DNB Palliative Medicine - Comprehensive Question Bank Answers

#!/usr/bin/env python3
"""
Generate a comprehensive DNB Palliative Medicine PDF
using ReportLab with professional formatting.
"""

import requests
import io
from PIL import Image as PILImage

from reportlab.lib.pagesizes import A4
from reportlab.lib import colors
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import cm, mm
from reportlab.lib.enums import TA_LEFT, TA_CENTER, TA_JUSTIFY
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, PageBreak, KeepTogether, Image
)
from reportlab.platypus.flowables import Flowable
from reportlab.pdfgen import canvas

# ── Colours ────────────────────────────────────────────────────────────────
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TEAL_LIGHT = colors.HexColor('#E8F4F6')
TEAL_MID   = colors.HexColor('#83C5BE')
GOLD       = colors.HexColor('#B5870B')
GOLD_LIGHT = colors.HexColor('#FFF8E7')
DARK       = colors.HexColor('#1A1A2E')
MID_GREY   = colors.HexColor('#6B7280')
LIGHT_GREY = colors.HexColor('#F3F4F6')
RED_SOFT   = colors.HexColor('#DC2626')
WHITE      = colors.white

PAGE_W, PAGE_H = A4

# ── Page template with header/footer ───────────────────────────────────────
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# ── Styles ──────────────────────────────────────────────────────────────────
base = getSampleStyleSheet()

def S(name, **kw):
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def mk_table(data, col_widths, span_header=False):
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def cell(text, bold=False, size=8.5):
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    return Paragraph(f'<font name="{style}" size="{size}">{text}</font>', styles['body'])

# ── Image loader ─────────────────────────────────────────────────────────────
def load_image_from_url(url, width=14*cm):
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        resp.raise_for_status()
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# ════════════════════════════════════════════════════════════════════════════
# CONTENT
# ════════════════════════════════════════════════════════════════════════════

def build_story():
    story = []

    # ── COVER PAGE ──────────────────────────────────────────────────────────
    story.append(Spacer(1, 3*cm))
    story.append(p('DNB PALLIATIVE MEDICINE', 'cover_title'))
    story.append(p('Comprehensive Question Bank Answers', 'cover_sub'))
    story.append(sp(8))
    story.append(HRFlowable(width='60%', thickness=2, color=TEAL, spaceAfter=8))

    cover_items = [
        'Q1 — Models of Palliative Care Delivery',
        'Q2 — Palliative Care vs Hospice Care',
        'Q3 — Palliative Prognostic Index (PPI) &amp; Palliative Prognostic Score (PaP)',
        'Q4 — Role of the Palliative Care Team',
        'Q5 — Illness Trajectories in Chronic Life-Limiting Illness',
        'Q6 — Patient-Reported Outcome Measures (PROMs)',
    ]
    for item in cover_items:
        story.append(p(f'&#8226; {item}', 'cover_sub'))
    story.append(sp(16))
    story.append(HRFlowable(width='60%', thickness=2, color=TEAL, spaceAfter=8))
    story.append(p('Sources: Harrison\'s Principles of Internal Medicine 22E · Tintinalli\'s Emergency Medicine · Rosen\'s EM · Sleisenger &amp; Fordtran\'s GI &amp; Liver Disease · Brenner &amp; Rector\'s The Kidney · Current Surgical Therapy 14E · Fuster &amp; Hurst\'s The Heart 15E · PubMed 2021–2026', 'cover_note'))
    story.append(p('July 2026', 'cover_note'))
    story.append(PageBreak())

    # ════════════════════════════════════════════════════════════════════════
    # Q1 — MODELS OF PALLIATIVE CARE DELIVERY
    # ════════════════════════════════════════════════════════════════════════
    story.append(p('QUESTION 1: Models of Palliative Care Delivery — Advantages, Disadvantages and Relevance', 'q_heading'))
    story.append(sp(4))

    story.append(p('<b>WHO Definition:</b> Palliative care is "an approach that improves quality of life of patients and their families facing problems associated with life-threatening illness, through prevention and relief of suffering by early identification and impeccable assessment and treatment of pain and other problems — physical, psychosocial and spiritual."', 'highlight'))
    story.append(sp(4))

    story.append(p('MODEL CLASSIFICATION', 'h2'))
    story.append(p('A. By Provider Level: Three-Tier Model', 'h3'))

    tier_data = [
        [cell('Level', bold=True), cell('Provider', bold=True), cell('Advantages', bold=True), cell('Disadvantages', bold=True)],
        [cell('PRIMARY\n(Generalist)'), cell('All clinicians at point of care\n(GPs, nurses, ward physicians)'),
         cell('Accessible; continuity; low cost; universal availability'),
         cell('Skill gap; burnout risk; uneven quality of care')],
        [cell('SECONDARY\n(Specialist Consultative)'), cell('Dedicated palliative care team — inpatient/outpatient consultation'),
         cell('Specialist symptom management; complex goal-setting; supports primary team'),
         cell('Limited reach; reactive referrals; may fragment care')],
        [cell('TERTIARY\n(Academic Centre)'), cell('Palliative medicine units at medical colleges/academic hospitals'),
         cell('Research & training; refractory/complex cases; protocol development'),
         cell('Highly specialised; limited geographic availability; high cost')],
    ]
    story.append(mk_table(tier_data, [2.8*cm, 4.5*cm, 4.5*cm, 4.5*cm]))
    story.append(sp(6))

    story.append(p('B. Service/Setting Models (Detailed)', 'h3'))

