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Possible Exam Questions Flashcards

1
Q

List medications to be prepared for EOL in the home

A
  • Hydromorphone 2mg/ml
  • Haldol 5 mg/ml
  • Midazolam 5mg/ml
  • Scopolamine 0.4 mg/ml or glycopyrrolate 0.4 mg
  • Tylenol suppositories 650 mg
  • Foley 16 french and bag
  • Mouth swabs
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2
Q

List medications that could cause constipation

A
  • Opioids
  • Anticholingerics
  • Antihistamines
  • TCAs
  • 5HT3 antagonists (ondansetron)
  • NSAIDS
  • Iron
  • Blood pressure medications (diltiazem, verapimil)
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3
Q

List side effects of opiods that you expect to resolve quickly

A
  • Sedation
  • Respiratory depression
  • Nausea
  • Urinary retention
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4
Q

List antipsychotics in order of EPS risk

A

High potency typical antipsychotics

  • Haldol
  • high affinity for D2–> highest EPS risk
  • fewer ACh side effects
  • fewer metabolic side effects

Low potency typical antipsychotics

  • Chlorpromazine
  • low affinity for D2 —> lowest EPS risk of typicals
  • more likely to cause ACH side effects
  • Methotrimeprazine (somewhere in the middle)

Atypical antipyschotics

  • Risperdone (higher risk of atypicals)
  • olanzapine (low risk)
  • Seroquel (low risk)
  • Lowest EPS risk
  • more metabolic side effects, like glucose interolance
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5
Q

Describe CANMEDS competencies relevant to Adult palliative Medicine

A

Medical Expert:

  • PC subspecialists integrate all canmeds roles, applyi medical knowledge, clinical skills, professional attitudes in the provision of patient centred care

Communicator:

  • effectively facilitate the doctor patient relationship adn dynamic exchanges that occur before, during and after medical encounter.

Manager

  • Subspecialists are integral participants in health care organizations, organizing sustainable practices, making decisions concerning the allocation of resources, and contributing to the effectiveness of the health care system.

Health Advocate

  • Subspecialists use their expertise and influence responsibly to advance the health and well being of individual patients, communities and populations

Scholar

  • Subspecialists demonstrate a lifelong commitment to reflective learning, and creation, dissemination, application and translationg of medical knowledge.

Professional

  • PC subspecialists are committed to the health and well being of individuals and society through ethical practice, profession-led regulation and high personal standards of behaviour.

Leader

  • PC subspecialists engage with others to contribute to a vision of a high-quality health care system and take responsibility for the delivery of excellent patient care through their activities as clinicians, administrators, scholars, or teachers.
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6
Q

Motor testing by level

A
  • C1-C4 Spontaneous breathing
    • C5 Shoulder abduction (deltoid)
    • C6 Wrist extension (carpi radialis longus and brevis)
    • C7 Elbow extension (triceps)
    • C8 Finger flexion (flexor digitorum superficialis/profundis, lumbricals)
    • T1 Finger adduction & abduction (dorsal/palmar interossei, abductor digiti quinti)
    • T1-T12 Intercostal and abdominal muscles
    • T12-L3 Hip flexion (iliopsoas)
    • L2-L4 Hip flexion, knee extension (quadriceps), hip adduction
    • L4 Ankle dorsiflexion and inversion (anterior tibialis)
    • L5 Big toe extension (ext hallucis longus), heel walk (ext digitorum), hip abduction (gluteus medius)
    • S1 Ankle plantarflexion and eversion (peroneus longus), toe walk (peroneus brevis), hip extension (gluteus maximus)
    • S2-S4 Rectal sphincter tone
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7
Q

Urinary incontinence - list types and 3 treatments

A

1. Stress Incontinence - Antimuscarinics (tolteridine)

  • urethral sphincter unable to prevent flow of urine in the setting of increased intra abdominal pressure
  • pelvis surgery. radiation, pregnancy

2. Urge incontinence - TCAs (Ach to increase sphincter tone) or Smooth muscle relaxant (oxybutynin)

  • inability to control urine when detrusor contracts
  • no warning, large volume
  • infection, tumour, drugs, radiation

3. Overflow incontinence - alpha adrenergic blockers (terazosin or doxazosin)

  • bladder fills to capacity but cannot contract
  • constipation, prostatic hypertrophy, stricture, tumour
  • small frequent volumes of urine

4. Total incontinence - timed self catheterization or indwelling cath

  • complete loss of sphincter function due to tumour invasion or spinal cord injury
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8
Q

List 5 drugs that increase methadone levels (CYP3A4 INHIBITORS)

A
  • INHIBITORS of CYP3A4
    • decrease methadone metabolism and increase levels
  • CNS depressants :
    • Alcohol
    • Benzos
    • Cannabis
  • Antiarrthymics
    • amiodarone
    • diltiazem
  • Anti-depressants
    • Fluvoxamine
    • Sertraline
    • Fluoxetine
    • metronidazole
  • Antibiotics
    • Cipro
    • Erythromycin
  • Antifungals
    • Fluconazole
    • Ketoconazole
  • Other
    • Cimetidine
    • topiramate
    • Quetiapine
    • haldol
    • grapefruit juice
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9
Q

