Fast Facts Quiz

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 phenylpiperidine 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.

Benzodiazepines are not used to manage opioid withdrawal symptoms, even though they are commonly utilized for alcohol withdrawal. Clonidine can be used to treat autonomic hyperactivity symptoms. Trazodone can be used to treat insomnia. Diphenoxylate/atropine can be used to treat diarrhea.

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.

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, the best answer is “Do your own independent evaluation of the patient’s lower extremity. Communicate your physical examination findings to the team and negotiate your role regarding lower extremity management with the primary team”.

There should not be therapeutic duplication consisting of more than one type of PRN opioid by the same route. An order that contains vague parameters ('partially controlled or uncontrolled') can be interpreted differently by different health care providers, patients and families and therefore is incorrect. Morphine has a duration of action of only 2-4 hours.

Answer: Patients are less accustomed to having to bring medical concerns to their clinician first in adult care models.
Pediatric medicine tends to have a more defined medical home care model that anticipates medical needs.  Therefore, patients are often less accustomed to the adult health care model where it is often the patient’s responsibility to bring their medical concerns to their treating clinician.  Answer regarding privacy concerns is wrong because only a minority transition to adult care with complete medical records which care continuity of care barriers. Patients are unaccustomed to working with non-physician interdisciplinary care team members is wrong because pediatric clinics tend to be more family-oriented and have a more robust interdisciplinary team to address community and psych-social care concerns.  Answer about wider access to clinicians to address their long-standing pediatric illnesses is wrong since many times patients are unable to find an adult clinician with experience or expertise in their long-standing, child-onset condition; this can lead to many young adults returning back to pediatric health systems for care even after the age of 18.

Infectious complications are very rare. Pain relief is better in osteoporotic as compared to malignant vertebral compression fractures. Neurologic damage related to a fracture is a relative contraindication for vertebroplasty.

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. Cardiac monitoring during studies of normal volunteers has not demonstrated cardiac toxicity at clinically appropriate levels. Metabolism of lidocaine does not involve the thyroid or lungs and there are no known adverse effects relating to thyroid or pulmonary function.

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 often overlook non-physical sources of pain and consequently treatable suffering can get missed or overmedicated.

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, a bedbound state, and changes in cognition including decreased wakefulness, and delirium. As the syndrome progresses, patients become more obtunded and eventually reach the latest stage characterized by mottled extremities, 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.

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.

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.

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. 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. The MELD score only utilizes three factors: serum creatinine, total bilirubin, and INR. Compensated cirrhosis is associated with a median survival of 12 years.

Answer: 9-12 years of age
2-5 is typically considered the “preschool” age of development when it comes to concepts of death and grief.  At this age most children see death as temporary and reversible; they may even believe that death can be caused by thoughts or magical explanations.  6-8 is considered the “school age” phase.  At this phase children usually do not believe that death is universal nor may they believe that it could happen to them; however they are beginning to understand death as being final and irreversible.  At the “pre-adolescent” phase, children begin to see death as final, irreversible, and universal.  They also begin to ask about biological causes and effects with death (e.g., “will my fingernails still grow when I die,” “did Grandpa die because he smoked?”).  As teenagers, children develop the ability to think more abstractly and tend to consider how fragile life can be and the existential implications of death.

The dose increase for mild to moderate pain should be 25-50%. Dose escalation for short-acting and long-acting opioids can be safely done every 2 and 24 hours respectively.

Refills are not allowed for schedule II opioids.  Each prescription of a scheduled II opioid should be for thirty days at most.  In this patient’s scenario, 180 tablets of morphine ER would constitute a 90 day supply of the opioid.  Faxing 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.  2 post-dated prescriptions are allowed for scheduled II opioids.

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.

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.