    models = [
        ('1. Consultative Model (Hospital-Based Inpatient)',
         'A specialist palliative care team provides consultation on request from the primary team within a hospital setting.',
         [
             '<b>Advantages:</b> Expert symptom management for complex patients; reduces LOS and ICU utilization; cost-effective (hospice saves 40% of costs in last month of life — Tintinalli\'s); supports without replacing primary team.',
             '<b>Disadvantages:</b> Reactive — often consulted very late; fragmented (not longitudinal); only 4–7% of hospitalised patients are referred from the ED (Tintinalli\'s); risk of "hand-off" perception.',
             '<b>Relevance:</b> Best for acute care hospitals — trigger criteria: LOS ≥7 days, uncontrolled symptoms, DNR conflicts, Stage IV cancer.',
         ]),
        ('2. Integrated / Concurrent Care Model',
         'Palliative care runs simultaneously alongside disease-modifying treatment from early in the illness trajectory.',
         [
             '<b>Key principle (Harrison\'s 22E):</b> "Beginning palliative care many months before death... patients will often receive palliative interventions long before they are formally diagnosed as terminally ill."',
             '<b>Advantages:</b> Earlier symptom control and goal-setting; normalises palliative care (not "giving up"); smooth transition to hospice; improves QoL and may modestly improve survival.',
             '<b>Disadvantages:</b> Resource intensive; risk of role confusion; requires culture change in curative teams.',
             '<b>Relevance:</b> Strongly supported by ASCO, ESMO, AHA/ACC. Recommended for Stage IV cancer, HF NYHA III–IV, COPD GOLD 3–4, advanced CKD.',
         ]),
        ('3. Outpatient / Ambulatory Clinic Model',
         'Dedicated palliative care clinic operating alongside oncology or subspecialty outpatient services.',
         [
             '<b>Advantages:</b> Longitudinal relationship; less stigmatising than inpatient consultation; earlier introduction; patients are still functionally independent; cost-effective.',
             '<b>Disadvantages:</b> Limited by sparse specialist workforce (major issue in India); transportation barrier for advanced disease; after-hours coverage gaps.',
         ]),
        ('4. Embedded Integration Model',
         'Palliative care clinician co-located within the oncology/cardiology department (Hui et al., Annals of Palliative Medicine).',
         [
             '<b>Advantages:</b> Face-to-face communication; rapid/same-day access; referral rates increase; saves oncologist ~170 min per referral; reduces stigma.',
             '<b>Disadvantages:</b> Difficult to embed entire IDT (space/logistics); studies mostly single discipline; unclear superiority over standalone clinic.',
         ]),
        ('5. Home-Based / Community Palliative Care Model',
         'Palliative care delivered in patients\' homes by community nurses, GPs, and specialist teams with home visits.',
         [
             '<b>Advantages:</b> Patient dies in preferred location (home); reduces ED visits and hospitalisation; caregiver empowerment; maintains dignity in familiar surroundings; most cost-effective.',
             '<b>Disadvantages:</b> Requires strong caregiver support; 24-hour coverage logistics; rural/low-income populations disadvantaged; medication supply challenges.',
         ]),
        ('6. Disease-Focused / Condition-Specific Model',
         'Integrated into disease-specific pathways — e.g., kidney supportive care, heart failure palliative care, neuropalliative care.',
         [
             '<b>Key concept (Brenner & Rector\'s Kidney):</b> The term "kidney supportive care" has replaced "kidney palliative care" because many CKD patients have high palliative needs for years before death.',
             '<b>Advantages:</b> Disease pathway integration; familiar team; reduces transition anxiety.',
             '<b>Disadvantages:</b> Siloed care; may miss psychosocial/spiritual domains; variable expertise.',
         ]),
    ]

    for title, desc, bullets in models:
        story.append(p(title, 'h3'))
        story.append(p(desc, 'body'))
        for b in bullets:
            story.append(p(f'&#8226; {b}', 'bullet'))
        story.append(sp(4))

    story.append(p('Summary Comparison Table', 'h3'))
    summary_data = [
        [cell('Model', bold=True), cell('Best For', bold=True), cell('Key Advantage', bold=True), cell('Key Limitation', bold=True)],
        [cell('Consultative (inpatient)'), cell('Complex hospital admissions'), cell('Specialist expertise'), cell('Late referrals, reactive')],
        [cell('Integrated/concurrent'), cell('Early advanced illness'), cell('Improves survival + QoL'), cell('Resource intensive')],
        [cell('Outpatient clinic'), cell('Ambulatory patients'), cell('Longitudinal, early'), cell('Access barriers')],
        [cell('Embedded'), cell('Oncology/cardiology clinics'), cell('Rapid access, co-location'), cell('Partial team only')],
        [cell('Home/community'), cell('Most advanced cancer, HF'), cell('Patient preference, cost-effective'), cell('Caregiver dependent')],
        [cell('Hospice'), cell('Dying (≤6 months)'), cell('Comfort-focused, holistic'), cell('Forfeits curative treatment')],
        [cell('Disease-specific'), cell('CKD, HF, COPD'), cell('Disease pathway integration'), cell('Siloed care')],
    ]
    story.append(mk_table(summary_data, [3.5*cm, 4*cm, 4.2*cm, 4.5*cm]))
    story.append(PageBreak())

    # ════════════════════════════════════════════════════════════════════════
    # Q2 — PALLIATIVE CARE vs HOSPICE CARE
    # ════════════════════════════════════════════════════════════════════════
    story.append(p('QUESTION 2: Palliative Care vs Hospice Care — Differences and When to Introduce Each', 'q_heading'))
    story.append(sp(4))

    story.append(p('Definitions', 'h2'))
    story.append(p('<b>Palliative Care:</b> An approach that improves quality of life of patients AND their families facing problems associated with life-threatening illness — applicable at any stage, any prognosis, concurrent with curative treatment. (WHO definition, Brenner &amp; Rector\'s The Kidney)', 'highlight'))
    story.append(sp(4))
    story.append(p('<b>Hospice Care:</b> Palliative care provided specifically to patients with an anticipated lifespan of ≤6 months, where the goal of care is entirely comfort-focused and disease-directed life-prolonging therapies are discontinued. "Hospice care recognises that dying is a normal life cycle event and seeks to neither unnecessarily hasten nor postpone death." (Sleisenger &amp; Fordtran)', 'highlight'))
    story.append(sp(6))

    story.append(p('Detailed Differences', 'h2'))
    diff_data = [
        [cell('Parameter', bold=True), cell('Palliative Care', bold=True), cell('Hospice Care', bold=True)],
        [cell('Eligibility'), cell('No specific criteria; any life-threatening illness at any stage'), cell('≤6 months prognosis if disease follows usual course')],
        [cell('Concurrent disease treatment'), cell('YES — alongside chemotherapy, dialysis, surgery'), cell('NO (Medicare model) — patient foregoes life-prolonging treatments')],
        [cell('Stage/prognosis'), cell('Any stage, any prognosis'), cell('Terminal; prognosis ≤6 months')],
        [cell('Setting'), cell('Hospital, ICU, outpatient, home, long-term care'), cell('Home (commonest), residential hospice, inpatient hospice')],
        [cell('Goal'), cell('Relieve suffering + support curative/disease-modifying goals'), cell('Comfort, dignity, quality of death')],
        [cell('Reimbursement'), cell('Via standard Medicare/Medicaid (specialty care billing)'), cell('Capitated (Medicare Hospice Benefit ~$190/day for all expenses)')],
        [cell('Team role'), cell('Consulting alongside primary team'), cell('IDT is the primary care team')],
        [cell('Duration'), cell('As long as needed'), cell('Until death; extended by recertification')],
        [cell('Key principle'), cell('Not all palliative care is hospice'), cell('All hospice care IS palliative care')],
    ]
    story.append(mk_table(diff_data, [4*cm, 6.5*cm, 6*cm]))
    story.append(sp(6))

