Prospective studies in terminal cancer patients have correlated all of the following physical examination signs with death in less than 3 days with a high degree of specificity EXCEPT (Fast Fact #392 Physical Examination of the Dying Patient):
For centuries, experts have been searching for physical examination signs that predict imminence of death. Recent prospective studies in terminal cancer patients have correlated specific clinical signs with death in < 3 days. These are loss of radial pulse; mandibular movement during breathing; anuria; Cheyne-Stokes breathing; the “death rattle” from excessive oral secretions; non-reactive pupils; decreased response to verbal/visual stimuli; inability to close the eyelids; drooping of both nasolabial folds (face may appear more relaxed); neck hyperextension (head tilted back when supine); and grunting of vocal cords, chiefly on expiration. While the presence of any of these signs may correlate with death within 3 days, their absence does NOT permit the opposite conclusion. Decreased performance status, dysphagia, and decreased oral intake constitute more commonly encountered, “early” clinical signs suggesting a prognosis of 1-2 weeks or less.
Which one of the following represents potential “splitting” behavior (Fast Fact #252 Borderline Personality):
Individuals with BPD have difficulty sustaining ambivalent feelings and may instead label clinicians as either “wonderful” or “terrible”, a defense mechanism known as “splitting”.
You are caring for a terminally ill patient whose subcutaneous infusion of hydromorphone has been escalated from 0.4 mg/hr. to 1 mg/hr. in the last 24 hours. On physical examination, light touch to his distal upper extremities elicits moaning and discomfort. You also notice non-rhythmic jerking motions of her lower extremities. All of the following are potentially effective treatment strategies EXCEPT (Fast Fact #58 Neuroexcitatory Effects of Opioids: Treatment):
The described symptoms are consistent with opioid-induced neuroexcitatory effects. Observation, opioid dose reduction, IV hydration, opioid rotation to a dissimilar opioid, benzodiazepine administration and administration of adjuvant analgesic therapy such as gabapentin or baclofen are all recognized strategies for approaching opioid induced neurotoxicity. However, changing the route of the subcutaneous infusion to intravenous is not a recommended strategy.
Which of the following is true regarding subcutaneous opioid infusions (Fast Fact #28 Subcutaneous Opioids)?
Answer choice A is incorrect because Methadone is known to cause skin irritation during a subcutaneous infusion. Answer choice B is incorrect because the dose conversion rate for Morphine is likely close to 1:1. Answer choice D is incorrect because needle insertion into the chest wall can result in iatrogenic pneumothorax. Ideal locations include the upper arm, shoulder, abdomen, or thigh.
As you near the end of a clinical work day, you notice a physician colleague on a computer purchasing international airline tickets. You excitedly ask your colleague about his travel plans, but your colleague replies that he is purchasing the tickets for an ill patient, not for his own travel. Your colleague then states that he still has regretful feelings for not traveling overseas to visit his own mother prior to her death. Therefore, he feels compelled to purchase these airline tickets for his patient so that the patient can visit certain family members prior to her death. What would be the best response (Fast Facts #167-170, 172 Health Professional Burnout)?
There are several ‘red flags’ in this case that should alert the clinician to boundary issues and health professional burnout symptoms among their colleagues. First, expensive gift-giving to a patient is a recognized warning sign for boundary blurring between clinician and patient. Also, there is concern that the colleague may be making this airline purchase to address his own’s emotional needs, rather than a therapeutic need of the patient. Boundary blurring is a recognized sign of health professional burnout and it is also a risk factor for health professional burnout. Helping the colleague to recognize this would be the most appropriate response as would encouraging the colleague to seek out professional counseling.
Which one of the following is true regarding intrathecal drug delivery systems (also known as IT pumps) compared with epidural analgesia (Fast Fact #98: Intrathecal Analgesia)?
Answer choice A is incorrect as IT pumps are generally reserved for patients with a life expectancy > 3 months. Answer choice C is incorrect as IT pumps are associated with fewer catheter problems. Answer choice D is incorrect as IT pumps are preferred in the presence of epidural pathology.
All of the following clinical features are suggestive of opioid induced hyperalgesia EXCEPT (Fast Fact #142: Opioid Induced Hyperalgesia):
Answers b-d are all recognized features of opioid hyperalgesia. Another common feature of hyperalgesia is allodynia; allodyina is pain that is elicited from an ordinarily non-painful stimuli, such as light touch of the distal extremity. Answer choice (a) is describing a known side effect of opioids (sedation) which is dose limiting for this patient and thereby prohibiting the patient from achieving optimal pain control. Sedation as a dose limiting opioid side effect is common, but it is not a sign of opioid-induced hyperalgesia.
Which of the following is correct regarding oral opioid orders for cancer pain (Fast Fact # 74 Oral Opioid Orders- Good and Bad)?
Answer choice A is incorrect because only one long acting opioid should be written for at a time. Answer choice C is incorrect because the fentanyl transdermal patch can only be safely dose escalated every 3 days. Choice D is incorrect because the peak effect of short acting opioids is typically 1-2 hours.
Which of the following is true regarding opioid pharmacokinetics (Fast Fact #307 Opioid Pharmacokinetics)?
Answer choice B is incorrect because the majority of opioid metabolites are excreted through the kidneys. Cytochrome P-450 enzymes are involved in liver metabolism (not excretion) and can contribute to significant drug-drug interactions. Answer choice C is incorrect because the proportion of active drug that enters the systemic circulation is described as bioavailability. Answer choice D is incorrect because the primary target tissue for opioids is the central nervous system.
Which of the following is a true statement regarding the analgesic effects of pregabalin in comparison to gabapentin (Fast Fact #289 Pregabalin vs Gabapentin)?
Answer A is wrong because pregabalin is 3 times more expensive than gabapentin, not the other way around. In one small randomized controlled trial, pregabalin was shown to be associated with statistically significant lower visual analogue pain scales for neuropathic cancer pain in comparison to gabapentin, placebo, or amitriptyline, making answer B incorrect. Pregabalin is a controlled V substance per the DEA; as of now gabapentin is not a controlled substance. Published medical data suggest pregabalin can be titrated to an effective dose range at 1-2 days; whereas it often takes 9 days or longer to titrate to gabapentin’s usual effective dose range of 900-1,800 mg/day.
One year mortality from onset of hepatic encephalopathy in end stage liver disease is approximately (Fast Fact #188 Hepatic Encephalopathy):
See Fast Fact #188 Hepatic encephalopathy
Which one of the following is the best choice for emergency treatment of severe dyspnea in an opioid-naïve dying patient (Fast Fact #27 Dyspnea):
Typically, dyspnea can be well managed with small doses in the opioid naïve patient thus small doses of a parenteral opioid is the best choice among these options. The key to treating severe dyspnea is a) picking a drug and dosage that can be administered and dose escalated quickly to achieve the desired effect, and b) safely so that respiratory depression can be avoided. Intravenous opioids have a rapid onset of effect allowing for rapid assessment and decisions about the need for changes. The oral route is too slow to provide needed relief although can be used if no parenteral drugs are available. The dose of hydromorphone in option a. is excessive, equivalent to ~ 20 mg of IV morphine.
Choose the best answer regarding the clinical utility of the surprise question – “Would I be surprised if this patient died within 12 months” (Fast Fact #360 The Surprise Question as a Prognostic Tool):
Answer choice A is wrong since “Yes” answers (meaning the clinician would be surprised if the patient died in < 12 months) have a predictive value of 93% while the positive predictive value of “no” answers may only be 37%. Answer choice (b) is wrong as the pooled accuracy of the surprise question for cancer patients appears to be slightly higher than non-cancer patients. Answer choice (c) is wrong because it has been studied and validated in general inpatient settings, high-risk primary care clinics, pediatric patients, advanced kidney disease, emergency departments, cancer clinics, and nursing home settings.
You are caring for a dying lung cancer patient who is receiving a morphine intravenous infusion for bone pain and dyspnea. The patient has not been eating or drinking the past four days and is sleeping most of the time. Over the next 24-48 hours the patient becomes less responsive, with an irregular breathing pattern, and a bluish discoloration of her feet. What is the most appropriate action to take (Fast Fact #39 Inpatient Naloxone)?
The patient is actively dying as evidenced by her declining functional status without reversible cause, which has now progressed to breathing changes and mottling. The morphine infusion is appropriate for management of her underlying pain. There is no rationale to discontinue or reduce the current morphine dose as any dose reduction may result in inadequate symptom control at the end of life. Administering naloxone is not appropriate in this patient.