Answer:  Many experts recommend a brief, open-ended inquiring focused on how to reduce trauma triggers in the health care space, as described in the correct answer response.  The Trauma History Questionnaire is primarily designed for research but it’s 24-question length makes it impractical to utilize routinely in clinical settings.  A CAPS-5 may be a useful screening tool for PTSD, but not all patients who would benefit from trauma-informed care principals will meet the DSM-V criteria for PTSD.  Eliciting a detailed history of all and any traumatic events is typically not vital and could be trigger emotional responses and feelings for some patients who have experienced or witnessed traumatic events.

Urge incontinence

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.

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. 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.

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 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.

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. 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 is possible, the onset of diarrhea shortly after an opioid dose increase and decreased oral intake makes constipation more likely. Chemotherapy-induced diarrhea is unlikely as the patient stopped this treatment weeks prior to the onset of this symptom. Bacterial gastroenteritis, while also possible, is less likely given the lack of other signs and symptoms of infection and the patient’s high risk for constipation.

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

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.

Methadone is known to cause skin irritation during a subcutaneous infusion. The dose conversion rate for Morphine is likely close to 1:1. Needle insertion into the chest wall can result in iatrogenic pneumothorax. Ideal locations include the upper arm, shoulder, abdomen, or thigh.

Tapentadol is a centrally acting, synthetic, oral mu-opioid receptor agonist which also inhibits norepinephrine and serotonin reuptake within the CNS. 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).

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).

Many clinicians struggle to find the right words to introduce the concept of palliative care to their patients, fearful of provoking anxiety or anger. “Palliative care clinicians can help you and your family deal with the changes brought on by your illness” is a neutral statement that can apply to any palliative care consultation, no matter what the diagnosis or prognosis. In contrast, ”palliative care clinicians have special expertise managing dying patients” is linked to the dying process, which does not fit the broad role for palliative specialists. Option “palliative care clinicians work together as an interdisciplinary team is correct, but is not specific to palliative care, as other clinicians work in teams and “palliative care clinicians are most useful when there is nothing more that can be done” is a false statement, since there is never a time when “nothing more can be done”.

Overflow incontinence

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?” The correct answer 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 skip 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.

There are no large, randomized studies directly examining the risk of driving while on opioids and there is no such US Federal law that prohibits driving while on opioids. One study of videotaped patients showed that those on chronic opioid therapies did not exhibit more driving errors nor attention errors as matched controls. Opioids can slow reaction time, cause drowsiness, or cloud judgment when they are first started or increased therefore patients should avoid driving until they hear otherwise from their clinician.

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. 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. 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 this clinical scenario that illicit marijuana was smoked.

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 is the correct answer. Ibuprofen and naproxen, while helpful in reducing fever, are incorrect in this case because oral medication would not be appropriate for a comatose patient. Dexamethasone intravenously, 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.

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.

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.

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.

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.

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. Differentiating xerostomia (dry mouth) 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. Similarly, not all thirsty patients will have xerostomia. 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.

Hospice agencies providing services under The Medicare Hospice Benefit must provide a wide range of services defined by Medicare. However, custodial care services are not one of the mandated covered services.

More cases of health professional burnout occur in clinicians without a life partner. 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. A sense of lacking control in one’s own clinical work or scheduling is a significant risk factor for burnout.

Answer: “While his illness journey was arduous, I know Tyler is in a better place now and no longer suffering.”
Providing genuine expressions of praise to the family can bolster long-term coping. Honoring the child by incorporating their first name, their sibling, and a specific memory can personalize condolence letters and help clinicians avoid clichés. Creating a legacy, or something that
positively represents the child after death can be an enduring source of meaning for families, so acknowledging the parents’ legacy creation for their child can communicate your support. It can be off-putting to many when clinicians make assumptions about the family’s belief systems and inserts the writer's belief system into their grief.

IT pumps are generally reserved for patients with a life expectancy of greater than 3 months. IT pumps are associated with fewer catheter problems. IT pumps are preferred in the presence of epidural pathology.