    story.append(p('Care Transition Flowchart', 'h2'))
    flow_data = [
        ['DISEASE DIAGNOSIS'],
        ['↓'],
        ['CONCURRENT (INTEGRATED) PALLIATIVE CARE\nSymptom management · Goals of care · Psychosocial support\nRuns ALONGSIDE curative / disease-modifying treatment\nIntroduced at ANY stage of life-limiting illness'],
        ['↓  Disease progresses; prognosis ≤6 months  ↓'],
        ['HOSPICE CARE\nDisease-modifying treatment stopped or not desired\nGoal: comfort, dignity, peace\nIDT team as primary care team\nIncludes bereavement support for family post-death'],
        ['↓'],
        ['DEATH  →  BEREAVEMENT SUPPORT (13 months)'],
    ]
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               colWidths=[15*cm])
    ft.setStyle(ts)
    story.append(ft)
    story.append(sp(8))

    story.append(p('When to Introduce Palliative Care', 'h2'))
    story.append(p('<b>The Surprise Question:</b> "Would I be surprised if this patient died within 12 months?" — If NO, a palliative care consult is beneficial. Positive predictive value = 93% for identifying patients who will live longer than a year. (Current Surgical Therapy 14E)', 'highlight'))
    story.append(sp(4))

    story.append(p('Inpatient Referral Criteria (Current Surgical Therapy 14E — Table 1):', 'h3'))
    ip_criteria = [
        'Length of stay ≥7 days with no pending discharge plan',
        'Admission from long-term care facility',
        'Patient/family requests for medically ineffective (futile) care',
        'DNR order conflicts',
        'Two or more hospitalisations for same illness within 3 months',
        'Stage IV cancer (any type) or Stage III lung/pancreatic cancer',
        'Uncontrolled symptoms: pain, dyspnea, delirium, nausea, psychological distress',
        'Uncertainty regarding prognosis (patient, family, or physician)',
    ]
    for c_ in ip_criteria:
        story.append(p(f'&#8226; {c_}', 'bullet'))

    story.append(p('Outpatient Referral Criteria:', 'h3'))
    op_criteria = [
        'Progressive incurable cancer (any Stage IV)',
        'End-stage COPD/Heart failure with symptoms at rest despite maximal therapy',
        'Advanced dementia with impaired mobility and inability to communicate',
        'Advanced CKD unwilling/unable to continue dialysis',
        'ALS/MND with bulbar symptoms or ventilator dependence',
    ]
    for c_ in op_criteria:
        story.append(p(f'&#8226; {c_}', 'bullet'))

    story.append(p('When to Introduce HOSPICE Care:', 'h3'))
    story.append(p('&#8226; Physician certifies survival ≤6 months if disease follows its normal course', 'bullet'))
    story.append(p('&#8226; Goal of treatment is comfort (palliative), not curative', 'bullet'))
    story.append(p('&#8226; Patient/family willing to forgo active disease-modifying treatment', 'bullet'))
    story.append(p('&#8226; Practical indicators: PPS ≤40%; weight loss >10% over 6 months; recurrent infections; progressive dysphagia; patient goal is comfort', 'bullet'))
    story.append(PageBreak())

    # ════════════════════════════════════════════════════════════════════════
    # Q3 — PPI & PaP
    # ════════════════════════════════════════════════════════════════════════
    story.append(p('QUESTION 3: Palliative Prognostic Index (PPI) and Palliative Prognostic Score (PaP)', 'q_heading'))
    story.append(sp(4))

    story.append(p('Prognosis is one of the three pillar tasks in clinical medicine alongside diagnosis and treatment. Accurate prognostication enables appropriate clinical decision-making, anticipatory guidance, resource utilisation, symptom management, and goals-of-care planning. (PCNOW Fast Facts #124, #444)', 'body'))
    story.append(sp(4))

    # PPI
    story.append(p('A. PALLIATIVE PROGNOSTIC INDEX (PPI)', 'h2'))
    story.append(p('<b>Development:</b> Morita et al., 1999 (Japan) — terminally ill cancer patients in a palliative care unit.', 'body'))
    story.append(p('<b>Key feature:</b> Uses 5 clinically observable variables; requires NO laboratory tests — ideal for home, hospice, and resource-limited settings.', 'body'))
    story.append(sp(4))

    story.append(p('PPI Scoring Table', 'h3'))
    ppi_data = [
        [cell('Variable', bold=True), cell('Finding', bold=True), cell('Score', bold=True)],
        [cell('Palliative Performance Scale (PPS)', bold=True), cell('10–20%'), cell('4.0')],
        [cell(''), cell('30–50%'), cell('2.5')],
        [cell(''), cell('≥60%'), cell('0')],
        [cell('Oral Intake', bold=True), cell('Severely reduced (≤mouthfuls)'), cell('2.5')],
        [cell(''), cell('Moderately reduced (>mouthfuls, reduced)'), cell('1.0')],
        [cell(''), cell('Normal'), cell('0')],
        [cell('Oedema', bold=True), cell('Present'), cell('1.0')],
        [cell(''), cell('Absent'), cell('0')],
        [cell('Dyspnoea at Rest', bold=True), cell('Present'), cell('3.5')],
        [cell(''), cell('Absent'), cell('0')],
        [cell('Delirium', bold=True), cell('Present'), cell('4.0')],
        [cell(''), cell('Absent'), cell('0')],
        [cell('TOTAL', bold=True), cell('Maximum'), cell('15')],
    ]
    ppi_t = Table(ppi_data, colWidths=[5.5*cm, 8*cm, 2.5*cm])
    ppi_ts = TableStyle([
        ('BACKGROUND', (0,0), (-1,0), TEAL),
        ('TEXTCOLOR', (0,0), (-1,0), WHITE),
        ('FONTNAME', (0,0), (-1,0), 'Helvetica-Bold'),
        ('FONTSIZE', (0,0), (-1,-1), 8.5),
        ('ROWBACKGROUNDS', (0,1), (-1,-2), [WHITE, LIGHT_GREY]),
        ('BACKGROUND', (0,-1), (-1,-1), TEAL_LIGHT),
        ('FONTNAME', (0,-1), (-1,-1), 'Helvetica-Bold'),
        ('GRID', (0,0), (-1,-1), 0.3, TEAL_MID),
        ('ALIGN', (2,0), (2,-1), 'CENTER'),
        ('VALIGN', (0,0), (-1,-1), 'MIDDLE'),
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        ('BOTTOMPADDING', (0,0), (-1,-1), 4),
        ('LEFTPADDING', (0,0), (-1,-1), 5),
    ])
    ppi_t.setStyle(ppi_ts)
    story.append(ppi_t)
    story.append(sp(6))

    story.append(p('PPI Interpretation', 'h3'))
    interp_data = [
        [cell('PPI Score', bold=True), cell('Predicted Survival', bold=True), cell('Sensitivity', bold=True), cell('Specificity', bold=True)],
        [cell('≤2'), cell('Median 155 days (>6 weeks)'), cell('—'), cell('—')],
        [cell('>2 to ≤4'), cell('Median 89 days (~6 weeks)'), cell('—'), cell('—')],
        [cell('>4 to ≤6'), cell('Median 18–21 days (<6 weeks)'), cell('80%'), cell('77%')],
        [cell('>6 ★', bold=True), cell('Median 5 days (<3 weeks)', bold=True), cell('80%'), cell('85%')],
    ]
    story.append(mk_table(interp_data, [3*cm, 6*cm, 3*cm, 3*cm]))
    story.append(p('★ PPI >6 is the most clinically useful threshold for hospice admission and goals-of-care decisions.', 'ref'))
    story.append(sp(4))

    story.append(p('<b>2023 Meta-Analysis (PMID 37310019, Palliat Med):</b> 39 studies, n=19,714 patients. PPI >6 best for &lt;3-week prediction (sensitivity 68%, specificity 80%). PPI >4 best for &lt;6-week prediction. PPI performs comparably to clinician gestalt for &lt;30-day survival. Does NOT require blood tests — advantage over PaP.', 'highlight'))
    story.append(sp(8))

