Palliative Medicine Formative Flashcards
Which fear is least likely to be experienced by dying patients?
- A: Becoming a burden
- B: Death
- C: Isolation
- D: Loss of dignity
- E: Pain
= B: Death
A significant proportion of dying patients have accepted the terminal nature of their illness and their concerns primarily relate to quality of life as opposed to prolongation of life.
An illness trajectory of slow decline with periodic crises and recoveries and a significant decline in the last few months of life in community is seen in which condition?
- A: Breast cancer
- B: Cognitive impairment
- C: Congestive heart failure
- D: Motor neurone disease
- E: Renal failure
= A: Breast Cancer.
The illness trajectory described is classical of advanced cancer. The non-malignant conditions listed generally have a more insidious steady decline.
The use of open-ended questions is recommended when communicating with patients.
Which question is ideally suited to commencing a therapeutic dialogue with a patient?
- A: Do you have any concerns?
- B: How are you feeling today?
- C: How can I help you today?
- D: What is your understanding of your illness?
- E: Where is your pain?
= D: What is your understanding of your illness?
An open-ended question style is recommended in communicating with patients. The majority of guidelines (e.g. SPIKES) advocate that establishing what the patient already knows/understands is critical to commencing a therapeutic or diagnostic dialogue. Whilst the other options are also open-ended, this one ensures that the patient is given opportunity to make explicit what his/her views are.
A 64 year old ex-smoker was recently diagnosed with metastatic small cell lung cancer. The disease has relapsed after chemotherapy and is now complicated by superior vena cava obstruction. She is admitted to hospital with severe dyspnoea. What is least likely to increase her comfort?
- A: Immediate commencement of palliative chemotherapy
- B: Provide supplemental oxygen via nasal cannula
- C: Start high dose corticosteroids
- D: Urgently arranging for palliative radiotherapy
- E: Using intravenous or subcutaneous opioid
= A: Immediate commencement of palliative chemotherapy.
- Further chemotherapy using a different agent may result in a useful response, though any beneficial response may be delayed. Radiation, corticosteroids, oxygen and opioids are all demonstrated to have a rapid beneficial palliative effect on the symptom of dyspnoea.
What is most likely to provide early symptomatic benefit for dyspnoea in a patient with lymphangitis carcinomatosis?
- A: Breathing into a paper bag
- B: Concurrent opioid and benzodiazepine
- C: Corticosteroids
- D: Diuretics
- E: Nebulised salbutamol
= B: Concurrent opioid and benzodiazepine.
- Lymphangitis is diffuse infiltration and obstruction of pulmonary parenchymal lymphatic channels by tumour causing impaired gas transfer. Corticosteroids may have a beneficial effect over hours to days and are usually recommended, but there is RCT evidence for low-dose opioids and benzodiazepines in palliating the sensation of shortness of breath.
In a terminally ill patient, which symptom is most suggestive of depression?
- A: Anorexia
- B: Decreased energy
- C: Desire to hasten death
- D: Feelings of worthlessness
- E: Weight loss
= D: Feelings of worthlessness.
The difficult part of diagnosing depression is that the physical symptoms of depression (decreased energy, sleep disturbance, change in appetite, fatigue and difficulty concentrating) can also be attributed to medical illness, especially in those with advanced disease. Endicott suggested using the criteria of depressed mood, marked disinterest or lack of pleasure in family and friends, and feelings of worthlessness and hopelessness to replace the neurovegetative signs.
A 54 year old female has advanced breast cancer with known pulmonary and skeletal metastases. She complains of severe pelvic pain on standing and walking. What is the most appropriate analgesic approach?
- A: Intravenous morphine 10 mg as required
- B: Oral methadone 8-hourly
- C: Oral paracetamol 1 gm with codeine 60 mg 4-hourly
- D: Oral paracetamol not exceeding 4 gm daily with sustained release opioid titrated to effect
- E: Oral sustained release oxycodone 12-hourly
= D: Oral paracetamol not exceeding 4 gm daily with sustained release opioid titrated to effect.
- The principle of ‘multi-modal analgesic’ therapy is recommended in managing malignant pain.
- Opioids alone and combination therapies exceeding the safe limit for paracetamol should be avoided.
During regular use of morphine for chronic pain control, what is the oral equivalent of 10 mg of subcutaneous morphine sulphate?
- A: 5 mg
- B: 10 mg
- C: 20 mg
- D: 30 mg
- E: 60 mg
= D: 30 mg.
The Health Department of WA Guidelines (lanyard card) recommend that approximate equi-analgesic effect for oral morphine is obtained by multiplying injected morphine dose by three. Conversion between oral and parenteral doses of opioids is necessary because the orally administered opioid undergoes first-pass hepatic metabolism.
In a patient with malignant spinal cord compression, which therapeutic option is most appropriate for emergency treatment to preserve function, whilst investigations or other therapies are being pursued?
- A: Dexamethasone 2 mg QID, subcutaneously
- B: Dexamethasone 16 mg daily, subcutaneously
- C: Hydrocortisone 100 mg IV QID
- D: Hydrocortisone 250 mg daily, subcutaneously
- E: Prednisolone 25 mg mane, orally for three days
= B: Dexamethasone 16 mg daily, subcutaneously.
High dose steroid in the form of 16 mg dexamethasone (usually by subcutaneous injection) is considered the most efficacious emergency treatment. This recommendation i almost universally accepted but randomised trials evidence is lacking.
An 82 year old male with metastatic prostate cancer and painful bone secondaries has recently become agitated, disoriented, repeatedly falls out of bed, and is verbally abusive. His past medical history includes ischaemic heart disease, and chronic renal failure.