List 5 drugs that decrease methadone levels (CYP3A4 INDUCERS)

A
  • Inducers of CYP3A4 etc —-> increase methadone metabolism and decrease serum levels —> pain
  • Anti-epileptics
    • carbamazepine
    • phenobarb
    • phenytoin
  • CNS depressants
    • chronic alcohol use
  • Dexamethasone (> 16 mg/day)
  • Rifampin
  • Spironolactone
  • Vit C, St John’s wort
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10
Q

What enzyme metabolizes methadone

A

CYP 3A4

CYP 2B6

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11
Q

Serotonin Discontinuation Syndrome

A

HANGMAN

Headache

Anxiety

Nausea

Gait instability

Malaise

Asthenia

Numbness

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12
Q

Who should be present for a family meeting?

A
  • Patient
  • Patient’s identified substitute decision maker
  • Patient’s family
  • All allied care providers involved.
  • Physician
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13
Q

List the format of a family meeting

A

Prepare:

  • Familiarize yourself with chart, goals of care and objectives of meeting
  • Consider a pre meeting with health care providers to discuss lead, goals, potential sources of conflict
  • Consider contacting other consultants in advance if their opinion is needed
  • If in a shared hospital room, make arrangements for roommates or inform them.

Meeting:

  • private setting in a circle
  • if patient unconscious, decide with SDM whether to hold in front of patient or not.
  • Introductions
  • Summary of goals /agenda
  • Ask for input
  • Clarify family’s understanding of the patient’s condition and treatment plan
  • Summarize current situation from the perpsective of the treating team. Clarify any misunderstandings.
  • Direct the meeting towards treatment plan, goals of care, disposition
  • Summarize plan and goals of care. Discuss follow up, next steps. Identify a family spokesperson.
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14
Q

Components of reflective writing

A
  1. Description of event
  2. Feelings : what were you thinking and feeling during the event?
  3. Evaluation : What was positive or negative about the event?
  4. Analysis : How can you make sense of the event?
  5. Conclusions : What alternatives to your action existed?
  6. Action plan: What would you do the next time a similar event occurs?

Stages of reflection (Gibbs 1998)

DFEACA

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15
Q

Five reasons not to use family as interpreters:

A
  • filtered, abbreviated or omitted information
  • lack of medical vocabulary
  • lack of understanding of medical terms
  • Unfair burden on family/friends
  • Issues of confidentiality
  • Conflict of interest (potential)
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16
Q

Development stages and understanding in children

A
  • Infancy (0-2)
    • sensory input, attachment, regulation, trust in caregivers
    • aware of tension, separation, unfamiliar and absence
    • use familiarity, routine, structure for comfort
  • Early Childhood (3-6)
    • death is reversible, not personalized
    • MAGICAL THINKING
    • provide concrete info about the state of being dead
    • address feelings of guilt
    • dispel misconceptions
  • Middle Childhood (7-12)
    • aware of finality of death
    • aware of causality
    • struggles with unfairness, spiritual issues
    • worry about their health and others
    • may request graphic details about death and decomposition
    • may benefit from learning about the illness
  • Adolescence (>12)
    • More adult understanding of universality of death
    • existential/spiritual issues
    • anticipation/worry about future
    • self absorbed
    • may engage in risky behaviours
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17
Q

Why not to use codeine in kids

A
  • genetic polymorphism is CYP 2D6
  • variable metabolism - can lead to respiratory depression and death
  • increased side effects - toxicity
  • lack of evidence for safety/efficacy in children
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18
Q

Steps of metabolism of codeine

A
  • CYP3A4 –> norcodeine
  • UGT2B7 –> Codeine 6 glucoronide
  • CYP2D6 –> Morphine –> M6g, M3G (toxicity)
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19
Q

List 4 types of populations looked after in pediatric palliative care

A

1. Progressive conditions that are palliative at diagnosis

2. Conditions for which curative treatment is possible, but may fail

3. Conditions involving severe non progressive disability causing vulnerability to health complications

4. Conditions requiring intensive long term treatment to maintain QOL

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20
Q

List DSM Criteria for Delirium

A
  1. Disturbance in attention
  2. Acute change from baseline. Fluctuating
  3. Must have one disturbance of :
    • memory
    • disorientation
    • language
    • visuospatial ability
    • perception
  4. Not better explained by a neurocognitive disorder
  5. Evidence it is caused by a medical condition
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21
Q

You are caring for a man in hospice whose goals are comfort. He doesn’t wish for any more investigations. He is an opioid for pain. He develops confusion. List 5 points related to how you would assess confusion?

A
  • CAM for delirium
  • Assess for dehydration
  • Assess for OIN / hyperalgesia
  • Neurologic exam
  • Physical exam
  • Review all medications
  • Assess for bloodwork if indicated
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22
Q

What is the mg/kg dose of ORAL morphine in opioid-naive child for pain?

For dyspnea?

