I'm Stuck, Help!
Ouch!
Catch All
Future Planning
At the End
200
Which of these laxatives is an osmotic laxative:
A ) magnesium hydroxide (Milk of magnesia)
B) senna (sennakot)
C ) docusate (colace)
D ) bisacodyl (dulcolax)
(A) magnesium hydroxide (Milk of magnesia)
Osmotic Laxatives pull water into the stool, resulting in softer stools and more frequent, easier to pass bowel movements. Some commonly used osmotic laxatives include polyethylene glycol (PEG), milk of magnesia, and lactulose
200
Which of the following is the most common adverse effect of nonsteroidal anti-inflammatory drugs?
A ) Depression
B ) Hepatic toxicity
C ) Hypertension
D ) Renal dysfunction
(D) Renal dysfunction
Prostaglandins dilate the afferent arteriole which is crucial for maintaining kidney blood flow and function.
NSAIDs inhibit prostaglandins, which is particularly problematic for individuals with pre-existing kidney disease, dehydration, or other factors that compromise renal perfusion. In these individuals, the use of NSAIDs can lead to acute kidney injury or exacerbate chronic kidney disease. Therefore, caution is required when prescribing NSAIDs, and alternative pain management strategies may be considered in at-risk populations.
200
A 52-year-old man has severe pain from lung cancer with direct invasion into the brachial plexus of the right upper extremity. Numerous trials of opioid and adjuvant therapies have either failed to relieve the pain or produced intolerable adverse effects. The physician recommends ketamine as a co-analgesic. Which of the following adverse effects is most likely with high doses of this medication?
A ) Constipation
B ) Dry mouth
C ) Hiccups
D ) Hypertensive crisis
E ) Psychomimetic reaction
(E) Psychomimetic reaction
Hypertension, hiccups, dry mouth, and constipation have not been reported as common side effects of ketamine. The psychomimetic reactions occur in a substantial minority of patients (20% to 50%) and can limit the usefulness of ketamine. Psychimimetic reactions such as hallucinations, dreams, feelings of unreality and drowsiness are the common side effects of ketamine. They limit tolerance of the drug in a substantial minority of patients.
200
A 54-year-old woman with recently diagnosed advanced ovarian cancer is preparing to undergo experimental chemotherapy. She is upbeat and good-humored and says that she is "determined to lick this thing." Her husband takes the oncologist aside and says to him that he is encouraged by her optimism but worries that her spirits will plunge if the therapy is not successful. Which of the following observations about hope in patients with cancer is the most appropriate response?
A ) Hope declines at the time of hospice referral
B ) Hope progressively decreases over time
C ) Hope can be maintained while planning for the worst
D ) Hope increases with increasing therapeutic options
E ) Hope occurs rarely in patients with advanced cancer
(C) Hope can be maintained while planning for the worst
This scenario is a common phenomenon in cancer patients and their families. Maintaining hope for a cure is important for most patients. However, they also need to face the serious reality that curative treatment may not work. The old saying, "hope for the best, plan for the worst" allows patients and family members to hold both possibilities at the same time and for the physician to do advance care planning with the patient and family. The physician has a responsibility not to offer false hope and to prepare the patient and family for a possible negative outcome to her cancer treatment.
Most patients with advanced cancer still maintain hope. Hope does not have to decline with time or with a hospice referral. Hope can be restructured or reframed. Most cancer patients hold multiple hopes. When the hope for a cure is gone, refocusing or reprioritizing to another set of expectations can maintain the patient and family's hope. Hope can be maintained or even increased as the number of therapeutic options decrease. In other words, hope does not correlate with the number of therapeutic options. Rather hope is related to the likelihood that a therapy will achieve the patient's goals. Thus one therapeutic option that is highly likely to achieve the patient's goal is more likely to maintain hope than several therapeutic options each with a low likelihood of achieving the patient's hope.
Take Home Point:
Hope can be maintained throughout a cancer patient's course by planning for the worst, discussing multiple hopes and reprioritizing goals at each phase of the illness
200
A 75-year-old man with end-stage lung cancer has Cheyne-Stokes breathing. He is stuporous and nonverbal. Dyspnea has been effectively controlled with regular doses of morphine and lorazepam. Secretions in the patient's airway are causing loud, sputtering sounds that are distressing to the patient's family. Which of the following is the most appropriate management of this patient's symptoms?