    # PaP
    story.append(p('B. PALLIATIVE PROGNOSTIC SCORE (PaP Score)', 'h2'))
    story.append(p('<b>Development:</b> Pirovano et al., 1999 (Italy) — multi-centre prospective study in cancer patients.', 'body'))
    story.append(p('<b>Key feature:</b> Uniquely incorporates the clinician\'s subjective Clinical Prediction of Survival (CPS) as a major weighted component. Requires full blood count (CBC).', 'body'))
    story.append(sp(4))

    story.append(p('PaP Scoring Table', 'h3'))
    pap_data = [
        [cell('Variable', bold=True), cell('Finding', bold=True), cell('Score', bold=True)],
        [cell('Dyspnoea', bold=True), cell('No'), cell('0')],
        [cell(''), cell('Yes'), cell('1.0')],
        [cell('Anorexia', bold=True), cell('No'), cell('0')],
        [cell(''), cell('Yes'), cell('1.5')],
        [cell('Karnofsky Performance Score', bold=True), cell('≥30'), cell('0')],
        [cell(''), cell('≤20'), cell('2.5')],
        [cell('Clinical Prediction of Survival (CPS)', bold=True), cell('>12 weeks'), cell('0')],
        [cell(''), cell('11–12 weeks'), cell('2.0')],
        [cell(''), cell('9–10 weeks'), cell('2.5')],
        [cell(''), cell('7–8 weeks'), cell('2.5')],
        [cell(''), cell('5–6 weeks'), cell('4.5')],
        [cell(''), cell('3–4 weeks'), cell('6.0')],
        [cell(''), cell('1–2 weeks'), cell('8.5')],
        [cell('Total White Blood Count', bold=True), cell('Normal (≤8,500/mm³)'), cell('0')],
        [cell(''), cell('High (8,501–11,000)'), cell('0.5')],
        [cell(''), cell('Very high (>11,000)'), cell('1.5')],
        [cell('Lymphocyte %', bold=True), cell('Normal (20–40%)'), cell('0')],
        [cell(''), cell('Low (12–19.9%)'), cell('1.0')],
        [cell(''), cell('Very low (<12%)'), cell('2.5')],
        [cell('TOTAL', bold=True), cell('Maximum (D-PaP = 19.5 if delirium present)'), cell('17.5')],
    ]
    pap_t = Table(pap_data, colWidths=[5.5*cm, 8*cm, 2.5*cm])
    pap_t.setStyle(ppi_ts)
    story.append(pap_t)
    story.append(sp(6))

    story.append(p('PaP Interpretation — 30-Day Survival Probability Groups', 'h3'))
    pap_grp = [
        [cell('Group', bold=True), cell('PaP Score', bold=True), cell('30-Day Survival Probability', bold=True)],
        [cell('A (Good)'), cell('0 – 5.5'), cell('>70%')],
        [cell('B (Intermediate)'), cell('5.6 – 11'), cell('30 – 70%')],
        [cell('C (Poor)'), cell('>11'), cell('<30%  →  Consider hospice')],
    ]
    story.append(mk_table(pap_grp, [3*cm, 4*cm, 9.2*cm]))
    story.append(sp(6))

    story.append(p('PPI vs PaP — Comparison Table', 'h2'))
    comp_data = [
        [cell('Feature', bold=True), cell('PPI', bold=True), cell('PaP', bold=True)],
        [cell('Variables'), cell('5 (clinical only)'), cell('6 (includes labs + clinician CPS)')],
        [cell('Lab tests required'), cell('No ✓'), cell('Yes (CBC required)')],
        [cell('Clinician gestalt (CPS)'), cell('No'), cell('Yes — core weighted component')],
        [cell('Prognosis provided'), cell('Categorical (<3 wks, <6 wks)'), cell('30-day probability (3 groups A/B/C)')],
        [cell('Maximum score'), cell('15'), cell('17.5 (D-PaP: 19.5 with delirium)')],
        [cell('Setting feasibility'), cell('Home, inpatient, hospice'), cell('Inpatient, outpatient (needs CBC)')],
        [cell('Validated population'), cell('Cancer (primary)'), cell('Cancer + limited non-cancer data')],
        [cell('Key study'), cell('PMID 37310019 (2023 meta, 39 studies, n=19,714)'), cell('Large prospective validation (Pirovano 1999 + subsequent studies)')],
    ]
    story.append(mk_table(comp_data, [4.5*cm, 5.5*cm, 6.2*cm]))
    story.append(sp(6))

    story.append(p('Clinical Application Flowchart', 'h3'))
    prog_flow = [
        ['Patient with advanced life-limiting illness — Need prognostic estimation?'],
        ['CBC available? / Inpatient / Outpatient        CBC NOT available / Home / Hospice'],
        ['         PaP Score                                        PPI Score'],
        ['   (30-day survival probability)              (Categorical: weeks to live)'],
        ['         Groups A / B / C                           PPI ≤2 / 2–4 / 4–6 / >6'],
        ['Goals of care discussion · Hospice referral · Family meeting · Advance care planning'],
    ]
    pf = Table(
        [[Paragraph(r[0], ParagraphStyle('pf', fontName='Helvetica', fontSize=9, alignment=TA_CENTER, leading=13))] for r in prog_flow],
        colWidths=[16*cm]
    )
    pf.setStyle(TableStyle([
        ('BACKGROUND', (0,0), (-1,0), TEAL),
        ('TEXTCOLOR', (0,0), (-1,0), WHITE),
        ('FONTNAME', (0,0), (-1,0), 'Helvetica-Bold'),
        ('BACKGROUND', (0,-1), (-1,-1), TEAL_LIGHT),
        ('FONTNAME', (0,-1), (-1,-1), 'Helvetica-Bold'),
        ('ROWBACKGROUNDS', (0,1), (-1,-2), [WHITE, LIGHT_GREY]),
        ('GRID', (0,0), (-1,-1), 0.5, TEAL_MID),
        ('TOPPADDING', (0,0), (-1,-1), 7),
        ('BOTTOMPADDING', (0,0), (-1,-1), 7),
    ]))
    story.append(pf)
    story.append(PageBreak())