A
  • PAIN : < 50 kg : 0.2 mg/kg po q4h
  • DYSPNEA : < 50 kg : 0.1 mg/kg po q4h
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23
Q

What is the formula for corrected calcium?

A

Corrected calcium = measured calcium + 0.02 (40-albumin)

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24
Q

List cancers that cause cord compression in men and women

A

Men:

  • Prostate
  • Lung
  • Renal
  • Myeloma

Women

  • Breast
  • Lung
  • MM
  • Renal
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25
Q

List 4 pyschosocial issues you will discuss with 16 year old patient with Duchenne’s muscular dystrophy?

A
  • Mental health - coping, depression, anxiety
  • Educational goals and planning
  • Transition to independent living planning
  • Relationships / social support
  • Sexuality
  • Risk taking behaviour
  • Prognosis and goals of care
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26
Q

An Afghani immigrant who does not speak English is worked up for cough and found to have metastatic cancer. Bilingual son is adamant that the patient is not told about the diagnosis. List 5 points to consider as you address this patient’s ethical dilemma

A
  • Fiduciary duty is to patient
  • Patient Autonomy and preferences regarding disclosure must be respected.
  • Discuss with patient his preferences for knowledge and communication
  • Gather all pertinent information / prognosis, capacity
  • Analyze information and generate all realistic options
  • For each option, consider underlying principles, consequences and beliefs
  • Judge which option brings the best consensus outcome
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27
Q

An elderly female has bladder cancer with hematuria. Not a candidate for cystectomy, not responded to radiation therapy. List 3 treatments to target bleeding for painful hematuria

A
  • Continuous bladder irrigation
  • Alum bladder irrigation
  • Silver nitrate
  • Percutaneous arterial embolization
  • TXA oral
  • Radiation if not already done
  • Cystoscopy and ablation
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28
Q

List 6 specific questions you will ask when adopting dignity conserving care

A
  1. How would I feel in this situation?
  2. Is my attitude towards this patient based on my own experiences, fears, anxieties or assumptions?
  3. What do I need to know about you as a person to better care for you?
  4. What is bringing you joy and hope in your life right now?
  5. What are you most proud of?
  6. Who are the people who are most important to you?
  7. Are there things about you that this disease does not affect?
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29
Q

What are the components of dignity conserving care?

A
  • Attitude (my own)
  • Behaviour
    • kindness and respect
    • treat the patient. not just illness
  • Compassion
    • ​convey with look, touch
  • Dialogue
    • use language to acknowledge the whole person
    • know about them as humans to make sense of their suffering
    • art of listening
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30
Q

List 4 ways of increasing access to palliative care for homeless populations

A
  • Provide pall care in shelters and on the street
  • Harm reduction strategies in hospices or hospital
  • Patient navigators
  • Increased training in mental health and susbtance abuse amongst palliative care professionals
  • Access to hospital and not for profit hospices
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31
Q

List 4 aspects of palliative care practice that are improved with practicing self reflection

A
  • Insight into personal limitations and assumptions
  • Improves resiliency, reduces burnout
  • Improves team functioning, resolution of conflict
  • Improves ability to provide dignity based care
  • Self learning
  • Improved patient care
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32
Q

List 5 causes of intractable, chronic hiccups in advanced cancer

A

Central

  • stroke
  • tumour
  • encephalitis
  • neurodegnerative

Peripheral

  • Irritation of diaphragm
    • pleural effusion
    • hepatic mets
    • ascites
    • pneumonia, hepatic abscess
    • lymphadenopathy
    • malignancy (esophageal, stomach)
    • MI
    • pericarditis
  • Gastric / bowel distention
    • obstruction
    • gastroparesis
    • GERD
    • distention
  • Irritation of vagus nerve
    • mediastinal lymphadenopathy
    • pharyngitis / tumour
    • esophagitis
    • GERD, gastritis
  • Toxic/metabolic causes
    • uremia
    • hypocalcemia
    • hyperventilation
    • infection
    • hypokalemia
    • hyponatremia
    • hyperglycemia
  • Drugs
    • antibiotics
    • antidepressants
    • antiparkinsonian drugs
    • benzos
    • STEROIDS (dex)
    • magnesium
    • morphine
    • NSAIDS
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33
Q

List three opioid side effects that resolve with time

A
  1. Respiratory depression
  2. Sedation
  3. Nausea
  4. Urinary retention
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34
Q

List 6 components of reflective writing?