An 86 year old man with end-stage dementia is brought into the inpatient hospice unit for management of terminal delirium. On day three of admission he is noted to be unresponsive and patient’s daughter who has held vigil at his bedside notes the onset of a “rattling” sound coming from the patient’s mouth. Which of the following agents for retained oral secretions is the least associated with delirium (Fast Fact #109 Death rattle)?
“Death rattle” occurs in patients at the end of life as a result of the pooling of oral or bronchial secretions. While there is not clear evidence for their effectiveness, anticholinergic agents are routinely used in clinical practice to manage this symptom which is often very distressing for loved ones. While all of the agents listed above are reasonable choices to treat death rattle, atropine (answer a and b) and scopolamine (answer c) are tertiary amines which cross the blood brain barrier and can result in CNS toxicity. As such, these agents carry the risk of worsening the patient’s delirium. Glycopyrrolate, a quaternary amine which does not cross the blood-brain barrier, carries less of a risk for delirium and thus is the most appropriate choice.
What neurologic sign is an early indicator of opioid-induced neurotoxicity and should be routinely assessed on all patients receiving opioids (Fast Fact #57 Neuroexcitatory Effects of Opioids: Patient Assessment)?
Current research implicates the 3-glucuronide opioid metabolites as one likely cause of neuroexcitatory side effects with some suggestion that symptoms may not develop until a neurotoxic threshold is surpassed. Myoclonus is an early sign of opioid induced neurotoxicity. As myoclonus worsens, patients may develop other neuroexcitatory signs: hyperalgesia (increased sensitivity to noxious stimuli), delirium with hallucinations, and eventually grand mal seizures.
When disclosing medical error to a patient or family, which answer below best reflects recommended practice (Fast Fact #194 Disclosing Medical Error)?
It is best to have the discussion about a medical error as soon as possible when all the appropriate people can be present. So, answer A is incorrect. Discussing errors with patients and families is a clinical not a legal task. Therefore, the leader of the medical team (often the attending physician), should lead the discussion. When trainees are involved in the patient’s care, it is important to invite trainees to the discussion so that they can foster their professionalism skills via role-modeling. Therefore, B and C are incorrect. D is incorrect because expressions of regret and sorrow for an individual error is not necessarily an admission of guilt, liability, but rather a clear and transparent way to convey to the patient and family the factors which contributed to the outcome. Most experts recommend utilizing statements such as “I am sorry this happened” in situations of individual and/or system-error. Answer E is correct because notification of risk management teams as soon as a medical error is discovered can offer clarity on institutional policies and procedures as well as enable appropriate fact-finding and documentation should legal inquiries be made.
Which of the following is recognized as the greatest risk for developing opioid induced constipation (Fast Fact #294: Opioid Induced Constipation Part 1)?
The risk of developing opioid induced constipation does not appear to be directly correlated with the route of opioid delivery nor the dosage of opioid therapy. There is little evidence to suggest that any particular opioid is more or less likely to lead to constipation. Rather it is the duration of opioid therapy which is recognized to be the strongest risk factor for developing this adverse effect.
What would be an appropriate initial dose of a corticosteroid for cancer related bone pain as described by the published medical literature (Fast Fact #129 Corticosteroids for Bone Pain)?
Although the ideal corticosteroid, dose, and duration of therapy has not been firmly established via carefully controlled published trials, experts have recommended choosing a corticosteroid that has lower mineralocorticoid activity and a longer half-life to allow for more convenient once a day or twice a day scheduling. Of the choices provided, only answer choice A offers a medically reasonable medication, dose, and duration as described in the published medical literature.
Choose the best description of a skin finding in an imminently dying hospitalized patient that would be consistent with a Kennedy Terminal Ulcer (Fast Fact #383 Kennedy Terminal Ulcer):
Answer choice (a) is a description of petechiae which commonly occur in patients with dangerously low platelet counts. Answer choice (b) is a description of calciphylaxis which is most commonly associated with end-stage renal disease. Answer choice (d) is a description of a MRSA skin infection. A Kennedy Terminal Ulcer is a term used to describe a skin wound that commonly occurs over the sacrum or other bony prominences despite best preventative measures and results from the skin failure associated with the dying process. The wound is usually irregularly-shaped, pear-shaped, or butterfly-shaped; > 2 inches in diameter; and may include red, yellow, black, and/or purple discoloration
What is the principle mechanism of action for naloxone, methylnaltrexone, and naloxegel as treatments of opioid induced constipation (Fast Fact #295: Opioid Induced Constipation Part 2)?
Since the majority of opioid induced constipation symptoms are felt to be secondary stimulation of mu-opioid receptors in the GI tract, naloxone, methylnaltrexone, and naloxegol are identified to be effective treatments for opioid induced constipation due to their peripheral opioid receptor antagonism in the GI tract. Hence b is the right answer. In general, these medications are reserved as second or third line treatments for opioid induced constipation due their cost, route of administration, and/or negative impact on opioid analgesia (as in the case of naloxone). Senna is an example of a stimulant laxative; lubiprostone is an example of a selective chloride channel-2 activator and liactolide is an example of a small intestine secretogogue.
Among the following signs and symptoms of the syndrome of imminent death, which would be expected to appear the latest in the trajectory of the syndrome (Fast Fact #3 Syndrome of Imminent Death)?
The syndrome of imminent death is characterized by a typical progression of clinical findings. The earliest stages of the syndrome are characterized a decreased interest or ability to eat and drink (answer a), a bedbound state (answer b), and changes in cognition including decreased wakefulness (answer d) and delirium. As the syndrome progresses, patients become more obtunded and eventually reach the latest stage characterized by mottled extremities (answer c), death rattle, coma, fever and changes in respiratory pattern. Mottling of the skin occurs as a result of decreased peripheral blood perfusion due to deceased cardiac output and intravascular volume. The time it takes to progress through these stages ranges from a period of hours to approximately two weeks.
All of the following laboratory findings are independent predictors of a shorter survival in advanced heart failure EXCEPT (Fast Fact #143 CHF Prognosis):
Anemia, elevated BUN/creatinine and low sodium are all common in heart failure and are independent survival prognostic factors.
You are concerned about opioid-induced testosterone deficiency in a patient with a total serum testosterone level of 115 ng/dl. Seeing that his cancer related pain has resolved, you discontinue opioid therapy. He asks how long it may take after opioid discontinuation for his testosterone to normalize. Choose the best answer (Fast Fact #284: Opioid-induce androgen deficiency):
Cessation of opioid therapy should lead to recovery of testosterone levels within days. Therefore, if this doesn’t occur, you should consider referral to endocrinology for further testing and analysis of the cause and potential treatment of the patient’s low testosterone.
Which one of the following is an appropriate opioid analgesic order (Fast Fact #70 PRN Range Orders)?
Answer choice A is incorrect because there should not be therapeutic duplication consisting of more than one type of PRN opioid by the same route. Answer choice B is incorrect since the order contains vague parameters (partially controlled or uncontrolled) which can be interpreted differently by different health care providers, patients and families. Answer choice C is incorrect because morphine has a duration of action of only 2-4 hours.
All of the following are examples of real-time mindfulness exercises which may help reduce healthcare professional burnout EXCEPT (Fast Fact # 316 Mindfulness):
Mindfulness has been defined as “paying attention on purpose, in the present moment, and nonjudgmentally, to the unfolding of experience moment to moment.” Although mindfulness techniques with the most robust clinical evidence supporting them require time-intensive training, recently several easy-to-perform, quick mindfulness techniques have been described in the medical literature as being potentially effective in mitigating burnout. Answer A is a description of a known mindfulness technique called a body scan. Answer D is a modified description of Loving-Kindness Meditation. Answer C is a commonly advocated technique of utilizing a short succession of deep breaths to interrupt the “Flight or Fight” stress response. Answer B provides an example of future thinking that may distract the clinician by taking him or her out of the present moment and perhaps compound the present level of stress experienced during the patient encounter.
Which statement is true regarding external beam radiation therapy to treat a painful solitary spinal metastasis (Fast Fact #66 and #67: XRT for palliation)?
Answer choice B is incorrect; external beam therapy can be used for multiple metastases. Answer choice C is incorrect because a pain flare may occur following external beam XRT and this is independent of number of lesions present. Answer choice D is incorrect, although pain relief may begin at the time of radiation initiation, peak analgesic effect typically occurs 2-4 weeks after therapy.
