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Pain
Non-pain Symptoms
Communication
Psych/Neuro
Prognosis
100
Name a drug that is an "Step 1" option on the World Health Organization's three step ladder framework
What is acetaminophen or NSAIDS?
100
A 55 yo M with gastric CA has developed severe abdominal pain. He previously was unwilling to take any pain medication because of how they may make him feel. He is now willing to start morphine. In addition to the opioid, what other medication should be initiated? A. Neurontin B. Fluoxetine C. Methylphenidate D. Diphenhydramine E. Ondansetron
What is "E"? Ondansetron, an anti-emetic. 25% of people who are opioid naive will develop n/v with an opioid. For those reluctant to start due to n/v sx, co-administration of antiemetics can prevent development of these symptoms. Opioid-induced nausea is typically transient and the anti-emetic can usually be d/c in 3-5 days.
100
At a family meeting, after introductions, list an initial open-ended question addressed towards the patient/family.
1.Determine what the patient & family knows; make no assumptions. Examples: What is your understanding of your present condition? What have the doctors told you? Fast Fact #11
100
87 year old M with metastatic lung cancer is admitted to the SNF with acute onset of disorientation, lethargy, poor attention, hallucinations and paranoid ideation. No evidence of impending death. What is the most appropriate initial pharmacologic intervention? A. Lorazepam B. Chlorpromazine C. Haloperidol D. Alprazolam
What is "C. Haloperidol"? Haloperidol, non-sedating anti-psychotic, is the first-line empiric treatment for symptoms of delirium.
100
If a patient receives and survives in-hospital CPR, name the percentage of those who will make it to discharge. A. <3% B. 17% C. 38% D. 52%
What is "B - 17%"?
200
Hydrocodone (opioid in vicodin) 5 mg is equivalent to what dose of morphine
What is 5 mg?
200
True or False? Ondansetron (Zofran) is most effective in patients with nausea due to vertigo.
What is "false"? Ondansetron is a 5HT3 (serotonin) receptor antagonist; shown to be most effective in chemotherapy and radiation therapy-induced nausea/vomiting. D2 antagonists (haloperidol, prochloperazine) are usually first-choice empiric anti-emetics. For vertigo, Scopolamine, diphenhydramine, and promethazine act on anti-histamine and muscarinic anti-cholinergic receptors.
200
True or False? The below are perceived as SUPPORTIVE statements for someone who is grieving a loss. "It was for the best." "She is happy now." "You should be getting over it by now." "It was his time to go."
What is "false"? What to say: "I'm sorry he is gone." "What are you remembering about your loved one today?"
200
All of the following are red flags for a patient who may be at risk for suicide EXCEPT: A. Has a specific plan B. Socially isolated C. Female gender D. Knows someone who successfully committed suicide E. History of serious attempt
What is "C Female gender"? From 1991–2009, the suicide rate was consistently higher among males. CDC
200
A person with dementia in stage FAST 7C is considered eligible for hospice. Name 2 characteristics of patients with dementia in this late stage.
What is: Ability to speak limited to 6 words/day Loss of ambulation
300
Opioids that are preferable in patients with severe renal disease (GFR<30)
What are methadone and/or fentanyl?
300
True or False? Palliative oxygen (providing O2 to patients who are not hypoxemic) has been shown to be more effective in relieving dyspnea than providing room air oxygen in patients with refractory dyspnea.
What is "false"? Since oxygen delivered by a nasal cannula provides no additional symptomatic benefit for relief of refractory dyspnoea in patients with life-limiting illness compared with room air, less burdensome strategies should be considered. Consider hand-held fan.
300
A 70-year-old Chinese woman who is a practicing Buddhist has had worsening weakness on her right side for the past month. The primary caregiver and durable power of attorney is her daughter-in-law. The patient’s understanding of English is limited, and her family members, who speak to her in Chinese, say that she appears to be intermittently confused. She says that she has no pain, but her facial expressions and whispered grunts suggest otherwise. Last week, an MRI of the brain showed a large mass in the left hemisphere, but her family would like to withhold this information from her because 3 years ago, after a suspicious hilar mass tested negative for cancer, she confided to them, "I can deal with anything, as long as I know it isn’t cancer." Accordingly, they tell her that she has had a stroke and they decline further testing and radiotherapy. The family is concerned that the patient will ask the hospice team whether she has cancer. Which of the following options is the best response to this concern? a. Agree to support the family’s request to not tell the patient about her diagnosis. b. Discuss with the family their concerns about disclosing the diagnosis to the patient. c. Help the members of the interdisciplinary team prepare responses that avoid the term "cancer." d. Reassure the family that although the hospice team must tell the patient her diagnosis, the news will be delivered gently
What is "option B"? Discuss with the family their concerns about disclosing the diagnosis to the patient. Discussing the family’s concerns will help the hospice team understand the family’s viewpoint and will lay the foundation for further discussions with the patient and family.