A
  • Description of event
  • Feelings during the event
  • Evaluation of positives and negatives
  • Analysis : how can you make sense of the event?
  • Conclusions : What alternatives to your action existed?
  • Actions for future : What will you do next time?
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35
Q

List steps for conversion of oxycodone to morphine

A
  • Current opioid regime and total daily dose
  • Oxycodone : morphine 1.5 : 1
  • Dose reduction 25-50%
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36
Q

List 5 potential consequences of interventional pain management

A
  • Epidurals/ Intrathecals:
    • infection
    • local anesthetic toxicity
    • catheter displacement
    • pump malfunction - medication withdrawal / pain crisis
    • epidural catheter fibrosis
    • intrathecal catheter granuloma
    • bleeding / epidural hematoma
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37
Q

Likelihood of EPS with anitpsychotics

A
  1. Typical antipsychotics
  • haldol
  • chlorpromazine
  • prochlorpromazine
  1. Methotrimeprazine (somewhere in the middle)
  2. Atypical Antipsychotics
  • Risperdone (worst)
  • Quetiapine (low risk)
  • Olanzapine (low risk)

Other drugs that case EPS:

  • metoclopramide
  • SSRIs
  • SNRIS
  • NDRI
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38
Q

A patient with end stage lung disease comes to hospital with vivid dreams and myoclonus. All other investigations are negative.

Drugs:

Hydromorphone 5 mg sc q4h

Olanzapine 2.5 mg sl bid prn

What is the first thing you will do to treat this patient?

A
  1. Reduce the dose of hydromorphone and reassess.
  2. Consider opioid rotation
  3. Treat myoclonus
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39
Q

List 6 classes of drugs that can be used to treat tenesmus

A
  • Opioids
  • topical calcium channel blockeres (diltiazem, nifedipine)
  • belladonna / opium supp
  • steroids (radiation proctitis)
  • Antispasmodics - buscopan
  • topical analgesics - lidocaine
  • nitroglycerin (if fissure)
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40
Q

What is the mg/kg dose of ORAL Hydromorphone for pain for kids?

A
  • Pain : < 50 kg : 0.06 mg po q4h
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41
Q

What are the treatments for hypercalcemia?

A
  • Mild (< 3.0)
    • avoid thiazides
    • po hydration if possible
    • avoid calcium and vit D
  • Moderate (3.0-3.5)
    • Hydration IV or PO
    • Bisphosphonate
  • Severe (> 3.5)
    • IVF to urine output 150 cc/hour
    • Calcitonin 100 u sc tid x 1-2 days
    • Bisphosphonate
    • Denosumab if RF or contraindication to bisphosphonate
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42
Q

A patient with ovarian cancer presents with colicky abdominal pain and feculent emesis. She has had no BM x 5 days and no flatus for 36 hours.

List 4 classes of medications that will improve her symptoms

A
  • Opioids
  • Corticosteroids - dexamethasone
  • Antiemetics - haldol
  • Antisecretory agents - somatostatin analogue
  • Anticholingerics - buscopan
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43
Q

A patient with bladder cancer is in the palliative care unit. He has a PPS of 40%. He is on SC hydromorphone regularly and prn. He has a foley catheter that requires frequent irrigation. He is going to be discharged home.

List 5 systemic barriers to a home discharge

A
  1. Accessibility to palliative home care nursing
  2. Access to respite care for family
  3. Access to palliative care MD support
  4. Availability of pharmacy 24 hours
  5. Availability of training for family or patient to administer sc meds in home
  6. Financial barriers for catheter and sc supplies
  7. Equipment for functional decline (hospital bed, commode, etc)
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44
Q

A patient with Parkinson’s disease is in hospice and suddenly loses the ability to take oral medications. They develop symptoms that seem like neuroleptic malignant syndrome.

List one drug and one route than can be used to treat this patient

A
  • Midazolam sc (hospice patient, EOL)
  • Other :
    • oral dissolvable carbodopa/levodopa
    • rectal carbodopa/levodopa
    • NG tube and levodopa
    • Transdermal rotigotine patch (dopamine agonist)
    • NMS: dantrolene, amantadine
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45
Q

A patient has end stage renal disease (uremia). List each of the following medications with the symptoms they treat (use each drug only once)

  • Baclofen
  • Cannabis
  • Methadone
  • Pramipexole (dopamine agonist)
  • Zinc
  • Restless leg syndrome
  • Insomnia
  • Alerations in taste and smell
  • Hiccups
  • Pain
  • Neuropathy
A
  • Restless legs - Pramipexole
  • Insomnia - cannabis
  • Alterations in taste and smell - Zinc
  • Hiccups - baclofen
  • Pain -
  • Neuropathy - methadone
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46
Q

What is the major risk of acutely stopping antiparkinsonian medications?

A

Withdrawal syndrome

Parkinsonism-hyperpyrexia syndrome

  • suppression of dopaminergic system
  • NMS
  • Rigidity, pyrexia, altered LOC, autonomic instability
  • treat with reinstatement of parkisonism meds or TD Rotigotine
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47
Q

A patient with early stage dementia has seen three of her family members develop complications of dementia and die. She wishes to die before she loses competency. For her own reasons, she does not want to access the MAID program. She asks what other ways she can hasten her death.

List 2 legal and ethical ways of responding

A
  • Review suicide risk and refer to psychiatry prn
  • Discuss advanced care directives re: po intake in advanced dementia
  • Goals of care for comfort rather than life prolonging treatments
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48
Q

List 4 agents that can be used for the management of agitation in a home setting and list 1 reason why this agent is a good choice. Use each reason only once.