Which medication is the most appropriate initial treatment?
- A: Clonazepam 1 mg sublingually
- B: Dexamethasone 16 mg subcutaneously
- C: Haloperidol 2.5 mg subcutaneously
- D: Midazolam 5 mg intravenously
- E: Morphine elixir 20 mg orally
= C: Haloperidol 2.5 mg subcutaneously
- The delirium associated with advanced disease is treated with haloperidol in the first instance, as the antipsychotic may partially reverse disordered thinking. A search for a reversible cause is then desirable. Sedation with the benzodiazepine group is only used as a last resort to diminish the risk of self-injury. Both morphine and dexamethasone may exacerbate confusion.
- A: Baclofen
- B: Dexamethasone
- C: Diazepam
- D: Gabapentin
- E: Haloperidol
- F: Hyoscine hydrobromide
- G: Macrogol
- H: Methadone
- I: Metoclopramide
- J: Midazolam
- K: Mirtazapine
- L: Phosphate enema
- M: Slow release morphine
- N: Subcutaneus hydromorphone
= I: Metoclopramide
- Metoclopramide not only acts at the chemoreceptor trigger zone to alleviate nausea, but is a gastrointestinal pro-kinetic agent. Increasing peristalsis in a patient suspected of a total bowel obstruction is likely to exacerbate colicky abdominal pain.
A male presents with motor neuron disease. He is troubled by painful muscle spasms in his legs.
Which medication should be prescribed?
- A: Baclofen
- B: Dexamethasone
- C: Diazepam
- D: Gabapentin
- E: Haloperidol
- F: Hyoscine hydrobromide
- G: Macrogol
- H: Methadone
- I: Metoclopramide
- J: Midazolam
- K: Mirtazapine
- L: Phosphate enema
- M: Slow release morphine
- N: Subcutaneus hydromorphone
= A: Baclofen
Baclofen is a derivative of GABA primarily used to treat spasticity and may have a beneficial effect on painful muscle spasms. The benzodiazepine group might also suppress muscle spasms but causes weakness of striated muscle, which would be undesirable in a patient with motor neurone disease. Baclofen is thought to cause less striated muscle weakness and is therefore preferred.
A patient is in the terminal stages of her illness. She is restless, agitated and confused. You have excluded reversible conditions contributing to her state. What is the most appropriate management strategy?
- A: Baclofen
- B: Dexamethasone
- C: Diazepam
- D: Gabapentin
- E: Haloperidol
- F: Hyoscine hydrobromide
- G: Macrogol
- H: Methadone
- I: Metoclopramide
- J: Midazolam
- K: Mirtazapine
- L: Phosphate enema
- M: Slow release morphine
- N: Subcutaneus hydromorphone
= E: Haloperidol
The delirium associated with advanced disease is treated with haloperidol as the antipsychotic may partially reverse disordered thinking.
A male with prostate cancer and extensive bone metastases develops urinary retention, increasing low back pain and numbness in his foot. What is the most appropriate medication to administer?
- A: Baclofen
- B: Dexamethasone
- C: Diazepam
- D: Gabapentin
- E: Haloperidol
- F: Hyoscine hydrobromide
- G: Macrogol
- H: Methadone
- I: Metoclopramide
- J: Midazolam
- K: Mirtazapine
- L: Phosphate enema
- M: Slow release morphine
- N: Subcutaneus hydromorphone
= B: Dexamethasone.
Until excluded by investigations, the presumptive diagnosis is developing spinal cord compression. Emergency management of suspected spinal cord compression is high dose dexamethasone.
A female with multiple myeloma was commenced on opioids to relieve her bone pain (with good effect). She now has griping abdominal discomfort, bloating and has not opened her bowels for several days. She wants to stop the opioids, as the pain is much better.
What is the most appropriate treatment?
- A: Baclofen
- B: Dexamethasone
- C: Diazepam
- D: Gabapentin
- E: Haloperidol
- F: Hyoscine hydrobromide
- G: Macrogol
- H: Methadone
- I: Metoclopramide
- J: Midazolam
- K: Mirtazapine
- L: Phosphate enema
- M: Slow release morphine
- N: Subcutaneus hydromorphone
= G: Macrogol.
Constipation is a universal adverse side-effect of opioid analgesic medications. An oral aperient is required to restore bowel function. Withdrawing opioid would result in recurrence of her pain.
What is your plan of management? (7 marks)
He is most likely entering terminal phase of his cancer with probable hepatic encephalopathy.
(1 mark)
The patient dies very peacefully in the hospital two days later.
Complete the six sections of the Medical Certificate of Cause of Death for this patient.
- Section 1: The disease or condition directly leading to death. (1 mark)
- Section 2: Approximate interval between onset and death. (1 mark)
- Section 3: Antecedent causes (morbid conditions, if any, giving rise to the above causes) stating the underlying condition last). (1 mark)
- Section 4: Approximate interval between onset and death. (1 mark)
- Section 5: Antecedent cause. (1 mark)
- Section 6: Approximate interval between onset and death. (1 mark)
- Section 1: The disease or condition directly leading to death = Hepatic encephalopathy. The first diagnosis appearing is always the MOST RECENT complication leading to death, but not only the mode of dying. (1 mark)
- Section 2: Approximate interval between onset and death = 1 week. From the history, we can determine that the home carer observed signs and symptoms consistent with the development of hepatic encephalopathy approximately 1 week (5 days) before eventual death. (1 mark)
- Section 3: Antecedent causes = Liver and lung metastases. The metastases were a necessary complication to explain the liver failure. (1 mark)