Answer:  BPSD is a pattern of behaviors that usually emerges over a period of weeks to months.  In that way, BPSD is unlike delirium since delirium is an abrupt (over the course of hours to a day) disruption of attention and alertness.  The patient who became upset when her favorite television was abruptly turned off may just be experiencing a proportionate emotional response from an event that she found frustrating.  Patients with dementia should be allowed to experience their usual range of emotions without fear of unwarranted clinical labeling.

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.

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.

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. Using a short succession of deep breaths is a commonly advocated for technique to interrupt the “Flight or Fight” stress response.  Self-guided body scan is a description of a known mindfulness technique called a body scan.  Mentally visualizing close loved ones and acknowledging the emotions associated with these loved ones is a modified description of Loving-Kindness Meditation.  Anticipating the triage order of the next 3 inpatient consults provides an example of future thinking that may distract the clinical by taking them out of the present moment and perhaps compound the present level of stress experienced during the patient encounter and therefore is the correct answer.

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.

The legal standard of informed consent varies between states. Some use: what a reasonable patient would want to know; in other states the standard is, what a reasonable clinician should provide.

Starting antibiotics represents an intervention with risks and alternatives. Therefore, an informed consent discussion is needed.  There is no “implied consent” just because 911 or a transport ambulance was called; such patients require the same level of informed consent discussions for medical care decisions as any other patient unless the medical situation satisfies the criteria for the emergency exception.  Physicians may proceed with treatment in emergency situations when all the following criteria are met:

• Life threatening emergency and time is of the essence.
• Patient is not decisional, and no legal surrogate decision maker is available.
• Reasonable person would consent to the emergency treatment.

Correct Answer: Can you tell me a little more about what leaving things in God’s hands means to you?

Spiritual beliefs commonly affect patient and surrogate decision-making.  The surrogate’s wish to leave things in “God’s hands” is a good indicator that spirituality is guiding their decision-making process in significant ways.  To better align with the surrogate, it’s best to explore with curiosity what they mean by this spiritual statement and what guides their beliefs.  Doing so will help the clinician acknowledge the surrogate’s spirituality as well as help the clinician eventually offer more individualized guidance once they understand these beliefs better.

Organ donation is legally permissible after brain death or cardiac death criteria have been met (Fast Fact #115 for Brain Death Criteria). An 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.

Answer: The diagnosis of addiction enables clinicians to prescribe methadone as an analgesic for cancer pain. 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.  The other answers are recognized potential benefits of directly addressing addiction concerns with patients.

Answer risky opioid use.  It is best to avoid non-diagnostic euphemisms when describing concerning opioid use patterns of behavior.  Addiction has a very specific diagnostic criteria as outlined in the DSM-V and it is not clear if the patient meets those criteria.  "Opioid abuse" and "chemical coping" are stigmatizing terms.  Utilizing these terms with the patient, in their chart, or with other colleagues risks preventable erosion of the clinician-patient relationship.

The correct answer is 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 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 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 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.

Only one long-acting opioid should be written for at a time. The fentanyl transdermal patch can only be safely dose escalated every 3 days. The peak effect of short acting opioids is typically 1-2 hours.

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.

Answer: Duloxetine
This patient is experiencing stress incontinence, likely from his recurrent malignant ascites.  Duloxetine has been shown to reduce stress incontinence episodes in multiple controlled trials.  Answers Finasteride and Terazosin are good options to treat overflow incontinence from a condition like benign prostatic hypertrophy. Oxybutynin is more targeted for urge incontinence (typically presented as a sudden and compelling desire to pass urine).  Besides oxybutynin would be a concerning choice considering this gentleman’s mild cognitive impairment and recent episode of delirium.

Neither the SOAPP or the ORT has been validated in cancer patients nor in patients with advanced illnesses. Both the SOAPP and ORT tools are designed to identify high-risk patients appropriate for close monitoring, but neither are diagnostic tools 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. The ORT tool is best designed for lower risk clinical settings such as a primary care clinic.  Family history of substance abuse, not chronic pain, is one of the 5 items screened for on the ORT tool.