A
  • Lorazepam - useful for alcohol or benzo withdrawal. long lasting, sublingual route
  • Methotrimeprazine - long acting, sedating
  • Haldol - multiple routes available (IM, PO, sc)
  • Olanzapine - useful for nausea, low risk EPS, oral dissolvable tablet
  • Seroquel - useful for anxiety, comes in liquid form
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49
Q

A patient with cancer presents with a complete bowel obstruction and has nausea and vomiting.

List 4 non pharmacological treatments for this patient’s symptoms

A
  • NG to suction
  • Venting gastrostomy tube
  • Surgical resection
  • Mouth care
  • Stent for proximal obstruction (GOO or duodenal)
  • Radiation
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50
Q

A patient has ALS and dyspnea. All reversible causes have been ruled out. List 5 management strategies for chronic dyspnea in this patient

A
  1. NIPPV (noctural or 24 hours)
  2. Midazolam for anxiety related to dypsnea
  3. Opioids
  4. Portable suction for secretions
  5. Chest physio
  6. Cough assist device
  7. Nebulized NAC as mucolytic
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51
Q

List 4 types of life limiting illness that are most likely to result in depression

A
  • Malignancy (pancreatic, lung, lymphoma - inflammatory cytokines)
  • ESRD
  • Parkinson’s
  • MS
  • ALS
  • HIV/AIDS
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52
Q

List 4 changes that occur in skin from chronic untreated lymphedema

A
  • fibrosis
  • papillomata
  • cellulitis
  • ulceration
  • hyperkeratosis
  • hyperpigmentation
  • lymphorrhea
  • lymphangectasia
  • Maceration
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53
Q

Other than etiology, list 2 differences between moisture induced dermatitis and pressure wounds

A
  • Moisture dermatitis:
    • diffuse distribution
    • pink or red
    • partial thickness
    • no slough or eschar
    • painful
    • Irregular shapes
    • No necrosis
  • Pressure ulcer
    • over bony prominence
    • red to bluish purple
    • partial or full thickness
    • may have slough, eschar
    • painful or painless
    • circular or regular shape
    • may have necrosis
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54
Q

List 4 topical treatments for the management of bleeding associated with a malignant wound

A
  • topical TXA
  • chemical cautery with silver nitrate
  • calcium alginate
  • topical thromboplastin
  • Electrocautery
  • zinc chloride paste (Moh’s paste)
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55
Q

A patient is in hospice and has terminal secretions. She appears comfortable. The family is distressed by the sound, but they do not want her any more sedated.

List 5 non pharmacological interventions for managing this situation.

A
  1. Reassurance and education that this is normal
  2. Repositioning regularly
  3. Gently suctioning of oropharynx only
  4. Discontinuation of fluids
  5. Music or fan in the room
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56
Q

List 4 broad categories of treatment for malodorous wounds

A
  1. Topical or systemic antibiotics (topical metronidazole/ gel)
  2. Odour absorbent dressings (charcoal)
  3. Environmental control (essential oils, peppermint, cat litter under the bed)
  4. Wound cleansing/ debridement
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57
Q

A patient with a long standing history of type 2 diabetes has neuropathy, some other complication and gastroparesis. Nausea and appetite are bothersome to patients.

List 4 interventions for managing this patient’s gatroparesis.

A
  1. Improved Glycemic control
  2. Dietary changes (small amounts, more frequently)
  3. Prokinetic agent (metoclopramide or domperidone)
  4. Anti-emetic (gravol, ondansetron)
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58
Q

A patient with a history of cocaine and alcohol use is seen by you. The patient tells you at their appointment that they need to increase their dose, but you don’t think they need it.

Other than an opioid contract, list 6 strategies to manage this patient’s care.

A
  1. Regular screening for abherrent use
  2. Interdisciplinary team
  3. Prescription with short dispensation
  4. Random urine drug screen
  5. Addictions counselling / support
  6. Frequent follow up to prescribe refills
  7. Maximize non opioid medications for pain
  8. Involve family in treatment plan
  9. Access to naloxone take home kit
  10. Choose medications with long duration and slower onset
  11. Inquire about involuntary diversion (stealing)
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59
Q

List 4 symptoms that can be managed using cannabinoids

A
  • Nausea - chemotherapy induced nausea and vomiting
  • Appetite / Anorexia from HIV/AIDS
  • Neuropathic pain - CIPN
  • Peds epilepsy
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60
Q

What enzyme converts codeine into active form?

Why is codeine dangerous to use in children?

A
  • CYP 2D6
  • genetic polymorphism:
    • variable metabolism from poor to ultrarapid metabolizers
    • ultrarapid metabolizers can result in rapid accumulation of morphine metabolites
    • leads to respiratory depression and death
    • increased side effects, variable efficacy
  • lack of evidence for safety
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61
Q

List 4 indications for the use of a lidocaine infusion. List 2 specific symptoms that would prompt you to NOT increase the rate of infusion.