    # ════════════════════════════════════════════════════════════════════════
    # Q4 — PALLIATIVE CARE TEAM
    # ════════════════════════════════════════════════════════════════════════
    story.append(p('QUESTION 4: Role of the Palliative Care Team — Key Members and Collaboration', 'q_heading'))
    story.append(sp(4))

    story.append(p('"Quality care near the end of life for complex physical and psychological problems cannot be provided by a single clinician. Care is ideally provided by an interdisciplinary team that includes physicians, nurses, social workers, chaplains, and bereavement counsellors. The interdisciplinary palliative care team works in concert with, and does not seek to replace, the primary medical team." — Sleisenger &amp; Fordtran\'s GI &amp; Liver Disease', 'highlight'))
    story.append(sp(6))

    story.append(p('Key Team Members and Their Roles', 'h2'))

    team_data = [
        [cell('Team Member', bold=True), cell('Core Responsibilities', bold=True), cell('Key Tools / Assessments', bold=True)],
        [cell('Palliative Care\nPhysician', bold=True),
         cell('Diagnosis, prognosis, prescribing (opioids, co-analgesics, anti-emetics, anxiolytics); goals-of-care conversations; advance care planning; IDT meeting leadership'),
         cell('ESAS-r, MSAS, PHQ-9, GAD-7, PPI/PaP, SPIKES, Serious Illness Conversation Guide')],
        [cell('Palliative Care\nNurse / NP', bold=True),
         cell('Daily symptom assessment; titration of medications; syringe driver management; wound care; patient and family education; night/weekend on-call; care transitions. In CONNECT trial (PMID 34515737), nurse-led primary PC significantly improved outcomes.'),
         cell('Edmonton Symptom Assessment Scale (ESAS-r); functional assessment; medication administration records')],
        [cell('Social Worker', bold=True),
         cell('Psychosocial assessment; financial navigation; family meeting facilitation; caregiver burden assessment; respite planning; community resource coordination (transport, meals, housing)'),
         cell('Zarit Burden Interview (ZBI); PHQ-9 for carers; social history; genogram')],
        [cell('Chaplain /\nSpiritual Care\nProvider', bold=True),
         cell('Assess spiritual distress; support meaning-making, legacy, reconciliation, forgiveness; rituals across religious and non-religious backgrounds; distinct from psychological support'),
         cell('FICA spiritual assessment; HOPE questions; faith history')],
        [cell('Bereavement\nCounsellor', bold=True),
         cell('Structured bereavement follow-up post-death (typically 13 months); identifies complicated grief requiring psychiatric referral; family support begins before death'),
         cell('Texas Revised Inventory of Grief; PHQ-9/GAD-7 for bereaved family')],
        [cell('Pharmacist', bold=True),
         cell('Medication reconciliation and deprescribing (stopping futile medications); opioid dose optimisation and rotation; drug interaction checks; palliative sedation protocols'),
         cell('Opioid equivalence tables; Beers criteria; polypharmacy review')],
        [cell('Physiotherapist /\nOT', bold=True),
         cell('Preserve function as long as possible; fatigue management; assistive devices; home environment adaptation for safety; breathlessness management techniques'),
         cell('Barthel Index; IADL assessment; home visit checklist')],
    ]
    story.append(mk_table(team_data, [3.5*cm, 7.5*cm, 5.2*cm]))
    story.append(sp(8))

    story.append(p('How the Team Collaborates to Improve Outcomes', 'h2'))

    collab_items = [
        ('1. Regular Interdisciplinary Team (IDT) Meetings',
         'All members discuss each patient; shared formulation of care plan. In ICU settings: structured palliative care intervention + interdisciplinary family meeting within 72 hours improves outcomes (Miller\'s Anesthesia 10E). Meeting typically weekly; more frequent for complex/rapidly changing cases.'),
        ('2. Shared Documentation',
         'Single, unified care plan visible to all disciplines. Prevents duplication and communication errors. Allows any team member to update goals and symptom burden in real time.'),
        ('3. Communication Frameworks',
         'SPIKES: Set up - Perception - Invitation - Knowledge - Emotions - Summary. Serious Illness Conversation Guide. GUIDE, BREAKS, SHARE frameworks. Used in family meetings with all relevant team members present (Harrison\'s 22E).'),
        ('4. Goals of Care Process (7-step protocol — Harrison\'s 22E)',
         '(1) Ensure medical information is complete and understood; (2) Explore what patient/family hopes for; (3) Share all options; (4) Respond empathetically to emotions; (5) Make a recommendation based on goals; (6) Establish a concrete plan; (7) Follow up and reassess goals continuously.'),
        ('5. Outcome Metrics for Team Performance',
         'Pain and symptom scores (ESAS-r); days at home vs. hospital; patient satisfaction scores; family satisfaction scores; bereavement outcomes; PPS trajectory over time. Stepped palliative care (JAMA 2024, PMID 38824442): tiered IDT intervention showed equivalent outcomes with reduced specialist burden.'),
    ]
    for title, desc in collab_items:
        story.append(p(title, 'h3'))
        story.append(p(desc, 'body'))
        story.append(sp(4))

    story.append(PageBreak())

    # ════════════════════════════════════════════════════════════════════════
    # Q5 — ILLNESS TRAJECTORIES
    # ════════════════════════════════════════════════════════════════════════
    story.append(p('QUESTION 5: Illness Trajectories in Chronic Life-Limiting Illness', 'q_heading'))
    story.append(sp(4))

    story.append(p('The concept of illness trajectories was described by Lunney, Lynn, and Hogan (J Am Geriatr Soc, 2002) and is central to prognostication and palliative care planning in all chronic life-limiting illnesses.', 'body'))
    story.append(sp(4))

