Palliative Care

Question 1

What are medications are most appropriate in the setting of palliative care for in pain management?

Answer 1

Opioids are used for pain relief and dyspnea in end-of-life care. Includes long-acting (scheduled) and short-acting (as needed) options.

Question 2

What is the mechanism of action of opioids?

Answer 2

Bind to opioid receptors (mu, kappa, delta) in the CNS, inhibiting pain transmission.

Question 3

Close observation for signs and symptoms of distress is the cornerstone of palliative care, what are the adverse effects of opioids that need to be watched for?

Answer 3

Respiratory depression, constipation, nausea, sedation, miosis, opioid tolerance.

Question 4

What is the preferred opioid for dyspnea and pain management in palliative care?

Answer 4

Morphine, a mu-opioid receptor agonist, reducing pain and dyspnea by decreasing respiratory drive.

Question 5

What are the adverse effects of morphine?

Answer 5

Respiratory depression, hypotension, constipation, sedation, nausea.

Question 6

Why would opioids still be given to patients despite respiratory depression?

Answer 6

Palliative care interventions are based on signs and symptoms of discomfort (eg, dyspnea, tachypnea) rather than with diagnostic testing or invasive procedures (although the tests may reveal abnormalities, their results usually do not influence clinical symptom management). Thus the main goal is to provide treatment of symptoms. For example patients with end-stage malignancy and acute respiratory failure that have been transitioned to palliative comfort care, the focus shifts toward treatment of symptoms (eg, dyspnea, secretions, pain, anxiety). Close observation for signs and symptoms of distress is the cornerstone of palliative care. Often times, these terminally patients will get extubated and given morphine for palliation of dyspnea at the end of life. There is a potential of developing expected adverse effects, including miosis and respiratory depression. However, if there are also signs of distress (ie, tachycardia, diaphoresis, inability to clear secretions) and active dying, including coma and agonal respirations (ie, irregular, rattling breaths), the patient’s comfort should be prioritized over his respiratory status in order to be consistent with the predefined goals of care. Administering additional morphine may hasten death, but it still should be given to minimize suffering. This ethical framework is known as the doctrine of double effect: Interventions that have adverse effects (eg, respiratory depression) are justified if they promote patient well-being (eg, allowing for a comfortable death).

Question 7

What is hydromorphone used for in the setting of palliative care?

Answer 7

Used as an alternative to morphine for pain relief, especially in patients with opioid tolerance.

Question 8

What is the mechanism of action of hydromorphone?

Answer 8

Mu-opioid receptor agonist, similar to morphine but more potent.

Question 9

Close observation for signs and symptoms of distress is the cornerstone of palliative care, what are the adverse effects of hydromorphone that need to be watched for?

Answer 9

Stronger respiratory depression, sedation, nausea, pruritus, constipation.

Question 10

What is glycopyrrolate used for in the setting of palliative care?

Answer 10

Used to reduce excessive respiratory secretions and ‘death rattle’.

Question 11

What is the mechanism of action of glycopyrrolate?

Answer 11

Anticholinergic; inhibits muscarinic receptors, reducing secretions.

Question 12

Close observation for signs and symptoms of distress is the cornerstone of palliative care, what are the adverse effects of glycopyrrolate that should be watched for?

Answer 12

Dry mouth, urinary retention, constipation, tachycardia.

Question 13

What is scopolamine used for in the setting of palliative care?

Answer 13

Used for respiratory secretions and nausea in palliative care.

Question 14

What is the mechanism of action of scopolamine?

Answer 14

Muscarinic antagonist; reduces secretions and has anti-nausea effects.

Question 15

Close observation for signs and symptoms of distress is the cornerstone of palliative care, what are the adverse effects of scopolamine that should be looked for?

Answer 15

Confusion, dry mouth, blurry vision, urinary retention.

Question 16

What is ondansetron used for in the setting of palliative care?

Answer 16

Used for nausea and vomiting management.

Question 17

What is the mechanism of action of ondansetron?

Answer 17

5-HT3 receptor antagonist; blocks serotonin in the CNS and gut.

Question 18

Close observation for signs and symptoms of distress is the cornerstone of palliative care, what are the adverse effects of ondansetron that should be watched for?

Answer 18

QT prolongation, constipation, headache, serotonin syndrome (rare).

Question 19

What is metoclopramide used for in the setting of palliative care?

Answer 19

Used for nausea, gastroparesis, and opioid-induced delayed gastric emptying.

Question 20

What is the mechanism of action of metoclopramide?

Answer 20

Dopamine (D2) receptor antagonist; increases gastric motility.

Question 21

Close observation for signs and symptoms of distress is the cornerstone of palliative care, what are the adverse effects of metoclopramide that should be watched for?

Answer 21

Extrapyramidal symptoms (tardive dyskinesia, akathisia), QT prolongation, drowsiness.