A
  1. Refractory pain.
  2. Neuropathic pain
  3. Dose limiting side effects of opioids and adjuvants
  4. Pain crisis from neuropathic pain

Symptoms that would cause you to NOT increase infusion:

  • circumoral paresthesias
  • tinnitus
  • lightheadness
  • metallic taste in mouth
  • drowsiness
  • bradycardia
  • hypertension

Severe toxicity:

  • restlessness
  • tremor
  • facial twitching
  • seizure
  • perspiration
  • dyspnea
  • apnea
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62
Q

List exclusion criteria for lidocaine infusion

A
  • Uncontrolled hypertension BP > 160
  • Altered LOC
  • Prior allergy
  • Liver failure
  • Cardiac failure
  • Heart block
  • Uncontrolled seizures
  • Hypokalemia
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63
Q

List 5 elements that are part of the Serious Illness Conversation Guide

A

SET UP the conversation

ASSESS illness understanding and info preferences

SHARE prognosis

EXPLORE key topics (goals, fears, trade offs)

SUMMARIZE conversation

DOCUMENT conversation, record goals of care

COMMUNICATE decisions with key clinicians, family (tracking record)

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64
Q

List 7 symptoms of complicated grief (Abnormal)

A
  1. Prolonged grief > 12 months
  2. Non acceptance of the death
  3. Intense anger
  4. Intense longing/yearning more days than not
  5. Symptoms are interfering with function
  6. Out of proportion to cultural norms.
  7. Not explained by another mental disorder
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65
Q

List 6 complications of a non resectable tumour that is encasing the celiac axis (vessel and nerves)

A
  1. Persistent epigatsric pain
  2. Weight loss
  3. Nausea and vomiting
  4. Bowel obstruction
  5. Biliary obstruction
  6. Thrombosis
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66
Q

Complications of a celiac plexus block

A
  • Diarrhea (transient)
  • Orthostatic hypotension (ephedrine 30 mg po tid)
  • Paraplegia (ischemic cord injury)
  • Aortic dissection
  • Seizures
  • Circulatory arrest
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67
Q

List 2 physical exam findings that palliative care physicians can use to predict death is likely to occur soon (< 8 hours)

A
  • Cheyne Stokes breathing
  • Periods of Apnea
  • Mottling of extremities
  • Cool extremities
  • Decreased consciousness
  • Pulselessness of radial artery
  • Inability to clear secretions
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68
Q

List 5 regular elements of pharmacokinetics that are different in an adult and a a child OVER 2 years of age.

List 1 element of pharmacokinetics that is increased in children

A

LADME

  • Liberation
  • Absorption
    • ​skin and BBB more effective as child ages, making them less vulnerable to toxicities
  • Distribution
    • ​higher volume of distribution
  • Metabolism
    • ​liver metabolism faster in children
    • drugs metabolized more quickly
    • half life reduced, need more frequent dosing
  • Excretion
    • ​greater rate of elimination of many drugs
  • List 1 element of pharmacokinetics that is increased in children:
    • CYP 450 liver metabolism is increased until adolescence
    • reduced body fat
    • increased vol of distribution
    • increased rate of renal elim
    • mg/kg dosing
    • increased surface area
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69
Q

List 5 regular elements of pharmacokinetics that are different between an adult and a child LESS THAN 2 years of age.

A
  • Liberation (dissolution)
    • decreased protein binding
  • Absorption
    • decreased gastric emptying time
    • increased surface area
    • decreased abosrption in GI tract
  • Distribution
    • increased fat to muscle ratio
  • Metabolism
    • drug half life increased (2-3 x longer)
  • Excretion
    • decreased renal clearance

Differences between adult and child < 2 years

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70
Q

A 22 year old male getting treated for testicular cancer presents to the hospital with dehydration. He has been vomiting profusely. The vomiting only subsides when he is immersed in hot water or a hot shower. What is the most likely cause of the vomiting?

A

Cannabis hyperemesis syndrome

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71
Q

List 2 opioid induced side effects that people typically develop tolerance to within the first few days

A
  • Nausea
  • Sedation
  • Respiratory depression
  • Urinary retention
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72
Q

List 4 mechanisms for opioid induced nausea

A
  1. Decreased GI motility - Constipation
  2. Delayed gastric emptying
  3. Direct effect on CRTZ
  4. Increased vestibular sensitivity
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73
Q

List 2 mechanisms for opioid induced constipation

A
  • decreased GI motility
  • increased rectal sphincter tone
  • decreased awareness of rectal fullness
  • prolonged bowel transit time
  • increased fluid resorption
    *
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74
Q

List 4 classes of agents that are used to treat opioid induced constipation and name 1 agent from each class

A
  • Stimulants
    • senna
    • bisacodyl
  • Osmotic laxatives (non absorbable)
    • PEG
    • lactulose
  • Saline laxatives (absorbable, electrolyte imbalance)
    • mag citrate
    • sodium phosphate
  • Opioid antagonists
    • Naloxegol
    • Methylnaltrexone
  • Enema
    • saline
    • fleet
    • mineral oil
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75
Q

