its own, allow the crew to recognise life extinct and not commence resuscitation?
ABoth pupils fixed, dilated and unreactive
BNo carotid pulse for 5 minutes, no resuscitation
CDependent lividity (post-mortem staining)
DAsystole after 10 minutes of resuscitation
EA cold body, tympanic temperature of 32 °C
Show answer
Answer: C
Dependent lividity (post-mortem staining)
The Oxford Handbook (Table 1.1) lists the situations in which a paramedic may pronounce death, and dependent lividity (post-mortem staining) is one of them on its own; the ABC likewise treats a patient who is obviously and irreversibly dead, with rigor mortis, dependent lividity or putrefaction, as someone in whom resuscitation should not be started. The pulse criterion in the same table is absence of both carotid pulses for more than 15 minutes without any cardiopulmonary resuscitation, followed by at least 30 seconds of asystole — five minutes is not enough. Asystole is a reason to consider stopping only after 20 minutes of full advanced life support, and only once hypothermia, drowning, overdose or poisoning and childhood have been excluded; after ten minutes it is not. A low temperature argues for continuing, not for recognising death. RCUK Guidelines 2025 (Ethics) state that pupil reactiveness should not be used as the basis for terminating resuscitation.
Where this comes from
Oxford Handbook of Pre-Hospital Care
Ch. 1 An approach to pre-hospital care · Pronouncing death: Table 1.1 · p. 34“Dependent lividity (post-mortem staining)”
Ch. 1 An approach to pre-hospital care · Pronouncing death: Table 1.1, carotid pulse criterion · p. 34“in the absence of any CPR with at least 30 seconds of subsequent asystole”
Ch. 2 Acute medical and surgical problems · Abandoning resuscitation · p. 68“Resuscitation may be abandoned after 20 minutes of full ALS with asystole”
ABC of Prehospital Emergency Medicinep. 123Ch. 22 Cardiac Arrest · Criteria for not starting CPR“obviously and irreversibly dead (rigor mortis, dependent lividity, putrefaction)”
Ethics guidelines 2025Resuscitation Council UK, October 2025·Termination of resuscitation“pupil reactiveness should not be used as the basis for terminating resuscitation”Open at this sentence
law-101 · Law, Ethics & Human Factors · Law & Ethics · Easy · v3