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 dexamethasone at 8 mg orally once a day offers a medically reasonable medication, dose, and duration as described in the published medical literature.

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 < 20 and weight loss > 2% or appendicular skeletal muscle loss plus weight loss > 2%. An orexigenic is a term used to describe an appetite stimulant.

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.

“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 and scopolamine 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.

Answer: Anticipatory grief best applies here since it refers to the emotional response to an anticipated loss and in this case is manifesting in a loss of meaning from lost ambitions.  Bereavement is a more specific term to describe the emotional response to the death of a loved one.  Mourning refers to the culturally influenced ways we express bereavement via customs like wearing black to a funeral.  Charlies' response would not qualify as prolonged grief, since that term infers a complicated grief response that has been going on for more than 12 months.

Under Federal rules, DNR status may not be used as a criterion 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.

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.

Answer: ECOG is a 6-point scale for measuring performance status in which higher numbers correlate with worse performance status.  It is validated in cancer populations but not well validated in non-cancer illnesses.  Higher ECOG scores are correlated with shorter survival times in multiple well designed studies.  Clinical trial data of most immunotherapies and chemotherapies for cancer treatment typically are limited to very functional patient populations with an ECOG of 0-1.  There are no specific calculations to account for preexisting disabilities that would limit one’s ECOG score.  Oncologists tend to rate ECOG scores to be lower (or a better functional status) compared to patient’s self-rating.

Inability to titrate the opioid dose to meet the patient’s pain needs because of associated sedation” 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.  The other answers are all recognized features of opioid hyperalgesia. Another common feature of hyperalgesia is allodynia. Allodynia is pain that is elicited from an ordinarily non-painful stimuli, such as light touch of the distal extremity.

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.

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.

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.

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 the option above is excessive, equivalent to ~ 20 mg of IV morphine and therefore is incorrect.

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. 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.

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. A history of psychological illness is not a part of the Maslach Burnout Inventory.

Anemia, elevated BUN/creatinine and low sodium are all common in heart failure and are independent survival prognostic factors.

The challenge with the continued use of buprenorphine as this patient’s principle analgesic, is that buprenorphine is a mixed opioid agonist/antagonist. Therefore, buprenorphine is unlikely to meet the patient’s analgesic needs. 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. 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.

Answer Hyperkatifeia . Abulia is used to describe a lack of will or initiative. Demoralization has been used by some published authors to describe feelings associated with wanting to stop medical therapy for a serious illness out of a loss of hope or meaning. Pseudoaddiction is a controversial term that was originally utilized to describe what on initial appearance seem like opioid-seeking behaviors in a patient with cancer, but proves to be related to undertreated cancer pain. Hyperkatifeia is a recognized mood disturbance that can result in patients on long term opioid therapy (meaning on opioid therapy >3 months) who are undergoing an opioid taper. It has been theorized to derive from a hypodopaminergic state and can create barriers to opioid tapering via symptoms such as anger, anxiety, insomnia, and social withdrawal.

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.

Answer: ENCALS utilizes forced vital capacity along with multiple other prognostic factors including site of onset, mutational status, and age of onset of muscle weakness.  But an ENCALS score is more evidence-based and accurate in predicting prognosis than answer choices a, c, and d alone.  One notable caveat: the ENCALS is limited in that it was developed to predict survival only for patients with ALS who are not being treated with a tracheostomy nor continuous non-invasive ventilation.

Patients with multiple painful bone metastases are the most appropriate candidates for radiopharmaceuticals. A predictable side effect of radiopharmaceuticals is a 30-70% drop in leukocyte and platelet counts, whereas this effect is less likely with XRT. Radiopharmaceutical administration requires no special patient isolation.

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.