Which of the following statements is true regarding suicide risk among physicians (Fast Facts #167-170, 172 Health Professional Burnout)?
Although physician suicide rates may be similar to the general population for both genders, both male and female physicians have a greater risk of suicide compared to other non-health care professionals. Among physicians, females are males are equally likely to complete a suicide gesture.
Which one of the following statements about intravenous (IV) hydration in the last week of life is TRUE (Fast Fact #133 Non Oral Hydration in Palliative Care):
For many years it was considered standard practice that all dying patients in the hospital setting receive intravenous fluids, with the thinking that such care improved symptoms of the dying process. However scant data exists to support this claim for most patients. It is true that in settings where fluid accumulation is a problem, such as in renal, liver or heart failure, intravenous hydration can worsen dyspnea
Which of the following is an appropriate conversion of 10 mg PO Oxycodone q4h to oral Hydromorphone (Fast Fact #36 Opioid Dose Conversions)?
- Calculate the 24 hour current dose: 10 x 6 doses in 24 hours = 60 mg PO Oxycodone/24 hrs
- Use the equianalgesic ratio of PO Oxycodone to PO Hydromorphone: 20-30 mg PO Oxycodone = 7.5 mg PO Hydromorphone
- Calculate new dose using ratios: 15-22.5 mg PO Hydromorphone in 24 hours
- Reduce dose 50% for cross-tolerance: 7.5-11.23 mg in 24 hours = 1.25-1.875 mg q4h
Which of the following medications is least likely to be associated with myoclonus (Fast Fact #114 Myoclonus)?
Myoclonus can result from multiple etiologies, ranging from metabolic derangements to focal CNS damage such as stroke. Many medications can result in myoclonus, including opioids, antiepileptic drugs, anti-depressants and antibiotics. When possible, the underlying cause should be identified and addressed. In the case of drug toxicity, the medication should be discontinued if not essential to therapy, or changed to a different agent if possible. At the end of life, if the causative agent cannot be reversed, refractory myoclonus can be treated with benzodiazepine medications (such as Midazolam). Although not relevant in the patient described above, midazolam has been an implicated cause of myoclonus in preterm infant population.
Which of the following is a moderate to strong indicator of a poor neurologic outcome from anoxic brain injury (Fast Fact #234 Prognosis from Anoxic Brain Injury):
Neither cause of cardiopulmonary arrest, total arrest time, duration of CPR, nor fever have been strongly associated with neurologic outcomes. However, the presence of myoclonic status epilepticus within 1 day of CPR or 1 day after rewarming from the hypothermia protocol has been associated with poor neurologic outcomes.
As a palliative care clinician, you are asked to consult in the care of a patient with metastatic pancreatic cancer. During the initial consultation, the patient expresses significant concern that his primary care clinician, who is a colleague, ignored warning signs of jaundice, weight loss, and pruritus for several months. The patient feels the symptoms should have prompted an earlier investigation for pancreatic cancer and the delay in diagnosis led to significant harm for him. Which of the following would be the most appropriate response (Fast Fact #195 Responding to a Colleague’s Error)?
Patients have a right to open disclosure. Being purposefully vague or evasive when patients raise concerns for a medical error by a colleague can erode patient-clinician trust. Beyond sharing the patient’s concerns with your colleague in a non-confrontational, private forum, you may also want to encourage your patient to reach out to your health care institution’s patient relations advocate.
A 57-year old male with a history of hepatocellular cancer was recently diagnosed with pneumonia. He was prescribed azithromycin and acetaminophen with codeine for cough. He is also on scheduled dronabinol for treatment of nausea. He returns to clinic for follow-up. Urine drug screen reveals the following:
Marijuana: Positive
Barbiturates: Negative
Amphetamines: Negative
Codeine: Negative
Methadone: Negative
Morphine: Positive
Benzodiazepine: Negative
The results of the urine drug screen are most consistent with which of the following (Fast Fact #110 Urine Drug Screen)?
Codeine and heroin are both metabolized to morphine. A prescription for codeine may result in a positive urine drug screen for morphine, however codeine would also be present in the urine (answer choice B is incorrect). If codeine is prescribed and only morphine is found in the urine, the most consistent interpretation is the unknown use of morphine or heroin. False positive results may result from cross reactivity from quinolones, but are not frequently seen with macrolide antibiotics (answer choice C). Most urine drug screens are unable to distinguish between the use of smoked marijuana from the appropriate use of a prescribed synthetic THC derivative such as dronabinol. Hence clinicians should refrain from making the conclusion in answer choice (d) in this clinical scenario.
Mr. K, a 68 year old male with a history of metastatic melanoma, presents with arm pain due to a humerus metastasis. He has no other known sites of bone lesions and no associated neurologic deficits. You recommend radiation therapy and advise him on the process. Choose the best answer (Fast Fact # 66 and # 67: XRT for palliation):
Answer choice A is incorrect, a standard course is 300cGy x 10 treatments. Answer choice B is incorrect because bone and peripheral nerves typically can tolerate a much larger total radiation dose as compared to liver and kidneys. Answer choice C is incorrect because each daily treatment will typically last minutes.
Choose the best statement regarding the sensation of thirst in seriously ill patients (Fast Fact #313 Thirst):
Thirst is a very common symptom in seriously ill and dying patients. Studies show that approximately 80-90 percent of dying patients will experience thirst, making answer a incorrect. Differentiating xerostomia from thirst is an important part of the evaluation of thirst as the two conditions do not always overlap. Not all patients with xerostomia report thirst, making answer b incorrect. Similarly, not all thirsty patients will have xerostomia. Answer c is correct as appropriate treatments for thirst in the ICU include oral swab wipes, sterile ice-cold water sprays and lip moisturizers. These treatments have been shown to decrease thirst intensity, distress related to thirst and dry mouth in the ICU. There is no clear evidence that artificial hydration alleviates thirst in seriously ill patients. Moreover, it carries serious risks including volume overload which can lead to increased suffering, a particularly important consideration in patients with end-stage renal disease and heart failure.
You are caring for a patient with chronic obstructive pulmonary disorder (COPD) who requires 3 liters of oxygen at rest. The patient has a serum albumin of 2.3, and lost 10 lbs of weight in the last 6 months. You are wondering if the patient would meet hospice eligibility guidelines as published by the NHPCO and decide to review the patient’s most recent transthoracic echocardiogram (TTE). Which finding on the TTE would be most suggestive that the patient would meet NHPCO hospice eligibility (Fast Fact #141 COPD Prognosis)?
The NHPCO guidelines for hospice admission in COPD include evidence of cor pulmonale (or right sided heart failure), pO2 < 55 mmHg while on oxygen, albumin 10%, and poor functional status. Therefore, B would be the best answer.
You are caring for a patient with advanced cancer. The patient has had stable weights and states she has been eating normally with a retained appetite. On physical examination you notice diffuse muscle loss that is associated with an increase in fat mass and abdominal circumference. Which clinical term would best describe her condition (Fast Fact #386 The Anorexia-Cachexia Syndrome):
Sarcopenia describes diffuse muscle loss associated with an increase in fat mass and abdominal circumference. Anorexia describes appetite reduction and can be psychogenic (anorexia nervosa) or secondary to an underlying advanced illness. Cachexia is a >5% weight loss over 6 months in absence of starvation or a BMI 2% or appendicular skeletal muscle loss plus weight loss > 2%. An orexigenic is a term used to describe an appetite stimulant.
Which one of the following is correct regarding a celiac plexus block for cancer pain (Fast Fact #97: Sympathetic Blocks)?
Answer choice A is incorrect as the main side effects are related to loss of sympathetic tone and include transient hypotension and increased intestinal motility resulting in diarrhea. Answer choice B is incorrect as a patient should anticipate a decrease in pain and opioid requirements after the procedure, but a complete resolution of pain in which opioids are no longer needed rarely occurs. Answer choice D is incorrect as a sympathetic block may be repeated.
Choose the single best answer regarding opioid-induced nausea (Fast Fact #25 Opioids and Nausea):
Commonly described as an allergy, opioid induced nausea is not an allergic reaction, but rather a side effect to which tolerance develops within 3-7 days in most patients. Hence b and c are wrong. There is little evidence in general comparing the emetogenic potential of various opioids, however there is some preclinical evidence that the transdermal fentanyl patch may be less nauseating and constipating compared with morphine.
As defined by Dame Cicely Saunders, which of the following is one of the 4 essential domains of “total pain” (Fast Fact #417 Total Pain)?