A ) Administration of nebulized ipratropium bromide
B ) Administration of nebulized morphine
C ) Administration of transdermal clonidine
D ) Repositioning the patient
E ) Suctioning the airway
(D) Repositioning the patient
Although it has not been systematically studied, repositioning the patient with “death rattle” is often recommended and can be a critical adjunct to pharmacologic management of this symptom. It is believed that repositioning the patient can shift the secretions away from the path of the passing air, thereby decreasing the observed sound. Repositioning also can allow for postural drainage of the secretions.
400
Which of these enemas should you avoid in patient's with impaired kidney function?
A) Sodium phosphate (i.e. fleet water enema)
B) mineral oil enema
C) bisacodyl enema (dulcolax)
D) tap water enema
(A) Sodium phosphate (i.e. fleet water enema)
This is because it contains ionized inorganic phosphate. The phosphate is excreted by the kidney's thus if a patient has renal failure, a patient can develop hyperphosphatemia leading to further electrolyte imbalances and fluid shifts in heart patients.
400
Administration of which of the following is the most appropriate management of severe chronic pain in a person with chronic renal failure who is addicted to heroin?
A ) Hydromorphone
B ) Oxycodone
C ) Extended release morphine
D ) Transdermal fentanyl
E ) Methadone
(E) Methadone
Methadone is primarily excreted in the stool and therefore does not depend upon the kidneys for clearance of metabolites. Methadone is a safe and effective treatment for pain in the addicted patient, even in the setting of renal failure.
400
You are at the bedside of a 94-year-old gentleman with a hospice diagnosis of end-stage dementia and colon cancer. He is actively dying. He has a history of profound susceptibility to delirium from medications. His family is distressed by the increasing oral secretions and gurgling. They ask you to do something to manage this upsetting symptom. To maximally manage his secretions while minimizing the risk of instigating delirium, you order which of the following?
A ) Glycopyrrolate 0.2 mg SQ or SL q2 hours prn
B ) Hyoscamine 0.125 mg SL/PO q4 hours prn
C) Scopolamine/Hyoscine hydrobromide 1.5 mg patch q3 days prn
D ) Atropine 1% opthalmic solution, 4 drops SL q4 hours prn
E ) Suction
(A) Glycopyrrolate (Robinul) 0.2 mg SQ or SL q2 hours prn
Prevention of delirium is ideal in patients with identified risk. Choosing medications that minimize the risk is crucial.
Glycopyrrolate is an anticholinergic agent that does not cross the blood-brain barrier because it is a quaternary amine. Whereas scopolamine, atropine, and hyoscyamine are tertiary amines, thus can cross the blood-brain barrier.
400
You are taking care of a 34-year-old male who has a widely metastatic spindle cell sarcoma, resistant to multiple chemotherapeutic regimens. He has 3 children between the ages of 3 and 10. When you walk into his room you think of your own children and how devastating it would be if you or your spouse died, and this makes you upset to the extent that you often become emotional and cry. What is the most professional way for you to approach this situation?
A ) Tell the patient why you are so upset and afraid so that he can understand how you feel.
B ) Continue to do what you are doing because it is okay to show emotion in front of the patient and family.
C ) Work with your team to distance yourself temporarily from the case while you work through your emotional reactions.
D ) Ignore your emotions and do your job, after all it’s not about you anyway
C ) Work with your team to distance yourself temporarily from the case while you work through your emotional reactions.
Understanding emotional boundaries in the work of palliative care is critical to effective patient care as well as to the professional longevity of the palliative care provider. Understand and monitor the boundary between emotion felt in sympathy for the patient and emotion felt due to the care provider’s personal suffering. If the boundary is breached, separate from the situation for a time to deal with the personal emotions, outside of the therapeutic relationship.
400
A 75-year-old woman who is in hospice because of end-stage renal failure has decreasing level of consciousness and noisy respirations. Although she appears quite comfortable, her son is distressed by the rattle and asks the physician, "Can't you do something? I can't stand to see her suffer like this." In addition to reassuring the son that the patient is not experiencing discomfort, which of the following interventions is most appropriate?
A ) Prescribe diphenhydramine syrup 25 mg sublingually every six hours
B ) Prescribe morphine 5 mg sublingually as needed for difficulty breathing
C ) Prescribe oropharyngeal suctioning hourly as needed
D ) Prescribe scopolamine 0.2 mg subcutaneously every six hours
E ) Re-evaluate the patient in 12 hours
(D) Prescribe scopolamine 0.2 mg subcutaneously every six hours
Standard of care is to use muscarinic acetylcholine receptor blockers (anti-cholinergic drugs) to dry the secretions. These include scopolamine, hyoscyamine, glycopyrrolate, and atropine. All of these agents can cause varying degrees of blurred vision, sedation, confusion, delirium, restlessness, hallucinations, palpitations, constipation, and urinary retention. Although many of these anticholinergic drugs can be administered either sublingually or transdermally, the best data for the treatment of death rattle involves subcutaneous or intravenous administration of these agents, as in choice D.