List 6 commonly prescribed classes of medications that can cause constipation

A
  • Opioids
  • Anticholinergics
  • 5HT3 receptor antagonists
  • Antipsychotics
  • TCAs
  • Antacids
  • NSAIDS
  • CCBS
  • Iron
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76
Q

List 2 typical antipsychotics. List 2 atypical antipsychotics. Then list them in order from GREATEST to LEAST likelihood of developing EPS

A
  • Haldol (typical)
  • Methotrimeprazine (typical)
  • Risperdone (atypical, EPS worst offender)
  • Olanzoapine (atypical, low risk)
  • Quetiapine (atypical, lowest risk)
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77
Q

List 6 distinct receptors that antipsychotics work on:

A
  1. Dopamine D1, D2
  2. Serotonergic 5HT2, 5HT3
  3. Acetylcholine M1, M2
  4. Histamine H1
  5. Alpha 1 adrenergic
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78
Q

List 4 treatments for SCC (pharm and non pharmacologic)

A
  • Dexamethasone
  • Radiation
  • Surgery
  • Opioids for symptoms management
  • Stereotactic radiation
  • transarterial embolization
79
Q

List 4 classes of common palliative care drugs that cause xerostomia

A
  1. Opioids
  2. Anticholinergics
  3. TCAs
  4. Antipsychotics
  5. Antiepileptics
  6. Diuretics
  7. Cannabinoids

Non pharm causes:

  • Head and neck rads
  • mouth breathing
  • dehydration
  • 02 therapy
80
Q

List 6 steps in planning (? conducting) an interprofessional family meeting with a patient who has progressive illness

A
  1. Plan
    * review chart, talk to consultants, pre-meeting with allied health
  2. Setting
    * private quiet setting, in a circle if possible
  3. Introductions
  4. Agenda and goals of the meeting
  5. Family understanding of patient condition and treatment plan
  6. Summarize current situation from treating team’s perspective.
  • clarify misunderstandings
  • identify family concerns
  1. Direct toward treatment plan, goals of care
  2. Summarize plan, next steps, goals of care. Designate family spokesperson. Document
81
Q

List 4 reason that a paracentesis would be performed for a patient with advanced illness

A
  • Dyspnea relief
  • Pain relief
  • Diagnosis of SBP
  • Diagnosis of malignancy by cytology
82
Q

List 3 mechanisms of hypercalcemia in the oncologic setting

A
  1. Direct osteoclast activity stimulated by bony metastases
  2. Secretion of PTHrP that stimulates osteoclastic bone resorption
  3. Vit D / calcitriol secreting lymphomas
  4. Ectopic PTH secretion (Rare)
83
Q

A 17 year old patient has relapsed Ewing Sarcoma with diffuse pulmonary metastases. List 5 non-pain emergencies that this patient is most likely to experience at the end of life.

The nurses tell you he has experiences one of the above emergencies. You expect the patient to die in the next 12-24 hours. List ONE drug and route that would best treat this patient.

A

Palliative Emergencies:

  1. Dyspnea crisis
  2. Pain crisis
  3. Pulmonary hemorrhage
  4. PE
  5. Terminal delirium
  6. Anxiety
  7. ? Spinal cord compression

Treatment:

Midazolam subcutaneously

84
Q

You wish to convert a patient from long acting oxycodone 10 mg po q8h to a morphine sc/iv infusion.

List 5 steps that are necessary in this conversion.

What rate would you order for this infusion?

use a ration of 2mg oral morphine : 1 mg oral oxycodone

A
  1. Total oxycodone in 24 hours - 30 mg
  2. Convert to MEDD : 30 mg x 2 = 60 mg oral morphine / 24 hours
  3. Convert MEDD to IV/sc morphine : 60 mg oral morphine/2 = 30 mg IV morphine/ 24 hours
  4. Convert to hourly infusion rate : 30 mg / 24 hours = 1.25 mg/hour
  5. Dose reduce by 25-50% for incomplete cross tolerance. 1.25 x 0.75 = 0.93 mg/hour. 1.25 x 0.5 = 0.63 mg/hour. Select rate = 0.75 mg/hour
85
Q

List 6 body systems and their associated side effect from glucocorticoid use

A
  1. GI
  • PUD
  • GIB
  1. CNS
  • euphoria
  • anxiety
  • insomnia
  • psychosis
  1. MSK
  • proximal myopathy
  • Avascular necrosis
  • Osteoporosis
  1. Derm
  • think skin
  • striae
  • acne
  • atrophy
  1. Endocrine
  • Adrenal suppression
  • hyperglycemia
  1. Immune system
  • impaired wound healing
  • risk of infection (TB, PJP, candida)
  1. Cardiovascular
    * Hypertensions
  2. Optho
  • cataracts
  • glaucoma
86
Q

Select 3 of the following drugs that can be used rectally in their oral form.