Answer: Pharmacotherapy with loop diuretics
Complete decongestive therapy (CDT) is typically done by licensed lymphedema specialist and involves five different types of lymphedema treatment including manual lymphatic drainage (answer choice a is an example of this); compression therapy (answer choice b is an example); lymph-reducing exercises (answer choice d is an example), skin care, and multi-layer short-stretch bandaging.  Diuretics is not a component of CDT and in fact evidence suggests that diuretics are less likely to provide significant relief compared to other forms of more generalized peripheral edema.

Systemic side effects are minimized because the drug is delivered close to the site of action. Analgesia can be administered by both a continuous infusion as well as patient-controlled analgesia. Epidural analgesia is most beneficial for well localized pain.

For this question you are changing opioid but keeping the same route so you start a new opioid at 50-75% of the calculated equianalgesic dose (or dose reduce by 25-50%).

First, calculate the 24-hour current dose: 10 x 6 doses in 24 hours = 60 mg PO Oxycodone/24 hours.  This total amount needs to be converted to PO Hydromorphone in 24 hours then the total divided into 6 doses (for the Q4hr use).  The equianalgesic ratio of PO Oxycodone to PO Hydromorphone ranges depending upon which conversion table is used.   Calculations with both commonly used conversions are shown below:
1) Use the equianalgesic ratio of PO Oxycodone to PO Hydromorphone:

20mg PO Oxycodone = 7.5 mg PO Hydromorphone

Calculate new dose using ratios: (60mg x 7.5)/20 = 22.5mg of PO Hydromorphone in 24 hours
Reduce dose 25-50% for cross-tolerance =1.25-16.875 mg in 24 hours

11.25mg/6 = 1.875mg PO Hydromorphone Q4hr (reduced by 50%)

16.875/6 = 2.81mg PO Hydromorphone Q4hr (reduced by 25%)

Therefore, 2mg PO Q4hr is the best answer.

2) Use the equianalgesic ratio of PO Oxycodone to PO Hydromorphone:

30mg PO Oxycodone = 7.5mg PO Hydromorphone

The calculation would be:

(60mg x 7.5)/30 = 15mg of PO Hydromorphone in 24 hours

Reduce dose 50% for cross-tolerance: 7.5-11.25mg in 24 hours

7.5mg/6 = 1.25mg PO Hydromorphone Q4hr (reduced by 50%)

11.25mg/6 = 1.875mg PO Hydromorphone Q4hr (reduced by 25%)

Therefore, of the above answers, 2mg PO Q4hr remains the best answer.

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.

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 and has FDA approval for the treatment of moderate to severe pain in adults.

Although the research is not robust and in fact in some cases is rather mixed for lacosamide, oxcarbazepine, and carbamazepine. The use of levetiracetam for neuropathic pain is not supported by any known clinical research.

Stress incontinence

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.

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.

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 < 2.5 gm/dl, weight loss of >10%, and poor functional status. Therefore, "evidence of right heart failure" is the best answer.

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.

A standard course is 300cGy x 10 treatments. Bone and peripheral nerves typically can tolerate a much larger total radiation dose as compared to liver and kidneys. Each daily treatment will typically last minutes.

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. The proportion of active drug that enters the systemic circulation is described as bioavailability (not distribution. The primary target tissue for opioids is the central nervous system.

“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%. The pooled accuracy of the surprise question for cancer patients appears to be slightly higher than non-cancer patients. The surprise question 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.

Hepatic encephalopathy (HE) is a neuropsychiatric syndrome with a fluctuating course associated with end stage liver disease (ESLD).  HE symptoms, which are graded from 0 to IV, range from subtle personality or sleep disturbances to confusion and coma.  Severe HE (grade III or IV) is manifested by gross disorientation, bizarre behavior, stupor, or coma.  Without transplantation, severe HE signifies a poor prognosis (58% 1-year and 77% 3-year mortality in one case series)

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 the correct answer is alpha antagonists (eg Doxazosin).  Clonidine and other alpha agonists are also associated with urinary retention.