Dame Saunders and other hospice and palliative care experts recognized that serious illness can fundamentally disrupt previously established expectations for a patient’s future. Four essential domains or components of “total pain” have been described: psychological pain; social pain; spiritual pain; physical pain. The interaction of these four domains is often complex and dynamic. Clinicians ofter overlook non-physical sources of pain and consequently treatable suffering can get missed or overmedicated.
Which of the following pharmacologic properties is most accurate regarding the 5% lidocaine patch for pain (Fast Fact #148 Lidocaine Patch)?
The most robust supporting data is for neuropathic pain syndromes such as post-herpetic neuralgia. It is cleared by the liver and therefore is contraindicated in advanced liver failure, not renal failure. Only 5% of the patch gets absorbed at all, which is an insufficient amount to cause any local anesthesia or numbness. Hence, patients should not expect to feel any numbness under the patch. Unlike the fentanyl transdermal patch, it is safe to cut the Lidoderm patch if desired and placed a portion of it over various painful areas.
You are admitting a patient into an inpatient hospice facility for severe bone pain from non-small cell lung cancer. The patient describes significant weight loss, anorexia, and functional decline. He has been on stable doses of buprenorphine/ naloxone (Suboxone) 8 mg per day sublingual tablets for two years which has helped him stay “clean” from heroin. He is still able to tolerate oral pills. Which of the following is the best management decision to address his cancer related bone pain (Fast Fact #221 Buprenorphine for Opioid Addiction):
The challenge with the continued use of buprenorphine as this patient’s principle analgesic, is that buprenorphine is a mixed opioid agonist/antagonist. Therefore, answers (a) and (b) are unlikely to meet the patient’s analgesic needs. Answer d is wrong because the most concerning clinical issue is the patient’s severe pain in the setting of cancer related bone pain and a prognosis of likely short weeks, not concern for potential addiction behaviors especially considering the closely supervised setting of an inpatient hospice. Answer c is recommended seeing that methadone is an effective analgesic for cancer pain and rotation from buprenorphine to methadone would allow other full mu-opioid receptor agonist medications to be added without issues related to use of a partial opioid agonist/antagonist.
A 2012 systematic review identified these three clinical factors as having the strongest association with a 6-month or less prognosis in elderly patients with advanced dementia (Fast Fact #150 Dementia Prognosis):
Identifying reliable and verifiable clinical factors which correlate with a prognosis of < 6 months has been difficult in advance dementia. This has made it challenging for clinicians to successfully identify patients who are appropriate for enrollment in hospice. Although the NHPCO guidelines utilize a FAST score of 7c or worse as an indicator for hospice enrollment for dementia, a 2012 systematic review found that malnutrition, feeding issues, and dysphagia had the strongest association with death in 6 months or less.
A 44 y/o man being seen today by his primary care provider in clinic for follow up of his hypertension and recent diagnosis of basal cell skin carcinoma on the side of his nose. He underwent Mohs Surgery 6 weeks ago with clean surgical margins. Today, he shares that he is having nightmares, with recurrent themes of death. He has been taking Lisinopril and metoprolol for hypertension for more than 3 years, with no problems; the nightmares started only after his skin cancer was diagnosed.
Although anxiety related to the cancer diagnosis would seem an obvious cause of subsequent nightmares, which one of the following should be assessed as another common cause of nightmares (Fast Fact #88 Nightmares):
Nightmares can result from many causes including psychiatric illness, organic brain disease, hypoglycemia, alcohol/drug intoxication and withdrawal. Treatment of nightmares is usually multi-modal including assessment and intervention for psychiatric issues, assessment and intervention for drug/alcohol related problems and assessment/adjustment of prescribed medication. In some patients, specific medication can be added to help reduce nightmares such as benzodiazepines or atypical anti-psychotics. In this patient, brain metastases or hypercalcemia are extremely unlikely. While a past history of depression is always important, an immediate and very common cause of nightmares that can be quickly evaluated relates to alcohol use.
Medical evidence suggests any of the following anti-epileptics may ameliorate neuropathic pain from conditions such as post-herpetic neuralgia, diabetic neuropathy or trigeminal neuralgia EXCEPT (Fast Fact #271 Anti-epileptics for neuropathic pain):
Although the research is not robust and in fact in some cases is rather mixed for answer choices B-D, the use of levetiracetam for neuropathic pain is not supported by any known clinical research.
Which of the following is NOT used in the management of opioid withdrawal (Fast Fact #95 Opioid Withdrawal)?
Benzodiazepines are not used to manage opioid withdrawal symptoms, even though they are commonly utilized for alcohol withdrawal. Clonidine (answer choice A) can be used to treat autonomic hyperactivity symptoms. Trazodone (answer choice C) can be use to treat insomnia. Diphenoxylate/atropine (answer choice D) can be used to treat diarrhea.
Which of the following statements is TRUE regarding the Screener and Opioid Assessment for Pain Patients (SOAPP) and the Opioid Risk Tool (ORT) screening tools for potential opioid misuse (Fast Fact #244: Screening for Opioid Misuse and Abuse)?
Neither the SOAPP or the ORT has been validated in cancer patients nor in patients with advanced illnesses so (a) is incorrect. Both the SOAPP and ORT tools are designed to identify high-risk patients appropriate for close monitoring, but neither are diagnostic tools so answer (b) is correct. Answer c is correct because clinicians administering the ORT tool can be misled by patients with a history of opioid misuse who downplay past behavior, therefore it’s use in higher risk clinical settings such as a pain management clinic with a high prevalence of addiction would be less than ideal. Family history of substance abuse, not chronic pain, is one of the 5 items screened for on the ORT tool.
Which of the following is a recognized pharmacologic benefit of IV acetaminophen (Fast Fact #302 IV vs PO Acetaminophen)?
Peak analgesic effect of IV acetaminophen may only be 10 minutes vs 1 hour for oral acetaminophen. This is likely due to the higher CSF concentrations with IV over oral acetaminophen. Hence, there has been great interest in IV acetaminophen as a better peri-operative analgesic when quick and controlled analgesic onset is desired. B is wrong because the duration of action is essentially equivalent between oral and IV. Both the high cost and recent trials which have shown that IV acetaminophen did not have a lower NNT in comparison to oral acetaminophen in achieving 50% analgesia (in fact oral acetaminophen NNT was 3.8 compared with 5.3 for IV acetaminophen), have dampened some of the excitement about IV acetaminophen as a perioperative analgesic. IV acetaminophen has not been well studied for use in the terminally ill.
Which one of the following is not required to say that a patient has decision-making capacity (Fast Fact #55 Decision-making capacity):
The three criteria patients must meet to demonstrate decision making capacity include:
- Understand the information (e.g. be able to relate what they have been told and what it means)
- Ability to make a rational Evaluation of the burdens, risks, benefits, and alternatives to the proposed health care
- Communicate a choice (implies ability to communicate)
Choose the best answer regarding prognosis in liver failure (Fast Fact #189 Prognosis in Cirrhosis).
Both types of hepatorenal syndrome are associated with a 6 month or less survival. Hence the presence of hepatorenal syndrome should be a clinical sign that hospice care could be a viable care option for treating clinicians. Answer A is wrong because the CTP score neither utilizes renal function in its score nor is able to calculate a probabilistic chance of survival in 3 or 6 months, only probabilistic survival scores in 1 and 2 years. Answer B is wrong because the MELD score only utilizes three factors: serum creatinine, total bilirubin, and INR. Answer D is wrong because compensated cirrhosis is associated with a median survival of 12 years.
Which one of the following is the most likely cause of a new delirium in a cancer patient (Fast Fact #1 Terminal Delirium):
All of the options can cause delirium, but by far, adverse drug effects are the most common. Many of the drugs used to treat other symptoms have delirium as a toxicity: anti-cholinergics, anti-depressants, anti-emetics, benzodiazepines, opioids, etc. In one study, cancer patients exposed to daily doses equivalent to lorazepam above 2 mg, above 15 mg of dexamethasone (or its equivalent) or above 90 mg of subcutaneous morphine (or equivalent) were at the highest risk for developing delirium. Delirium in palliative care settings is frequently multifactorial with more than one etiology involved.Of note, in cancer patients, brain metastases is often first on clinicians minds when confronted with new onset delirium; in fact, most patients present with a focal finding such as aphasia or hemiparesis, rather than delirium, a more global sign of brain dysfunction. Don’t forget other causes of delirium, especially in the elderly, such as new infection, urinary retention or constipation.