    # Insert the trajectory image
    story.append(p('Fig. 1 — Four Theoretic Trajectories of Dying (Lunney JR, Lynn J, Hogan C, 2002)', 'h3'))
    trajectory_img = load_image_from_url(
        'https://cdn.orris.care/cdss_images/fb161cff38ca843df17f5e35777c0298081e9ddf52862be1753306cc0840d5c2.png',
        width=14*cm
    )
    story.append(trajectory_img)
    story.append(p('Source: Rosen\'s Emergency Medicine — Concepts and Clinical Practice. From: Lunney JR, Lynn J, Hogan C. Profiles of older Medicare decedents. J Am Geriatr Soc. 2002;50:1108–1112.', 'caption'))
    story.append(sp(8))

    trajectories = [
        {
            'num': '1', 'name': 'SUDDEN DEATH (~15% of deaths)',
            'pattern': 'High function maintained until abrupt catastrophic event, then immediate death. No preceding decline.',
            'colour': TEAL,
            'examples': ['Massive myocardial infarction (VF/VT arrest)', 'Massive pulmonary embolism', 'Severe polytrauma (road traffic accident)', 'Spontaneous subarachnoid haemorrhage', 'Sudden cardiac arrest'],
            'pc_implications': [
                'No opportunity for advance care planning at the terminal event itself',
                'Palliative care focuses on resuscitation decisions, ICU withdrawal protocols, family support post-death',
                'Preventive advance directives (DNAR, living will) are critically important for high-risk patients',
                'Bereavement support for families — sudden loss = high complicated grief risk',
                'Palliative care may play a role in ICU if patient survives initial event but has non-survivable injury',
            ]
        },
        {
            'num': '2', 'name': 'TERMINAL ILLNESS / CANCER TRAJECTORY (~25–30%)',
            'pattern': 'Reasonably good function maintained for months to years, followed by a relatively brief period of accelerating decline close to death. "Patients with cancer may remain independent and functional for some time but often experience a significant decline in overall health as death nears." (Rosen\'s EM)',
            'colour': colors.HexColor('#0D7377'),
            'examples': ['Metastatic solid organ carcinomas (lung, colorectal, breast, pancreatic)', 'Haematological malignancies (multiple myeloma, AML)', 'Stage IV cancer of any type', 'Advanced hepatocellular carcinoma'],
            'pc_implications': [
                'Clear window for advance care planning while patient is still functional and has decision-making capacity',
                'Palliative Performance Scale (PPS) most studied prognostic tool in this trajectory',
                'Integrated palliative care from time of cancer diagnosis; transition to hospice in final weeks',
                'PPI and PaP most validated in this trajectory',
                'Early palliative care improves QoL AND modestly improves survival (Temel, NEJM 2010; PMID 38824442)',
                'WHO analgesic ladder most applicable — step up pain management as disease progresses',
            ]
        },
        {
            'num': '3', 'name': 'ORGAN FAILURE TRAJECTORY (~25–30%)',
            'pattern': 'Background of declining function punctuated by acute exacerbations (some requiring hospitalisation), partial recovery with each episode, but each peak lower than the last. Prognosis unpredictable; death may occur during any exacerbation.',
            'colour': colors.HexColor('#B45309'),
            'examples': ['Chronic Heart Failure (HF) — repeated decompensations (Fuster & Hurst: "palliative care can be initiated at any point in the illness trajectory")', 'COPD with acute exacerbations requiring ICU admission', 'Cirrhosis with repeated variceal bleeds, HE, SBP', 'End-stage renal disease (CKD 5D)', 'Advanced HIV/AIDS'],
            'pc_implications': [
                'DIFFICULT timing — patient may appear well between exacerbations; clinicians hesitant to label as "dying"',
                'Each acute episode seems treatable — leads to over-aggressive, under-palliative care',
                'Surprise question is particularly useful in this trajectory',
                'Parallel planning: treat acute exacerbation AND prepare for possibility of death in same admission',
                'Implanted devices (ICD, LVAD) — deactivation planning MUST be part of advance care planning',
                'ESC 2021 and AHA/ACC/HFSA 2022 HF guidelines both recommend early palliative care in NYHA III–IV',
                'For CKD: "Kidney supportive care" provided throughout illness trajectory, not only terminally (Brenner & Rector)',
            ]
        },
        {
            'num': '4', 'name': 'FRAILTY / DEMENTIA TRAJECTORY (~25–30%)',
            'pattern': 'Prolonged period of low but relatively stable function, with very slow gradual decline over months to years. Each intercurrent illness causes a small but often irreversible drop in function. No single dramatic decline; death appears almost imperceptible.',
            'colour': colors.HexColor('#6B21A8'),
            'examples': ['Advanced dementia (Alzheimer\'s disease, Lewy body dementia)', 'Frailty syndrome in the elderly (polypharmacy, sarcopenia, recurrent falls)', 'Advanced Parkinson\'s disease', 'Progressive neurodegenerative diseases (ALS/MND, Huntington\'s)', 'Severe malnutrition/cachexia in the elderly'],
            'pc_implications': [
                'Advance directives ESSENTIAL — patient loses decision-making capacity progressively over time',
                'Feeding decisions: PEG tube insertion in advanced dementia is NOT beneficial (evidence shows increased aspiration and no survival benefit)',
                'Surrogate decision-makers (family) require extensive support, education, and regular family meetings',
                'Hospitalisation is often inappropriate for terminal events (pneumonia in severe dementia) — goals: comfort at home/care home',
                'FAST scale (Functional Assessment Staging Test) for dementia staging and hospice eligibility',
                'Chang et al. 2025 (JAMA Netw Open, PMID 40366652): defined referral criteria for specialist palliative care in dementia',
                '"Advanced dementia — Impaired mobility and inability to communicate health needs" = indication for palliative care (Tintinalli\'s)',
            ]
        },
    ]

    for traj in trajectories:
        story.append(p(f"Trajectory {traj['num']}: {traj['name']}", 'h2'))
        story.append(p(f"<b>Pattern:</b> {traj['pattern']}", 'body'))
        story.append(p('<b>Clinical Examples:</b>', 'h4'))
        for ex in traj['examples']:
            story.append(p(f'&#8226; {ex}', 'bullet'))
        story.append(p('<b>Palliative Care Implications:</b>', 'h4'))
        for imp in traj['pc_implications']:
            story.append(p(f'&#8226; {imp}', 'bullet'))
        story.append(sp(6))

    story.append(p('Trajectory Summary Comparison Table', 'h2'))
    traj_sum = [
        [cell('Trajectory', bold=True), cell('Pattern', bold=True), cell('Examples', bold=True), cell('Key Challenge', bold=True), cell('PC Timing', bold=True)],
        [cell('Sudden death'), cell('Abrupt — no warning'), cell('MI, Trauma, PE'), cell('No advance warning'), cell('Advance directives; bereavement support')],
        [cell('Terminal illness\n(Cancer)'), cell('Good function then rapid decline'), cell('Solid tumours, haematologic malignancy'), cell('Transition timing'), cell('From diagnosis; hospice in final weeks')],
        [cell('Organ failure'), cell('Episodic; partial recovery; each peak lower'), cell('CHF, COPD, CKD, Cirrhosis'), cell('Unpredictable; clinician hesitance'), cell('Early; parallel planning')],
        [cell('Frailty/Dementia'), cell('Prolonged low function; slow decline'), cell('Dementia, Frailty, ALS'), cell('Capacity loss; surrogate decisions'), cell('Early; surrogate engagement; ADs')],
    ]
    story.append(mk_table(traj_sum, [3*cm, 4*cm, 3.8*cm, 3.5*cm, 4*cm]))
    story.append(PageBreak())