Question 22

What is chlorpromazine used for in end of life care?

Answer 22

Used for nausea, vomiting, and agitation in end-of-life care.

Question 23

What is the mechanism of action of chlorpromazine?

Answer 23

Dopamine (D2) antagonist, also blocks histamine and muscarinic receptors.

Question 24

Close observation for signs and symptoms of distress is the cornerstone of palliative care, what are the adverse effects of chlorpromazine that should be watched for?

Answer 24

Sedation, orthostatic hypotension, extrapyramidal symptoms, anticholinergic effects.

Question 25

What is haloperidol used for?

Answer 25

Used for delirium and terminal agitation.

Question 26

What is the mechanism of action of haloperidol?

Answer 26

Dopamine (D2) receptor antagonist; blocks dopaminergic transmission in the CNS.

Question 27

Close observation for signs and symptoms of distress is the cornerstone of palliative care, what are the adverse effects of haloperidol?

Answer 27

QT prolongation, extrapyramidal symptoms, akathisia, neuroleptic malignant syndrome.

Question 28

What is midazolam used for?

Answer 28

Short-acting benzodiazepine used for severe anxiety and agitation in palliative care.

Question 29

What is the mechanism of action of midazolam?

Answer 29

Enhances GABA-A receptor activity, leading to CNS depression.

Question 30

Close observation for signs and symptoms of distress is the cornerstone of palliative care, what are the adverse effects of midazolam?

Answer 30

Respiratory depression, sedation, paradoxical agitation in elderly patients.

Question 31

What additional services are included in spiritual and social support?

Answer 31

Includes chaplain services, social work, advanced care planning, and financial counseling.

Question 32

What are the adverse effects of lack of spiritual and social support?

Answer 32

Lack of support may lead to increased psychological distress in patients and families.

Question 33

What is the most appropriate next step in pain management for a 75-year-old man with metastatic lung cancer experiencing severe pain?

Answer 33

Opioids (e.g., morphine) should be initiated for moderate to severe cancer pain. Opioids bind to mu-opioid receptors in the CNS, inhibiting pain transmission. Adverse effects include respiratory depression, constipation, and sedation.

Question 34

What is the most effective pharmacologic treatment for dyspnea in end-of-life care?

Answer 34

Opioids (e.g., morphine) are the first-line treatment for dyspnea in palliative care. They reduce dyspnea by decreasing respiratory drive and altering the perception of breathlessness. Adverse effects include respiratory depression, nausea, and sedation. The non-medication alternatives are cooling fans, breathing exercises, and suctioning.

Question 35

What is the preferred pharmacologic intervention for a terminally ill patient with loud, rattling respiration due to excessive secretions?

Answer 35

Anticholinergic agents (e.g., glycopyrrolate, scopolamine) reduce excessive secretions by blocking muscarinic receptors. Adverse effects include dry mouth, constipation, and confusion.

Question 36

Why is glycopyrrolate preferred over scopolamine for secretion management in palliative care?

Answer 36

Glycopyrrolate does not cross the blood-brain barrier, reducing the risk of central anticholinergic effects such as confusion and delirium. Scopolamine, in contrast, has more CNS effects.

Question 37

What is the best initial treatment for a patient receiving opioids for palliative care who develops persistent nausea and vomiting?

Answer 37

Metoclopramide is effective for opioid-induced nausea by blocking dopamine (D2) receptors and promoting gastric motility. Adverse effects include extrapyramidal symptoms and QT prolongation.

Question 38

What alternative medication can be used for a palliative care patient with severe nausea refractory to ondansetron?

Answer 38

Chlorpromazine or haloperidol can be used for refractory nausea, particularly in opioid-induced or chemotherapy-related cases. These drugs block dopamine receptors and have sedative properties.

Question 39

What is the role of megestrol acetate in palliative care?

Answer 39

Megestrol is a progestin that stimulates appetite and is used for cancer-related cachexia. Adverse effects include thromboembolism, adrenal insufficiency, and fluid retention.

Question 40

What is the preferred pharmacologic treatment for agitation and delirium in a palliative care patient with metastatic cancer?

Answer 40

Haloperidol is the first-line treatment for delirium in palliative care. It blocks dopamine receptors and helps reduce agitation. Adverse effects include QT prolongation, extrapyramidal symptoms, and akathisia.

Question 41

What is the preferred benzodiazepine for severe anxiety in palliative care?

Answer 41

Midazolam is preferred due to its short half-life and rapid onset. It enhances GABA-A receptor activity, leading to sedation. Adverse effects include respiratory depression and paradoxical agitation.

Question 42

What non-pharmacologic interventions can improve quality of life in palliative care patients?

Answer 42

Psychosocial support (spiritual care, social work, advance care planning) is essential. Addressing emotional, existential, and financial concerns improves well-being and provides holistic care.