Presence of a death rattle generally indicates a prognosis measured in hours to days. If the family does not wish to use medicine, often repositioning the patient may help the noise.
600
A 62-year-old man with pancreatic cancer has new onset of frequent oozing diarrhea. He has chronic pain, which is controlled with sustained-release morphine, and he is often constipated. Six weeks ago he was treated at home with a course of oral antibiotics for a urinary tract infection. Which of the following is the most likely cause of the diarrhea?
A ) Clostridium difficile enterocolitis
B ) Fecal impaction
C ) Pancreatic insufficiency
D ) Spinal cord compression
(B) Fecal impaction
Fecal impaction is a common problem in patients who take chronic opioids. It can manifest as diarrhea that oozes around the impaction.
600
An 81-year-old woman has had continuous postherpetic neuralgia in the left lower extremity for the past two years. The pain is burning and shocklike and varies in intensity from 6/10 to 10/10. On examination, the patient describes pain over the left L5 and S1 dermatomes. Trials of morphine, oxycodone, methadone, gabapentin, valproic acid, nortriptyline, desipramine, and amitriptyline have resulted in inadequate analgesia or intolerable adverse effects. Administration of which of the following is the most appropriate next step?
A ) Fluoxetine
B ) Olanzapine
C ) Sertraline
D ) Venlafaxine
(D) Venlafaxine
Venlafaxine is a drug that blocks both serotonin and neuropinephrine reuptake, and is effective in neuropathic pain syndromes.
600
Which of these medications for appetite stimulation also helps with chemotherapy-induced nausea?
A ) olanzapine
B ) dronabinol
C ) megestrol
D ) mirtazapine
(A) Olanzapine
Olanzapine has a unique receptor profile amongst antipsychotics, which in part accounts for its various uses and side effects. In addition to antagonizing dopamine receptors in the CNS (nausea, delirium), it blocks serotonin (5HT2) receptors (insomnia, anxiety, cachexia) and is anticholinergic.
600
A 67-year-old widow has metastatic cervical cancer that is refractory to chemotherapy. She is "slow," according to her brother-in-law, who has cared for her since her husband died six years ago. The brother-in-law has signed medical power of attorney and insists that she not be informed that the chemotherapy has been unsuccessful. He asks that mock treatment be administered to keep up her hope. Which of the following is the most appropriate next step?
A ) Agree to administer mock treatment
B ) Ascertain what the patient knows and wants to know about her condition
C ) Consult the hospital attorney and ethics committee
D ) Question the validity of his medical power of attorney Explanation
(B) Ascertain what the patient knows and wants to know about her condition
An agent under a medical power of attorney has proxy decision-making power under one of two circumstances: (1) if the patient does not have the ability to make decisions or (2) if the patient chooses not to make decisions.
Mock treatment is unethical.
“Understanding”
“Appreciation”
“Reasoning”
Expression of a Choice, can itself be deceptively complex. At its most basic level, it simply refers to the ability to communicate a decision. However, some authors have also emphasized the notion of a “clear and consistent” choice.
600
A 95-year-old woman who has had Alzheimer's disease for the past 10 years had onset of cough, agitation, and fever 10 days ago. Aspiration pneumonia was successfully treated with antibiotics. She is bedbound in a nursing home and requires assistance with all activities of daily living. Because she has lost more than 10% of her weight over the past 6 months, the family asks about placing a gastrostomy tube for feeding. Which of the following is the most accurate statement regarding this patient's life expectancy?
A ) Is longer than six months
B ) Is not correlated with recurrent fevers
C ) Will not change regardless of treatment intensity
D ) Will double with placement of a feeding tube
E ) Will increase with use of antibiotics
(C) Will not change regardless of treatment intensity
Aspiration pneumonia is the most common mechanism of death in patients with advanced dementia. Once patients with dementia begin to aspirate, no intervention will reduce the aspiration risk or risk of death because aspiration is a natural consequence of the progressive neurodegenerative disease. Aspiration pneumonia is therefore a sentinel indication of the "beginning of the end." Placement of feeding tubes in patients with dementia does not reduce aspiration, change survival, or improve nutritional status.
800
Which of the following laxatives is CONTRAINDICATED in a dying patient on opioids with little oral intake?