300
Pain assessment in advanced dementia scale (PAINAD) scale includes assessments of all of the following except: A. Breathing B. Facial expressions C. Body language D. Caregiver report E. Negative vocalization
What is "D"? Caregiver report is not part of the assessment tool. Consolability is also part of the assessment.
300
Your pt with ESRD has elected to stop hemodialysis and go on hospice. What is his life expectancy once hemodialysis is discontinued? A. 3 days B. 7-10 days C. 14-16 days D. 1 month
What is "B. 7-10 days"?
400
True or False? Methadone is a short-acting drug which makes it an ideal choice for rapid dose escalation in severe, acute pain.
What is "false"? Methadone has an extended terminal half-life of up to 190 hours. This long half-life can lead to increased risk for sedation and respiratory depression, especially in the elderly or with rapid dose adjustments. Do not increase oral methadone more frequently than every 4 days. Fast Fact #75
400
Case: 62 y.o. M with pancreatic CA has new onset of frequent oozing diarrhea. He has chronic pain, well controlled with sustained-release morphine, and he is often constipated. Six weeks ago he was treated with a course of antibiotics for a UTI. What is the most likely cause of his diarrhea? A. C. diff diarhea B. Fecal impaction C. Pancreatic insufficiency D. Spinal cord compression
What is "B. Fecal impaction"? Fecal impaction is a very common problem in patients with cancer who take opioids chronically. It very commonly manifests as oozing diarrhea or frank fecal incontinence in a patient taking opioids who previously suffered from constipation. It can be diagnosed by a simple rectal exam or a plain abdominal film, both of which will reveal impacted stool, around which liquid stool is oozing.
400
True or False? Physicians tend to underestimate patient prognosis in incurable disease e.g. they give patients estimates of time that are less than what they actually have.
What is "false"? In general, physicians over estimate prognosis by a factor of 3. Example: physicians predicted 6 weeks and the patient lived 2 weeks.
400
All of the following are hospice prognostic criteria for CHF EXCEPT: A. NYHA Class III B. Already on optimal medical management C. EF < 20% D. Resistant V-tach or supraventricular arrhythmias
What is "A. NYHA Class III"? Correct answer is NYHA Class IV: Symptoms at rest. Associated with 1-year mortality of 20-52%
500
Your patient with metastatic breast CA is on escalating, high doses of MS Contin. Family notes spontaneous twitching of the limbs. Name the side effect and possible interventions.
What is "myoclonus"? Options for treatment: opioid rotation (switch to another opioid), possibly hydration, BDZs.
500
A patient with end-stage COPD has refractory dyspnea. Name which drug class is most likely to relieve symptoms of dyspnea.
What are "opioids"?
500
A 52 yo F was admitted to the ICU 5 days ago after an intracranial hemorrhage. A family conference with the attending physician to determine goals of care is convened by the resident physician and RN who are involved with the patient's care. The patient's husband and 2 adult children are anxious to learn as mush as they can about her condition, rehab and prognosis. The physician provides an overview of the case and answers the family's questions, sometimes deferring to the resident physician and nurse. The family's satisfaction with the conference is most likely to be associated with which of the following? A. Experience of the attending physician B. Experience of the resident physician C. Length of the meeting D. Percentage of time the family members spoke E. Percentage of time the nurse spoke
What is "D"? The percentage of time family members speak in a family conference has been shown to be significantly associated with improved family satisfaction with the meeting. In addition, the greater percentage of time family members speak significantly decreases the family’s perception of conflict between family and physician. The mean proportion of time the family spoke in one study was 29%.
500
An 86-year-old woman with advanced dementia who is a resident of a nursing home has lost 10 lbs during the past 3 weeks. During feedings, she tries to refuse her food and sometimes chokes. The patient’s daughter is concerned that her mother is at risk of dying from starvation and asks the nursing home physician about using a feeding tube. The outcomes of tube feeding in patients with advanced dementia include which of the following? a. Improved healing of decubitus ulcers b. Increased use of restraints c. Reduced functional status d. Increased life expectancy e. Reduced risk of pneumonia
What is "b. Increased use of restraints"?
500
List the 3 components of the MELD score which is used for prognosis in end-stage liver disease patients.
What is INR, total bilirubin and serum creatinine?