    # ════════════════════════════════════════════════════════════════════════
    # Q6 — PROMs
    # ════════════════════════════════════════════════════════════════════════
    story.append(p('QUESTION 6: Role of Patient-Reported Outcome Measures (PROMs) in Continuum of Care', 'q_heading'))
    story.append(sp(4))

    story.append(p('<b>Definition:</b> A Patient-Reported Outcome Measure (PROM) is "any report of the status of a patient\'s health condition that comes directly from the patient, without interpretation of the patient\'s response by a clinician or anyone else." (FDA Guidance for Industry)', 'highlight'))
    story.append(p('<b>Key principle:</b> PROMs capture outcomes important to <i>patients</i> rather than to healthcare providers. In palliative care, where the goal is symptom relief and quality of life — not tumour response or biomarker normalisation — PROMs are the most clinically relevant measures available. (Bailey &amp; Love\'s Short Practice of Surgery 28E; Harrison\'s 22E)', 'body'))
    story.append(sp(6))

    story.append(p('Key PROMs Used in Palliative Care', 'h2'))
    prom_data = [
        [cell('PROM', bold=True), cell('Full Name', bold=True), cell('Domains', bold=True), cell('Use', bold=True)],
        [cell('ESAS-r'), cell('Revised Edmonton Symptom Assessment Scale'), cell('10 symptoms: pain, fatigue, nausea, depression, anxiety, drowsiness, dyspnoea, appetite, wellbeing, others'), cell('Daily / clinic symptom monitoring; serial tracking')],
        [cell('MSAS (condensed)'), cell('Memorial Symptom Assessment Scale'), cell('Symptom frequency, severity, distress'), cell('Comprehensive symptom burden assessment')],
        [cell('PROMIS'), cell('Patient-Reported Outcomes Measurement Information System (NIH)'), cell('Physical function, fatigue, pain, social health, mental health'), cell('Research; cross-disease comparison')],
        [cell('IPOS'), cell('Integrated Palliative care Outcome Scale'), cell('10 physical + emotional + communication items'), cell('Validated across settings — cancer and non-cancer')],
        [cell('PaO / POS'), cell('Palliative care Outcomes Scale'), cell('10 items: symptoms, family anxiety, practical concerns'), cell('Routine clinical use in palliative care')],
        [cell('PHQ-9'), cell('Patient Health Questionnaire-9'), cell('Depression screening (9 items)'), cell('Psychological domain assessment')],
        [cell('GAD-7'), cell('Generalised Anxiety Disorder 7'), cell('Anxiety (7 items)'), cell('Psychological domain assessment')],
        [cell('FACT-G'), cell('Functional Assessment of Cancer Therapy — General'), cell('Physical, social/family, emotional, functional wellbeing'), cell('Oncology quality of life')],
        [cell('ZBI'), cell('Zarit Burden Inventory'), cell('Caregiver burden (22 items)'), cell('Family/caregiver assessment; bereavement risk')],
    ]
    story.append(mk_table(prom_data, [2.5*cm, 4*cm, 5*cm, 4.7*cm]))
    story.append(p('Harrison\'s 22E (2025) explicitly lists ESAS-r, MSAS, PROMIS, Rotterdam Symptom Checklist, Symptom Distress Scale, MD Anderson Brief Symptom Inventory, and ISAAC tool as validated instruments for palliative care assessment.', 'ref'))
    story.append(sp(6))

    story.append(p('Role of PROMs Across the Care Continuum', 'h2'))

    prom_phases = [
        ('EARLY PHASE — Baseline PROM Assessment', TEAL_LIGHT,
         ['Establish pre-treatment symptom baseline (ESAS-r, PROMIS)',
          'Identifies unmet needs early: depression, fatigue, anxiety before treatment starts',
          'Triggers early palliative care referral when symptom burden is high',
          'Establishes patient\'s personal goals and values while patient is fully competent']),
        ('TREATMENT / DISEASE-MODIFYING PHASE — Serial PROM Monitoring', LIGHT_GREY,
         ['Detect treatment-related symptom burden (chemotoxicity, radiotherapy mucositis)',
          'Compare symptom burden with expected trajectory; identify outliers',
          'Inform dose modifications and supportive care needs',
          'CONNECT RCT (PMID 34515737, JAMA Intern Med 2021): nurse-led PROM-guided palliative care improved outcomes in advanced cancer patients']),
        ('ADVANCED / PALLIATIVE PHASE — Goal-Directed PROM Use', TEAL_LIGHT,
         ['Align PROMs with patient\'s personal goals of care (not clinician-defined endpoints)',
          'Daily ESAS-r to monitor symptom control; guide opioid titration and anti-emetic choice',
          'IPOS for holistic assessment covering physical, emotional, and communication domains',
          'Stepped palliative care (JAMA 2024, PMID 38824442): PROM-guided stepped interventions showed equivalent outcomes with reduced specialist burden']),
        ('END-OF-LIFE / HOSPICE PHASE — Comfort-Focused PROMs', LIGHT_GREY,
         ['Simplified instruments (2–3 item tools) due to cognitive decline and fatigue',
          'Proxy PROMs (family-reported) when patient cannot self-report',
          'Measure: pain at rest, dyspnoea, agitation, mouth care adequacy',
          'After death: Family-reported satisfaction with quality of dying and care']),
        ('BEREAVEMENT PHASE — Family/Caregiver PROMs', TEAL_LIGHT,
         ['Caregiver burden (ZBI) assessed during illness AND post-death',
          'PHQ-9/GAD-7 for family members at risk of complicated grief',
          'Structured bereavement follow-up at 1, 3, 6, and 13 months',
          'Identifies need for specialist psychiatric referral for complicated grief disorder']),
    ]

    for phase_title, bg_colour, items in prom_phases:
        phase_rows = [[Paragraph(phase_title, ParagraphStyle('ph', fontName='Helvetica-Bold', fontSize=9.5, textColor=DARK, leading=13))]]
        for item in items:
            phase_rows.append([Paragraph(f'&#8226; {item}', ParagraphStyle('pi', fontName='Helvetica', fontSize=9, textColor=DARK, leading=12, leftIndent=12))])
        pt = Table(phase_rows, colWidths=[16*cm])
        pt.setStyle(TableStyle([
            ('BACKGROUND', (0,0), (-1,0), bg_colour if bg_colour != LIGHT_GREY else TEAL),
            ('TEXTCOLOR', (0,0), (-1,0), DARK if bg_colour != TEAL else WHITE),
            ('TEXTCOLOR', (0,0), (-1,0), WHITE if bg_colour == TEAL else DARK),
            ('BACKGROUND', (0,1), (-1,-1), bg_colour),
            ('TOPPADDING', (0,0), (-1,-1), 5),
            ('BOTTOMPADDING', (0,0), (-1,-1), 5),
            ('LEFTPADDING', (0,0), (-1,-1), 8),
            ('BOX', (0,0), (-1,-1), 0.5, TEAL_MID),
            ('INNERGRID', (0,0), (-1,-1), 0.3, TEAL_MID),
        ]))
        story.append(pt)
        story.append(sp(4))