For further reading and evidence, see:
- Incidence, etiology and reversibility of delirium: http://www.ncbi.nlm.nih.gov/pubmed/10737278?dopt=Abstract
- Psychoactive Medications and Risk of Delirium in Hospitalized Cancer Patients: http://jco.ascopubs.org/content/23/27/6712.full
- Evidence-based summary (2014): http://www.ncbi.nlm.nih.gov/pubmed/24480529
Routine vital signs show that a cancer patient developed an acute drop in blood pressure 30 minutes after the administration of IV fentanyl. She is asymptomatic. Choose the best management option (Fast Fact #175 Opioid Allergies):
Anaphylaxis or anaphylactoid reactions to opioids are typically associated with itching, urticaria, and bronchospasm. Fortunately, these reactions to opioids are felt to be rare, especially with fentanyl. Transient hypotension may occur after a bolus dose of an opioid due to vasodilation and vagally-induced hypotension; this is not felt to be a true allergic reaction. Hence, avoiding all opioids all together is unnecessary (answer choice a). Because this is not a true allergic reaction, rotating to a different opioid in either the same phenylpiperadine class (answer choice b) or rotating to a different opioid pharmacologic class (answer c) would be unlikely to be helpful. Rather close monitoring of the patient after the next fentanyl dose would likely be the best management option, especially since IV fentanyl has a shorter half life than other opioids.
“The Four A’s” for the appropriate clinical monitoring chronic pain in patients with a history of substance use disorders include all of the following EXCEPT (Fast Fact #312 Opioids for chronic pain in patients with a history of substance use disorders Part 2):
It is recommended that the “Four A’s of Pain” be utilized before and after every analgesic intervention in this patient population. The Four A’s include: analgesia (pain relief); activities of daily living (functional status); adverse effects; aberrant drug-taking behaviors.
You are initiating opioid therapy for 68-year old patient with severe bone pain from metastatic cancer. He inquires about driving safety while on opioids. Choose the best answer (Fast Fact #248 Counseling Patients about Opioid Side Effects and Driving Restrictions).
There are no large, randomized studies directly examining the risk of driving while on opioids so (a) is not correct. (b and d) are wrong because there is no such US Federal law. Furthermore, one study of videotaped patients showed that those on chronic opioid therapies did not exhibit more driving errors nor attention errors as matched controls. (c) is correct because opioids can slow reaction time, cause drowsiness, or cloud judgment when they are first started or increased.
Which one of the following is true regarding epidural analgesia via indwelling epidural catheters (Fast Fact #85: Epidural Analgesia)?
Answer choice B is incorrect because systemic side effects are minimized because the drug is delivered close to the site of action. Answer choice C is incorrect because analgesia can be administered by both a continuous infusion as well as patient controlled analgesia. Answer choice D is incorrect because epidural analgesia is most beneficial for well localized pain.
Which antidepressant medication has shown effectiveness in treating chemotherapy-induce peripheral neuropathy per a 2013 randomized controlled trial (Fast Fact #187 Non-tricyclic Antidepressants for Neuropathic Pain)?
Despite several trials assessing a multitude of different adjuvant analgesics (e.g. gabapentin, pregabalin, etc), the only non-opioid adjuvant analgesic to show efficacy in treating the pain associated with chemotherapy-induced peripheral neuropathy is duloxetine at a dose of 60 mg by mouth once a day. Of note, although venlafaxine has shown some efficacy in preventing chemotherapy-induced peripheral neuropathy, no trial to date has shown its efficacy in treating chemotherapy-induced peripheral neuropathy after the onset of the symptom.
Fast Fact #127 All of the following are recognized reasons clinicians should transparently address addiction concerns with their patients EXCEPT (Fast Fact #127 Substance Abuse in the Palliative Care Patient):
When methadone is utilized as an analgesic it does not require any extra licensing beyond a standard DEA license. Therefore, the diagnosis of “addiction” would not make easier for a clinician to prescribe methadone as an analgesic. Answer b-d are recognized potential benefits of directly addressing addiction concerns with patients.
A 74 year old woman with metastatic breast cancer is seen in palliative care clinic with recent onset diarrhea. She notes three days of liquid stool and worsening diffuse abdominal pain. One month ago, the patient was treated for clostridium difficile infection shortly after her last dose of systemic chemotherapy. One week ago, she presented to the clinic with worsening L sided chest pain attributed to tumor invasion into her L chest wall. At that time she was given prescriptions for dexamethasone and an increased dose of oxycodone. She reports that since then her pain has improved but her po intake for liquids and solids has greatly diminished. She denies nausea, vomiting, fevers, melena, or bloody stools.
Which of the following is the most likely cause of her diarrhea?
Diarrhea is a common symptom in patients with serious illness including cancer. This patient’s recent increased opioid dose combined with her decreased fluid intake place her at significant risk for constipation (answer a). When patients are severely constipated, “overflow diarrhea” can occur in which liquid stool is all that is able to pass around the area of impaction. While recurrent c.difficile infection (answer b) is possible, the onset of diarrhea shortly after an opioid dose increase and decreased oral intake makes constipation more likely. Chemotherapy-induced diarrhea (answer c) is unlikely as the patient stopped this treatment weeks prior to the onset of this symptom. Bacterial gastroenteritis (answer d), while also possible, is less likely given the lack of other signs and symptoms of infection and the patient’s high risk for constipation.
You are called by the home hospice nurse of a 47 year old man who is dying of end-stage lymphoma. The patient has been bedbound and comatose for the last two days. He is cared for by his wife and parents who have notified the nurse that his skin feels very warm today. They worry this may be causing him discomfort. When the hospice nurse arrives at the home, she finds a diaphoretic man with a temperature of 39 degrees Celsius. In addition to providing education to the family about fevers at the end of life, which of the following orders would be most appropriate (Fast Fact #256 Fever)?
Fever is a common symptom at the end of life. When considering treatments for fever in the dying patient, a number of factors must be considered. It is first important to decide if the fever is distressing to the patient. Next, if treatment is initiated, consideration of the appropriate medication, dose and route of administration are important. In this case, the patient is comatose and so cannot offer a symptom history. While it is not clear whether treating a fever reduces suffering for the actively dying patient, having an antipyretic medication available is reasonable to promote the patient’s comfort and is common practice in hospice medicine. In this case, as needed acetaminophen given per rectum (answer a) is the correct answer. Ibuprofen and naproxen (answers b and c), while helpful in reducing fever, are incorrect in this case because oral medication would not be appropriate for a comatose patient. Dexamethasone intravenously (answer d), while potentially effective in reducing fever, is incorrect because placement of an IV line would be unnecessarily burdensome in a hospice patient for whom per rectum medications are just as likely to be effective.
Which of the following is not provided as a mandated covered service of the Medicare Hospice Benefit (Fast Fact #82 Medicare Hospice Benefit):
Hospice agencies providing services under The Medicare Hospice Benefit must provide a wide range of services defined by Medicare. However, custodial care services is not one of the mandated covered services.
Which of the following medical conditions is a relative contraindication for the use of parenteral lidocaine for pain control (Fast Fact #180: Parenteral lidocaine for neuropathic pain)?
Lidocaine is extensively metabolized by the liver and metabolites are secreted by the kidney, therefore careful consideration of its use and dose adjustments should be made for patients with hepatic and renal insufficiency. Answer choice B is incorrect because cardiac monitoring during studies of normal volunteers has not demonstrated cardiac toxicity at clinically appropriate levels. Answer choices A and D are incorrect because the metabolism of lidocaine does not involve the thyroid or lungs and there are no known adverse effects relating to thyroid or pulmonary function.
All of the following have been used to control wound odor EXCEPT (Fast Fact #218 Managing Wound Odor):
Metronidazole can help reduce bacteria in wounds, a source of infection. Honey and Yogurt have been used with some success, although controlled trials are lacking.
What is the best response to emotions like anger or sadness after the delivery of bad medical news (Fast Fact #203 Managing One’s Emotions as a Clinician).