A ) Bisacodyl
B ) Docusate
C ) Psyllium
D ) Senna
(C) Psyllium
Psyllium is a bulk forming laxative (fiber additive). Because it is an additive, in the setting of acute dehydration/third spacing there is a risk of exacerbating the constipation leading to intestinal obstruction.
Instead, for opioid induced constipation, we use osmotic and stimulant laxatives.
800
A 65-year-old man has sharp, constant, aching pain in the back from bone metastases. Which of the following best describes this type of pain?
A ) Incidental
B ) Neuropathic
C ) Nociceptive
D ) Visceral
(C) Nociceptive
- Nociceptive (Pain stimulus originates from pain receptors in a damaged tissue, and that pain stimulus is carried on normal nerves to the central nervous system). Common descriptors for this type of pain include sharp, achy, constant, localized, tender, or stabbing.
- Somatic (MSK, dull, movement)
- Visceral (organ, poorly localized, deep/cramping)
- Neuropathic (nerve pain, burning, shooting, electrical)
Bone pain is often described as sharp, aching, stabbing, and is well localized, all classic features of nociceptive pain
800
A 75-year-old woman with ovarian cancer is admitted to the hospital because of a partial small-bowel obstruction. Administration of a corticosteroid and which of the following drugs is most appropriate to manage the obstruction?
A ) Erythromycin
B ) Scopolamine
C ) Morphine
D ) Octreotide
(D) Octreotide
Octreotide is a synthetic analog of somatastatin, that essentially "shut downs" the gut by inhibiting the release of secretion hormones, decreasing the release of enzymes, inhibiting peripheral nerves of GI system, and ultimately decreasing peristalsis and splanchnic blood flow.
Among the antisecretory drugs, octreotide has been shown to reduce nausea and vomiting in bowel-obstructed patients owing to a reduction of gastrointestinal secretions, thus allowing in most patients removal of the nasogastric tube and the associated distress.
800
An 82-year-old woman with advanced multi-infarct dementia is referred by her parish priest to home hospice. She has been confined to bed for the past six months and can only say "help" and "no." Her family desires to care for her at home and accepts that her death is near. They spend more than four hours each day hand-feeding her, and have told their priest that they will ask that a feeding tube be placed, should she become unable to eat. Which of the following is the most appropriate next step?
A ) Ask the family to complete a detailed advance directive form before certification
B ) Certify the patient for home hospice benefits on the basis of dementia and initiate discussion about goals of care
C ) Decline to certify the patient for home hospice because the prognosis is greater than six months if a feeding tube is placed
D ) Suggest a meeting with the physician, pastor, and family to discuss tube feedings and advanced dementia before certifying for hospice
(B) Certify the patient for home hospice benefits on the basis of dementia and initiate discussion about goals of care
Patients can be certified for hospice even if the patient and/or the family still desire tube feeding, IVs, or full code status. Tube feeding does not prolong life or improve quality of life in patients with advanced dementia.
800
A 33-year-old woman has been hospitalized since sustaining trauma in a motor vehicle collision six months ago. She is comatose and is being terminally weaned from ventilatory assistance. When the physician writes orders for appropriate doses of morphine and lorazepam for comfort, titrated to the patient’s symptoms, a medical student asks if these drugs will hasten the patient's death. Which of the following is the most appropriate response?
A ) Benzodiazepines have been shown to hasten death, but opioids have not
B ) Both benzodiazepines and opioids have been shown to hasten death
C ) Neither benzodiazepines nor opioids have been shown to hasten death
D ) Opioids have been shown to hasten death, but benzodiazepines have not Explanation
(C) Neither benzodiazepines nor opioids have been shown to hasten death
Opioids and benzodiazepines given for symptom management during withdrawal of mechanical ventilation are not associated with a hastened death.
1000
Which of these is the best agent to treat opioid induced constipation?
a) Methylcellulose
b) Ducosate
c) Sennakot
d) Relistor
e) Miralax
(D) Relistor
An opioid receptor antagonist which blocks opioid binding at the mu receptor, methylnaltrexone is a quaternary derivative of naltrexone with restricted ability to cross the blood-brain barrier. It therefore functions as a peripheral acting opioid antagonist, including actions on the gastrointestinal tract to inhibit opioid-induced decreased gastrointestinal motility and delay in gastrointestinal transit time, thereby decreasing opioid-induced constipation. Does not affect opioid analgesic effects.