Answer: The patient self-rates their pain
The Wong-Baker Faces Scale utilizes 6 cartoon faces (face 0 signifies no hurt; face 5 signifies worst hurt you can imagine).  It is designed for pediatric patients 4 and above.  The patient, not the parent, rates the pain on this scale.  The FLACC scale designed for patients 3 years or less.

A clinician rates the patient’s pain based on 5 observed, behavioral categories – facial expressions, legs, activity, crying, and consolability.

The Individualized Numeric Rating Scale (INRS) is a pain assessment tool designed for nonverbal children, particularly those with cognitive or developmental disabilities, or those who are unable to communicate their pain verbally. It is an adaptation of the standard numeric rating scale (NRS), which typically uses a 0-10 scale where 0 represents no pain and 10 represents the worst possible pain. The INRS differs in that it incorporates the individual patient's unique pain indicators as described by their parents or caregivers.

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.

All other answer choices describe recognized consequences of health professional burnout in the published medical literature. "Shorter clinical work hours due to more efficient documentation" 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.

The main side effects of a celiac plexus block for cancer pain are related to loss of sympathetic tone and include transient hypotension and increased intestinal motility resulting in diarrhea. 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.

It is best to have the discussion about a medical error as soon as possible when all the appropriate people can be present.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. Expressions of regret and sorrow for an individual error are 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. 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.

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.

Answer – suvorexant.  Suvorexant is a relatively new medication within a broader class of medications called orexin antagonists.  While more expensive than many other insomnia medications, as a class they appear to be safer than many commonly prescribed insomnia medications like temazepam (Restoril ®), zolpidem (Ambien ®), or trazodone.  Suvorexant is unique in that it is one of the only hypnotics shown to be safe in patients with mild to moderate Alzheimer’s dementia. 

External beam therapy can be used for multiple metastases. A pain flare may occur following external beam XRT and this is independent of number of lesions present. Although pain relief may begin at the time of radiation initiation, peak analgesic effect typically occurs 2-4 weeks after therapy.

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.

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.  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.

Aspirin-induced pruritus can mimic opioid-induced pruritus thus is not a recognized treatment. Methylnaltrexone, ondansetron, and paroxetine are all recognized therapies to palliate opioid induced pruritus with varying degrees of evidence to support their use.

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.

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.

Answer:  Pancreatic enzymes need to be mixed with food.  The enzymes are only released when the capsule reaches the higher pH of the duodenum.  As such, the best time to take PERT is right at the time of food consumption.  Because the enzymes degrade within 10 minutes, it is also recommended take additional doses every 10 minutes while eating.

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.

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. 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.  As of January 2017, the only FDA approved abuse deterrent opioids available in the US are long-acting brand name opioids. To be considered abuse-deterrent by the FDA, formulations must undergo in vitro studies, pharmacokinetic studies, long term epidemiological studies, and post market studies to assess their clinical misuse potential.

Tiny non-blanching, flat red or purple spots seen on arms and legs in clusters” is a description of petechiae which commonly occur in patients with dangerously low platelet counts. ” Large purple net-like patterns of painful lumps seen on the thigh creating difficult to heal areas of black-brown crust” is a description of calciphylaxis which is most commonly associated with end-stage renal disease. ” Swollen, boil-like red bumps that are painful and warm to touch; located on the lateral calf” 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; greater than 2 inches in diameter; and may include red, yellow, black, and/or purple discoloration.

Pregabalin is 3 times more expensive than gabapentin. 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. Pregabalin is a controlled V substance per the DEA; as of now gabapentin is not a federally 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.

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)

Individuals with BPD have difficulty sustaining ambivalent feelings and may instead label clinicians as either “wonderful” or “terrible”, a defense mechanism known as “splitting”.

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.