The correct answer is D: validate the patient’s experiences by naming their emotions. Expressing the affect of the patient can help convey that the practitioner is listening, and empathizing with the situation. This can be accomplished either as a statement, “you seem really sad given everything that is going on,” or as a question, “given everything that is going on, are you sad?” Offering additional treatments (B) and medical resources may attenuate the underlying emotions temporarily. But, the nidus of suffering will continue and may get worse as the treatments offered fail to work. Showing emotions (A) such as tears with sadness can often help demonstrate physician compassion and empathy. Most patients appreciate certain displays of emotions. The expression of emotion is acceptable as long as the focus of therapeutic intervention does not shift away from the patient. It is inappropriate for a clinician to lose all control of their emotions in front of patients. Although reframing the experiences and highlighting the positive aspects of a situation (C) can be helpful in some circumstances, it is not a clear first-step response. Trying to fix the problem without acknowledging and addressing the underlying emotion may exacerbate the situation and further alienate the patient.
You are called by the spouse of a patient for whom you have been prescribing immediate release oxycodone for bone pain related to multiple myeloma. He is currently on systemic cancer therapy, has life prolonging goals of care, and an estimated prognosis of several months to years. His spouse states he accidentally took three 15 mg oxycodone immediate release tablets instead of three 5 mg oxycodone immediate release tablets approximately 40 minutes ago. His spouse appropriately administered intranasal naloxone about 20 minutes later when the patient became unarousable and developed an agonal breathing pattern. He is now awake, alert, and back to his usual cognitive and respiratory baseline level of functioning. Which of the following statements would be correct to share with his wife (Fast Fact #328 Outpatient Use of Naloxone for Seriously Ill Patients):
Family members should be advised to contact 911 after every administration of intranasal naloxone. The peak effect of intranasal naloxone is 20 to 30 minutes with a half-life of about 2 hours. Therefore, for his safety, answer a is the best response.
Controlled trials have suggested that botulinum toxin injections (BoNTs) may have efficacy in palliating all of the following symptoms EXCEPT (Fast Fact #324 Palliative Uses of Botulinum Toxin):
Controlled studies have shown that serotype A BoNTs can help reduce spasmodic pain, hence it is FDA approved to treat spasticity of upper and lower extremities in adults. Smaller randomized trials have shown efficacy of BoNTs in reducing pain severity in post-herpetic neuralgia and trigeminal neuralgia. Although psychotherapy and anti-depressant medications remain the mainstay of depression treatment, BoNTs have been associated with anti-depressant effects lasting 2 weeks to 4 months in several small randomized controlled studies. While randomized studies have shown BoNTs to be useful for sialorrhea, no controlled study has demonstrated a role for BoNTs to treat xerostomia.
Patients with which type of illness are more likely to utilize hospice services in comparison to other chronic illnesses, likely because of a more predictable trajectory of physical decline and psycho-spiritual distress (Fast Facts #326 Illness Trajectories).
A study of Medicare patients showed that cancer patients were more likely to utilize hospice services in comparison to other chronic illnesses and that the more predictable illness trajectory is a likely factor in the increased hospice utilization of cancer patients. Reference: Lunney JR, Lynn J, Hogan C. Profiles of Older Medicare Descendents. JAGS. 2002;50:1108-1112.
All of the following medication classes are associated with acute urinary retention EXCEPT (Fast Fact #287: Drug-induced urinary retention):
Opioids are known precipitants of acute urinary retention; the mechanism is thought to be due to peripheral mu-opioid receptor agonism. Medications with anticholinergic properties, such as antipsychotics and antihistamines, are also commonly associated with urinary retention. Alpha antagonists are a recognized treatment of acute urinary retention especially when the urinary retention occurs in a patient with concomitant benign prostatic hypertrophy. Hence c is the correct answer. Clonidine and other alpha agonists are also associated with urinary retention.
Choose the most accurate statement regarding outcomes of patients who underwent cardiopulmonary resuscitation (CPR) for cardiopulmonary arrest in the hospital (Fast Fact #179 CPR Survival in the Hospital Setting).
Despite the rising prevalence of “rapid response teams”, there is no convincing evidence these teams have improved survival rates. In fact, there is no convincing evidence that survival from CPR in hospitalized patients has changed much at all in the last several decades. This is likely because the cause of cardiopulmonary arrest is usually associated with an advanced, incurable chronic illness in hospitalized patients rather than an easily reversible acute cardio-pulmonary event such as an isolated arrhythmia. Hence, A&B are both incorrect. The presence of sepsis has been found to be a poor prognostic indicator in hospitalized patients who underwent CPR per a 1998 meta-analysis, so C is incorrect.
Choose the best answer regarding tramadol as an analgesic in cancer pain in comparison with morphine (Fast Fact #290 Tramadol)?
A large population cohort study from the UK comparing tramadol with codeine found a significantly increased risk of hospitalization from hypoglycemia, especially in the first 30 days of initiation in non-diabetic patients. Other studies have found that tramadol may have less risk for respiratory depression, abuse and misuse than with other opioids. Morphine is about ½ the cost of an equivalent dose of immediate release tramadol and 1/6th the cost of sustained release tramadol. Tramadol is a Step II agent on the World Health Organization’s (WHO) pain ladder (1) and has FDA approval for the treatment of moderate to severe pain in adults.
Choose the functional status scale below that best matches the following descriptor. This functional scale was formalized in 1982. Published evidence has validated its usefulness in prognosticating overall survival for adults receiving chemotherapy for a variety of solid tumors. Scores greater than 2 on this scale have been correlated with a prognosis of 3 months or less in patients with solid cancers in the pre-immunotherapy era (Fast Fact #416 Functional Status Assessment in Serious Illness).
ECOG is a 5-point global functional scale with 0 set as a normal functional status without any noted limitations and 4 being a moribund functional status. Higher scores have been correlated with shorter survival in many malignant conditions. ECOG does not appear to correlate with anticipated survival as accurately in non-malignant illnesses. EFAT is a more involved scale that assesses 10 different domains and is most commonly utilized in research, not clinical settings. KPS is a 100 point scale that evaluates functional status; scores 50 or less have correlated with a shorter prognosis in patients with cancer. PPSis a modernized version of the KPS and is commonly utilized in hospice or palliative care units as a prognostic tool for patients with comfort-focused goals of care.
Which one of the following is an acceptable practice when prescribing Morphine ER 15 mg Q12 for a patient who logistically cannot be seen by the practitioner more frequently than every three months (Fast Fact #198 Schedule II Prescribing).
Answer choice (a) is wrong because refills are not allowed for schedule II opioids. Answer choice (c) is wrong because each written prescription of a scheduled II opioid should be for thirty days. In this patient’s scenario, 180 tablets of morphine ER would constitute a 90 day supply of the opioid. Answer choice (d) is wrong because facsimile prescriptions of schedule II opioids are not allowed by most states unless the patient resides in a long-term care facility or is receiving hospice care. Answer choice (b) is correct because 2 post-dated prescriptions are allowed for scheduled II opioids. When this is done, prescribing clinicians should counsel patients to leave the post-dated prescriptions with their pharmacist for safe keeping.
A long-term kidney hemodialysis patient who does not have any urine output wants to know how long she would likely survive if she stopped dialysis. The best response would be to say that the average patient in her clinical situation who stops dialysis survives approximately (Fast Fact #191: Prognostication in End-stage Renal Disease Patients Receiving Dialysis):
A 2013 study of 1947 patients who discontinued dialysis found the mean survival was 7.4 days (range, 0-40 days) . Reference: O'Connor NR1, Dougherty M, Harris PS, Casarett DJ. Survival after dialysis discontinuation and hospice enrollment for ESRD.Clin J Am Soc Nephrol. 2013; 8 (12):2117-22. See Patient information from the National Kidney Foundation: https://www.kidney.org/atoz/content/dialysisstop
Which one of the following is the best answer regarding to the use of opioids for chronic pain in patients with a history of substance abuse (Fast Fact #311: Opioids for chronic pain in patients with a history of substance use disorders Part 1):
The goal of analgesic therapy in chronic pain patients with a history of substance abuse is to ensure the therapy is safe, effective, and does not contribute to a worsening of substance use. As such, appropriate patient selection factors with regards to initiating opioids in this patient population involves a complex interplay of the patient’s prognosis, status of the substance abuse (recovery vs active), pain severity, and risk of adverse opioid effects. Clinicians should differentiate active substance use from patients in recovery or enrolled in a treatment program. There are no federal laws prohibiting opioid use in chronic pain patients with + marijuana urine drug screens, rather the decision to use opioids in these patients should be done on a case-by-case basis. There is some emerging evidence that long-acting opioids may be more associated with unintentional overdoses than short-acting opioids in the first 2 weeks after initiation.