1000
A 57-year-old Vietnamese woman with inoperable cholangiocarcinoma is observed by the hospital nursing staff to be in apparent discomfort. She moans in bed and does not seem to be sleeping at night, despite increasing doses of opioids. A consulting physician is called in to evaluate the patient's condition. The patient's adult children serve as interpreters. In addition to adding adjuvants for the patient's pain management, which of the following is the most appropriate initial approach for the consulting physician?
A ) Initiate temporary palliative sedation
B ) Ask the patient's children about their mother's source of suffering
C ) Recognize that spiritual distress can manifests as physical symptoms
D ) Recommend starting an antidepressant
E ) Recommend starting a sleeping pill
(C) Recognize that spiritual distress can manifests as physical symptoms
One of the more common contributors to uncontrolled pain is non-physical pain. Spiritual pain or distress is a source of non-physical pain that may manifest itself as physical symptoms. Spiritual distress can be a cause of opioid-refractory pain.
1000
A 40-year-old man with persistent pain from colon cancer metastatic to liver and lungs has decreased level of consciousness and is unable to swallow pills but is able to recognize family members. His current drug regimen includes transdermal fentanyl, oral morphine concentrate, and oral dexamethasone. The dexamethasone was initiated for management of dyspnea and liver capsular pain one month ago, but it has not provided sustained relief, despite titration to 16 mg per day. Considerations regarding the parenteral use of dexamethasone in this patient support which of the following steps?
A ) Continue use because sudden withdrawal may cause adrenal crisis and hasten death
B ) Discontinue use because it is not beneficial orally and would be painful subcutaneously
C ) Discontinue use and initiate palliative sedation
D ) Rotate the corticosteroid to methylprednisolone acetate for better symptom management
A ) Continue use because sudden withdrawal may cause adrenal crisis and hasten death
Abrupt discontinuation of corticosteroids in critically ill patients who have had prolonged steroid therapy may precipitate adrenal crisis and hasten death
1000
You are asked to provide palliative care consultation for a 77-year-old male with severe peripheral vascular disease and diabetes who has been in the ICU for 28 days following a 4 vessel coronary bypass and aortic valve replacement. He has had recurrent respiratory failure related to pneumonia and congestive heart failure. He is failing to wean from the ventilator. He has renal failure which has most likely become dialysis dependent. He is delirious and requires sedation to tolerate his current treatments. The patient’s wife has begun to question whether the patient “would want to keep going like this.” The attending cardiothoracic surgeon has heard this from the nurses but refuses to make the patient a DNR, saying that he will not allow any change in goals of care sooner than 30 days after the operation. When you hear this you become angry and call the surgeon on the phone. After listening to the surgeon’s explanation for why he’d make such a statement, what should you say next?
A ) Tell him that he can dictate the timing of decision making because 30 day mortality rates are important to the sustainability of your hospital’s heart program.
B ) Tell him you are going to report him to the Chief of Staff for unprofessional conduct and also tell him to screen his operative candidates more carefully.
C ) Tell him you’d like to arrange a meeting for him and the Palliative Care team to talk with the family about their goals and concerns for their loved one, then be present to listen and facilitate.
D ) Tell him that while you understand his concerns, the patient and family come first, so you plan to write the DNR order yourself and take the patient off of life support when the family is ready.
(C) Tell him you’d like to arrange a meeting for him and the Palliative Care team to talk with the family about their goals and concerns for their loved one, then be present to listen and facilitate.
Inviting the surgeon to meet with the family will serve two purposes: (1) it will clarify the surgeon’s understanding of the patient’s operative consent for the family, and (2) it will clarify the family’s understanding of the patient’s wishes regarding life support for the surgeon.
Even when upset by another’s comments, listen and try to understand their perspective. Mediation of shared solutions is superior to unilateral judgments and is an important part of the Palliative Care consultant's role.
1000
A 65-year-old man who is dying of advanced pancreatic cancer has had declining urine output over the past 24 hours; output is now almost zero. Regular doses of morphine provide good pain control. Intravenous fluids are being administered at 100 mL/hr. He is somnolent most of the time, but has periods of lucidity during which he reports only mild abdominal pain and no other distress. Examination shows 4+ pitting edema to the thighs bilaterally and 2+ ascites. A foley was placed, and only 150 mL dark-colored urine resulted. Which of the following is the most appropriate management?
A ) Administer dopamine intravenously
B ) Administer furosemide intravenously
C ) Discontinue intravenous fluids
D ) Increase morphine dose by 25%
E ) Initiate transdermal scopolamine
(C) Discontinue intravenous fluids
Intravenous fluids at the end of life are contraindicated in patients with volume overload and do not improve outcomes or time to death.