    story.append(sp(4))
    story.append(p('Benefits and Limitations of PROMs in Palliative Care', 'h2'))

    ben_lim = [
        [cell('Benefits', bold=True), cell('Limitations', bold=True)],
        [cell('Improved symptom detection — patients disclose in questionnaires what they might not mention verbally (depression, existential distress, sexual concerns)'),
         cell('Cognitive impairment/delirium limits self-reporting in final weeks of life')],
        [cell('Objective monitoring of whether palliative interventions are working'),
         cell('Questionnaire burden in very ill patients with fatigue or dyspnoea')],
        [cell('Facilitates communication — PRO data displayed in clinic creates structured opening for difficult conversations'),
         cell('Response shift — patients adapt expectations downwards, altering PROM scores over time')],
        [cell('Enables research and quality improvement — standardised comparison across institutions'),
         cell('Cultural and literacy barriers — especially significant in Indian context (multiple languages, low literacy)')],
        [cell('FDA increasingly requires PROMs as primary endpoints in palliative drug trials (regulatory role)'),
         cell('Proxy respondents (family) may not accurately reflect patient experience')],
        [cell('ePROMs: real-time symptom reporting between visits; triggers nurse alerts for deteriorating symptoms (PMID 38812853)'),
         cell('Digital divide: older/rural patients cannot access electronic systems; EMR integration challenges')],
        [cell('Empowers patients — gives patients a voice; aligns care with patient priorities'),
         cell('Not all PROMs validated across cultures and translated into regional languages')],
    ]
    t = Table(ben_lim, colWidths=[8*cm, 8.2*cm])
    t.setStyle(TableStyle([
        ('BACKGROUND', (0,0), (-1,0), TEAL),
        ('TEXTCOLOR', (0,0), (-1,0), WHITE),
        ('FONTNAME', (0,0), (-1,0), 'Helvetica-Bold'),
        ('FONTSIZE', (0,0), (-1,-1), 8.5),
        ('ROWBACKGROUNDS', (0,1), (-1,-1), [WHITE, LIGHT_GREY]),
        ('GRID', (0,0), (-1,-1), 0.3, TEAL_MID),
        ('VALIGN', (0,0), (-1,-1), 'TOP'),
        ('TOPPADDING', (0,0), (-1,-1), 5),
        ('BOTTOMPADDING', (0,0), (-1,-1), 5),
        ('LEFTPADDING', (0,0), (-1,-1), 5),
    ]))
    story.append(t)
    story.append(sp(8))

    # ── References page ──────────────────────────────────────────────────────
    story.append(PageBreak())
    story.append(p('KEY REFERENCES AND EVIDENCE BASE', 'q_heading'))
    story.append(sp(6))

    refs = [
        ('Harrison\'s Principles of Internal Medicine 22E (2025, McGraw Hill)', 'End-of-Life and Palliative Care, Assessment and Care Planning, Communication Frameworks, PROM instruments'),
        ('Tintinalli\'s Emergency Medicine — A Comprehensive Study', 'Palliative Care in the ED; Functional Decline; Prognosis; Palliative Prognostic Score; Identifying patients for PC'),
        ('Rosen\'s Emergency Medicine — Concepts and Clinical Practice', 'End-of-Life Trajectories and Prognostication; Illness Trajectory Figure (Lunney/Lynn/Hogan 2002)'),
        ('Sleisenger & Fordtran\'s GI & Liver Disease', 'Hospice vs Palliative Care; IDT team definition; Goals of Care; Exploring Patient Goals'),
        ('Brenner & Rector\'s The Kidney, 2-Volume Set', 'Kidney Supportive Care; Illness trajectory in CKD; Conservative kidney management'),
        ('Current Surgical Therapy 14E', 'Differences between PC and hospice; Specialist PC measures; Referral criteria; Surprise question'),
        ('Fuster & Hurst\'s The Heart 15E', 'Palliative Care in Advanced Heart Failure; illness trajectory for organ failure'),
        ('Miller\'s Anesthesia 10E', 'Palliative care in ICU; interdisciplinary family meeting evidence; Pediatric palliative care'),
        ('PMID 37310019 (2023)', 'Yoong et al. — PPI systematic review and meta-analysis (39 studies, n=19,714). Palliat Med 2023.'),
        ('PMID 34515737 (2021)', 'Schenker et al. — CONNECT RCT: nurse-led primary palliative care in advanced cancer. JAMA Intern Med 2021.'),
        ('PMID 38824442 (2024)', 'Temel et al. — Stepped Palliative Care for Advanced Lung Cancer. JAMA 2024.'),
        ('PMID 40366652 (2025)', 'Chang et al. — Referral criteria for specialist palliative care in dementia. JAMA Netw Open 2025.'),
        ('PMID 38812853 (2024)', 'Salmani et al. — Advantages/disadvantages of ePROM systems in cancer. Digit Health 2024.'),
        ('PMID 33096217 (2021)', 'Yoon et al. — Accuracy of PaP score with/without clinician prediction. J Pain Symptom Manage 2021.'),
        ('PCNOW Fast Facts #124, #444', 'Palliative Prognostic Score (PaP) and Palliative Prognostic Index (PPI). Palliative Care Network of Wisconsin.'),
        ('Lunney JR, Lynn J, Hogan C. 2002', 'Profiles of older Medicare decedents — 4 illness trajectories. J Am Geriatr Soc 2002;50:1108–1112.'),
        ('Hui et al. Ann Palliat Med', 'Models of integration of oncology and palliative care — solo, congress, integrated, embedded models.'),
    ]

    ref_data = [[cell('Source', bold=True), cell('Topic Covered', bold=True)]]
    for source, topic in refs:
        ref_data.append([cell(source), cell(topic)])
    story.append(mk_table(ref_data, [7.5*cm, 8.7*cm]))

    return story


# ── Build PDF ─────────────────────────────────────────────────────────────────
output_path = '/tmp/workspace/palliative-care-pdf/DNB_Palliative_Medicine_QBank.pdf'

doc = SimpleDocTemplate(
    output_path,
    pagesize=A4,
    leftMargin=1.8*cm,
    rightMargin=1.8*cm,
    topMargin=2*cm,
    bottomMargin=1.8*cm,
    title='DNB Palliative Medicine — Comprehensive Question Bank',
    author='Orris Medical AI',
    subject='Palliative Medicine — Models, Trajectories, PPI, PaP, PROMs',
)

story = build_story()
doc.build(story, onFirstPage=make_page, onLaterPages=make_page)
print(f'PDF generated: {output_path}')