When a referring clinician wants to broach the subject of a palliative care specialty consultation with a patient and family, which one is the best suggested phrases to use (Fast Fact #42 Broaching the Topic of Palliative Care Consultation with Patients and Families):
Many clinicians struggle to find the right words to introduce the concept of palliative care to their patients, fearful of provoking anxiety or anger. Option c) is a neutral statement that can apply to any palliative care consultation, no matter what the diagnosis or prognosis. In contrast, option a) is linked to the dying process, which does not fit the broad role for palliative specialists. Option b) is correct, but is not specific to palliative care, as other clinicians work in teams and option d) is a false statement, since there is never a time when “nothing more can be done”.
The Maslach Burnout Inventory is a validated, readily available screening tool that evaluates three domains to help identify signs of health professional burnout. Which of the following answer choices is NOT one of the domains assess in the Maslach Burnout Inventory (Fast Facts #167-170, 172 Health Professional Burnout):
The Maslach Burnout Inventory assess three scales a) Emotional Exhaustion measures feelings of being emotionally overextended and exhausted by one's work. B) Depersonalization measures an unfeeling and impersonal response toward recipients of one's service, treatment, or instruction. C) Personal accomplishment measures feelings of competence and successful achievement in one's work. B is the correct response because history of psychological illness is not a part of the Maslach Burnout Inventory.
Which of the following is true regarding vertebroplasty for a new compression fracture at the site of a known lytic spinal metastasis (Fast Fact #202: Vertebroplasty/kyphoplasty)?
Answer choice B is incorrect as infectious complications are very rare. Answer choice C is incorrect as pain relief is better in osteoporotic as compared to malignant vertebral compression fractures. Answer choice D is incorrect because neurologic damage related to a fracture is a relative contraindication for vertebroplasty.
A 43 year-old cyclist is intubated in the ICU after sustaining multiple fractures and brain trauma after being hit by an intoxicated driver. She has multiple skull fractures with bilateral intraparenchymal hemorrhage. Her Glasgow Coma Scale (GCS) remains 2/15 after 2 weeks in the ICU. Her pupils don’t respond to light and she does not withdraw to noxious stimulus but still has EEG activity and some brain stem reflexes; she does not meet brain death criteria. The power of attorney for health care and family reach consensus that she would not want to continue pursuing life-prolonging therapies, and request that all artificial life-support be discontinued. They request that her organs be donated in accordance with her wishes.
Which one of the following statements is True about organ Donation after Cardiac Death (DCD) (Fast Fact #242 Organ Donation After Cardiac Death):
Organ donation is legally permissible after brain death or cardiac death criteria have been met (Fast Fact #115 for Brain Death Criteria). Aan OPO representative should be contacted prior to death to approach the family about organ donation, and consent the family/patient decision makers for organ donation. However, members of the OPO and organ recovery teams should not participate in patient care decisions or medical care prior to the declaration of death; this policy aims to prevent conflict of interest. There is no mandate to involve specialist palliative care providers in organ donation decisions.
All the following are recognized consequences of health professional burnout EXCEPT (Fast Facts #167-170, 172 Health Professional Burnout):
Answer choices B-E all describe recognized consequences of health professional burnout in the published medical literature. Answer choice A is the correct answer because many times clinicians who are experiencing burnout work longer hours because of reduced productivity and a mistaken belief that if he or she were only to work harder than the issues they are encountering at work will go away.
Under the Medicare Hospice Benefit, which one of the following admission criteria is not required (Fast Fact #82 Medicare Hospice Benefit):
Under Federal rules, DNR status may not be used as a criteria for admission under the Medicare Hospice Benefit. Although it seems counter-intuitive, Medicare realized that forcing patients to choose DNR status placed an undue burden on patients that would limit enrollment of otherwise eligible patients.
All of the following are recognized toxicity concerns when continuous infusions of ketamine are utilized continuously for analgesia for greater than a 2 weeks duration EXCEPT (Fast Fact #132 Ketamine):
There is increasing concern about the potential for neuropsychiatric, urinary, and hepatobiliary toxicity with long term exposure to ketamine. Specifically, delusions, memory impairment, dysuria, and abnormal liver functional tests have been associated with therapeutic analgesic doses of just 2 weeks duration. Therefore, in patients with a prognosis more than a few weeks, attempts to withdraw ketamine at least 2-3 weeks after initiation should be made in earnest. Mucositis, on the other hand, is not a recognized side effect of ketamine use. In fact, there are case reports describing the analgesic benefit of low dose ketamine for mucositis
Based on published medical evidence, match the agent with the best supported indication for use ():
Placebo-controlled trials have shown fairly convincing evidence that baclofen can safely reduce muscle hypertonicity, clonus and involuntary muscle movements associated with multiple sclerosis. Although a few skeletal muscle relaxants have shown some short term (approximately 2 weeks) analgesic efficacy for acute back pain, a systematic review showed no convincing evidence that skeletal muscle relaxants were effective analgesics for muscle pain or spasms from mechanical back pain beyond 2 weeks. Tizanidine is one of the more sedating skeletal muscle relaxants, therefore it should be avoided in the elderly with preexisting cognitive impairment due to its risk of eliciting delirium. Conversely, metaxalone is one of the least sedating skeletal muscle relaxants. So, for several reasons it would not be a prudent agent to prescribe for insomnia induced by chronic back pain.
Which of the following is the most accurate statement regarding contributors for health professional burnout (Fast Facts #167-170, 172 Health Professional Burnout)?
More cases of health professional burnout occur in clinicians without a life partner, so a is not the correct answer. Being early in one’s health professional career (e.g. first 5-10 years of their career) is an established individual risk factor for burnout as are passive approaches to job stressors and attributing one’s achievements to luck or chance rather than one’s own abilities. Therefore, b and c are incorrect. A sense of lacking control in one’s own clinical work or scheduling is a significant risk factor for burnout. Therefore, answer d is the correct answer.
Which of the following is an appropriate approach to opioid dose escalation for cancer related pain (Fast Fact #20 Opioid Dose Escalation):
Answer choice A is incorrect because the dose increase for mild to moderate pain should be 25-50%. Answer choices C and D are incorrect because dose escalation for short-acting and long-acting opioids can be safely done every 2 and 24 hours respectively.
The single most important feature in establishing a diagnosis of addiction (psychological dependence) to a medication is (Fast Fact #68 Pain vs Addiction):
There is much discussion and debate over definitions of physical and psychological dependence in the addiction literature. However, at its core, psychological dependence requires evidence of behavioral impact including use despite harm and loss of control. These features are distinct from drug withdrawal (physical dependence) or drug tolerance (the need to use increasing doses to achieve the same therapeutic effect).
Which of the following statements is true regarding the known benefits of abuse deterrent opioid formulations (Fast Fact #329 Abuse Deterrent Opioids)?
Answer choice A is incorrect because Medicaid claims data specific to Oklahoma has only demonstrated lower health care costs with abuse deterrent opioid formulations in members with coexisting ICM-9 codes associated with opioid abuse. Hence, some experts have postulated that the most cost-effective patient strategy for utilizing abuse-deterrent opioids would be to reserve their use to patients with a prior history of addiction. Answer choice B is incorrect. Although the emergence of an abuse deterrent formulation of OxyContin ® has been shown to reduce OxyContin-related fatalities, at the same time heroin overdoses have increased which has led to concern that abuse deterrent opioids may contribute to shifting patterns of opioid abuse, rather than a broad reduction in opioid abuse. Answer choice C is incorrect because, as of January 2017, the only FDA approved abuse deterrent opioids available in the US are long acting brand name opioids. Answer choice D is correct, because any newly released opioid must demonstrate decreased clinical abuse potential in clinical trials before it.
After 10 days in the intensive care unit, a patient’s family makes the agonizing decision to discontinue all forms of life support, including mechanical ventilation and have their loved one extubated so he can die more peacefully from end stage liver disease. Now that the goals of care have transitioned to comfort, hospital administrators ask the treating clinician to consider whether the patient would be a good candidate for their hospital’s inpatient hospice program. To meet criteria for this program, the patient must meet general inpatient care (GIP) criteria as described in the Medical Hospice Benefit. Which of the following clinical factors would best support that the patient meets GIP criteria (Fast Fact #415 General Inpatient Hospice Care):
While GIP criteria can be individualized, at minimum they require appropriate orders and documentation of acute symptom management needs. Importantly, anticipated survival of hours-to-days (i.e., imminent death) is not justification alone to meet GIP standards nor is the discontinuation of all life prolonging medical interventions. Similarly, GIP cannot be used for caregiver stress relief or respite.
You are caring for patient who appears more anxious after being initiated on an immune-based therapy for her metastatic melanoma. You are concerned that financial hardships from undergoing this cancer therapy may be contributing to her emotional distress. What would be the best clinical question to explore whether financial toxicity or hardship from her cancer care may be contributing to her distress (Fast Fact #409 Financial Toxicity in Cancer Care)?
Two clinical models have shown promise in screening and addressing concerns for financial hardship with regards to clinical care. One is the validated single-question screening tool for financial toxicity: “Are you having difficulty paying for your medical care?” Answer d is the closest approximation of this screening tool. The other model is a 3-step approach derived from the “Ask Advise Refer” clinical model designed by the US Department of Health and Human Services for tobacco control. The other 3 responses (a-c) skips the first step of asking or screening for financial step. Doing so, could be problematic as the clinician is assuming they know the answer in how to fix the issue prior to understanding the issue fully from the patient’s perspective.
Choose the best answer regarding the pharmacologic properties of tapentadol in comparison to traditional opioids such as morphine or oxycodone (Fast Fact #228 Tapentadol).
Tapentadol is a centrally-acting, synthetic, oral mu-opioid receptor agonist which also inhibits norepinephrine and serotonin reuptake within the CNS. Therefore, answers A-C are incorrect. Structurally it is quite similar to a traditional opioid, although it tends to be costlier. A pooled analysis of randomized controlled trials suggest that gastro-intestinal side effects are likely milder with tapentadol than other opioids (Etropolski M, Kuperwasser B, et al. Safety and tolerability of tapentadol extended release in moderate to severe chronic osteoarthritis or low back pain management: pooled analysis of randomized controlled trials. Adv Ther 2014; 31:604-620).
Which one of the following statements about depression at end-of-life is true (Fast Fact #43 Is it Grief or Depression):
Distinguishing between normal grief and depression in patients near the end of life can be challenging. It is a common misconception that a clinical depression is a normal part of the dying process. The common symptoms of a clinical depression such as appetite and energy level changes are not helpful in the dying as these are often present and due to the underlying disease. In contrast, anticipatory grief is common, noted by alternating periods of normal mood with introspection and sadness. What is helpful in diagnosing depression is a constant sense of personal hopelessness/worthlessness; these findings are not present in normal anticipatory grief.
All of the following are recognized pharmacologic treatments of opioid induced pruritus EXCEPT (Fast Fact #37 Pruritus):
Aspirin-induced pruritus can mimic opioid-induced pruritus thus is not a recognized treatment. B-d are all recognized therapies to palliate opioid induced pruritus with varying degrees of evidence to support their use.
Survival from a traumatic adult brain injury, with an initial Glasgow Coma Score of 3-5 can be expected in what percentage of patients (Fast Fact #239 Prognosis in Traumatic Brain Injury):
Reference: Kothari S. Prognosis after severe TBI: a practical, evidence-based approach. In: Zasler ND, Katz DI, Zafonte RD, eds. Brain Injury Medicine: Principles and Practice. New York: Demos; 2007: 169-99
You are asked to consult in the care of a hospitalized patient with congestive heart failure to help address goals of care and hospice eligibility. Before you see the patient, the bedside nurse informs you that she thinks he may have a new deep vein thrombosis as his right leg became considerably more swollen than his left leg earlier in the day. What is the best response (Fast Fact #266 Consultation Etiquette)?
Negotiating roles, doing independent evaluations, gathering your own medical data, being responsive, and coordinating direct discussions with the primary team regarding medical concerns are all pivotal tenets of good consultative medicine, especially with regards to medical concerns which are not in the purview of the consultative question. Therefore, of all these choices, C is the best answer.
A patient is started on Patient Controlled Analgesia with a basal rate of 2 mg morphine. For poorly controlled pain, what is the minimum recommended time interval before the basal rate should be increased (Fast Fact # 92: Patient controlled analgesia in palliative care)?
The correct answer is 8 hours which accounts for the 5 half-lives of morphine necessary to achieve steady state. During this time, repeated bolus doses, escalated if needed, can be used to manage pain.
Mr. H is 75 year old man who is residing a VA-based palliative care unit whilst he undergoes palliative radiotherapy for recurrent head and neck cancer. While his cancer is not curable, his cancer clinicians are optimistic that his prognosis may be measured in months to short years. While on the palliative care unit, he is experiencing nightmares about past tours of combat duty. Clinicians note that he is avoiding physical therapy sessions and when asked he says it is because certain providers within physical therapy remind him of veterans who he watch die when stationed in Iraq and this has triggered him to relieve strong feelings of guilt and anger about what he could have done differently. You are worried he is suffering from post-traumatic stress disorder (PTSD).
Which of the following is considered a first-line pharmacotherapy for PTSD for Mr. H (Fast Fact #398 Assessment and Treatment of PTSD at the End of Life)?
Sertraline is a selective serotonin reuptake inhibitor (SSRI). This class of medications is considered to be first-line pharmacotherapeutics for PTSD. SSRIs often take several weeks to begin to work. In Mr. H’s situation, his prognosis is estimated to be between months to years, so it would be a very reasonable agent for his PTSD symptoms. There is little supporting evidence for mirtazapine and olanzapine in treating PTSD symptoms. Lorazepam and other benzodiazepines should only be utilized short-term to manage severe anger outbursts or other behavioral manifestations of PTSD. There is concern that they could worsen PTSD symptoms however long-term.
A patient with painful spinal metastases is wondering if he might benefit from radiopharmaceutical therapy rather than radiation. How should you advise him (Fast Fact #116: Radiopharmaceuticals)?
Answer choice A is incorrect because patients with multiple painful bone metastases are the most appropriate candidates for radiopharmaceuticals. Answer choice B is incorrect because a predictable side effect of radiopharmaceuticals is a 30-70% drop in leukocyte and platelet counts, whereas this effect is less likely with XRT. Answer choice D is incorrect because radiopharmaceutical administration requires no special patient isolation.
You are caring for an elderly, non-decisional patient with end stage renal disease who is receiving chronic hemodialysis. His spouse notices a new, painful subcutaneous nodule with a surrounding lace-like purplish discoloration on both of his forearms. What would be the best diagnostic test to order to confirm the diagnosis of calciphylaxis (Fast Fact #325 Calciphylaxis)?
Calciphylaxis is a clinical diagnosis. Serum lab tests are usually non-specific. Although a skin biopsy is pursued in rare occasions, it is usually not necessary especially when cardinal clinical features such as livedo reticularis (lace-like purplish discoloration of the skin) are present in the upper extremities. Furthermore, skin biopsy has been associated with poor wound healing for this indication. Although X-rays and CT scans may show calcification, imaging is usually unnecessary.
A breast cancer patient has dull-achy midline back pain that is progressively more intense over several weeks. The patient has a normal neurological examination. The first diagnosis that should be ruled out is (Fast Fact #62 Epidural Metastases):
Progressive midline back pain in a cancer patient must be evaluated for epidural metastases, (spread of cancer into the epidural space). The time from onset of pain to onset of neurological deficits (spinal cord compression) is typically many weeks or longer. The incidence of epidural metastases is highest in those cancers that frequently spread to the axial skeleton: breast, lung, prostate, myeloma, melanoma and hypernephroma.
Which one of the following statements is TRUE (Fast Fact 164 and 165 Informed Consent Part 1 and 2):
The legal standard of informed consent varies from state to state, Some use: what a reasonable patient would want to know; in other states the standard is, what a reasonable physician should provide (check with your local ethics committee). Informed consent is always required for medical testing and treatment except in cases where the situation meets all criteria for the “emergency exception”
- Life threatening emergency and time is of the essence.
- Patient is not decisional and no legal surrogate decision maker is available.
- A reasonable person would consent to the emergency treatment.
Which of the following is true regarding the concentrated oral morphine solution (20 mg/mL) (Fast Fact #53 Sublingual Morphine):
The bioavailability of the concentrated oral morphine solution is 23.8% which is greater than the bioavailability of SL morphine – just 9%. SL morphine and the concentrated oral morphine solution are equianalgesic. A crushed immediate release morphine tablet will not liquefy under the tongue and therefore are not believed to lead to any SL absorption. Only about 20% of the concentrated oral morphine solution is absorbed sublingually, the majority is felt to be absorbed through the gastro-intestinal tract. Hence (a) is the right answer.