Select 5 of the following drugs that if held for at least 72 hours would result in withdrawal symptoms

Methadone

Hydromorphone

Gabapentin

Nortriptyline

Dexamethasone

Haloperodol

Lorazepam

Venlafaxine

A

Rectal administration

  • methadone
  • lorazepam
  • dexamethasone
  • antiepileptics
  • ondansetron
  • maxeran

Withdrawal symptoms after AT LEAST 72 hours

  • hydromorphone
  • methadone
  • lorazepam
  • venlafaxine
  • gabapentin
  • dexamethasone (AI?)
87
Q

List 3 benefits of pediatric palliative care for children and families

A
  • Support for family members
  • Coordination of services in the community
  • Symptom management
  • Care at end of life
  • Improved QOL
  • Improved healthy grieving and supprt for family
  • Expert symptom management
  • Coordination of services
88
Q

A patient’s son asks you if his mother should use medical cannabis oil (high THC content) to treat nausea.

List 3 contraindications to the use of medical cannabis oil that you would discuss with the patient/son.

List 4 adverse effects of cannabis.

List 2 commonly used drugs that would interact with cannabis.

A

Contraindications:

  • hypersensitivity to cannabinoids
  • severe CV or cerebrovascular disease (MI, stroke)
  • severe liver disease
  • severe renal disease
  • personal history of mood disorder or psychosis

Adverse effects:

  • psychosis
  • hyperemesis
  • dependence
  • somnolence
  • dry mouth
  • tachycardia
  • Anxiety
  • MI
  • dizziness

Interactions with cannabis

  • CYP 2C9, 3A4
  • CNS depressants - benzos, alcohol
  • Opioids
  • Phenobarbital, carbamazepine/phenytoin
  • Omeprazole
  • fluoxetine
  • Azithromycin
89
Q

List 4 causes for respiratory congestion at the end of life

A
  1. Decreased mucociliary clearnace
  2. Impaired cough reflex
  3. Pulmonary edema
  4. Aspiration
  5. Continued fluids / volume overload
  6. Pneumonia
90
Q

List 4 factors that increase the perception of pain

A
  1. Previous experiences with pain
  2. Meaning of the pain
  3. Unknown source of pain
  4. Pain is overwhelming
  5. Feeling of being a burden
  6. Feeling out of control
  7. Previous experiences with pain
91
Q

List 6 functions of palliative care societies or associations that would allow them to advocate for patients with advanced illness.

A

Mission and Goals from CSPCP:

  1. Promote education for health care workers
  2. Develop clinical practice guidelines
  3. Advocate for government policy to improve care
  4. Contribute to health and human resource planning
  5. Promote interprofessional palliative care for patients
  6. Support and promote research, QI, KT.
92
Q

An 82 year old patient has myeloma. They are no longer responding to treatment. They have received numerous red blood cell transfusions. The family wants to continue transfusions.

List 5 facts and issues associated with transfusion that you would discuss with this family.

A
  1. Anemia is a result of bone marrow failure from incurable myeloma. It is not curable and death will occur at some point despite transfusions.
  2. Frequent need to access health care for transfusions may impact quality of life.
  3. Risks of transfusions (TACO, TRALI, hemolytic reactions, etc)
  4. Goals of care around bloodwork, hospital visits, etc should be clear.
  5. There is no clear evidence to guide the use of blood transfusions in the palliative care population.
93
Q

List 2 validated pain scales that can be used for a non-verbal 10 year old patient

A
  1. FACES pain scale
  2. Visual analogue scale (0-10)
  3. FLACC (face, legs, arms, cry, consolability) scale
94
Q

List 4 clinical features of neuroleptic malignant syndrome.

List 2 laboratory values that would be abnormal and can be used to differentiate between NMS and Serotonin Syndrome.

A
  • Fever
  • Rigidity
  • Autonomic instability
  • Encephalopathy / altered LOC

Lab values:

  1. CK elevation
  2. WBC elevation
95
Q

List 2 opioid receptors that methadone works on.

List 2 non opioid receptors that methadone works on.

A

OPIOID (r methadone):

  1. Mu
  2. Kappa (and delta)

NON-OPIOID (s methadone):

  1. NMDA
  2. Serotonin reuptake inhibition
  3. Norepinephrine reuptake inhibition
96
Q

List 5 reasons why using non medical professionals, including family or friends, as interpreters is not advisable in palliative care.

A
  1. Lack of medical vocabulary
  2. Faulty translation by omission or filtering information
  3. Burden on family member
  4. Lack of confidentiality
  5. Conflict of interest
97
Q

Communication in palliative care is important. Communication can be enhanced using narrative writing. List 3 components of reflective writing.

A

DFEACA

  1. Description
  2. Feelings
  3. Evaluation
  4. Analysis
  5. Conclusions
  6. Action plan
98
Q

A patient has increasing pain and you wish to switch to a different opioid. List 4 scenarios in which you would not dose reduce for incomplete cross tolerance.

A
  • Need to change to a different route with well controlled pain
  • Poorly controlled pain and no OIN
  • rotating to TD fentanyl (dose reduction already factored into dosing)
  • End of life and strong desire to avoid underdosing given short timeline
  • Intubated patient and in severe pain with risk of respiratory compromise mitigated
99
Q

List 2 situations in which it would be ethically acceptable not to disclose a life limiting diagnosis to a patient.

A
  • The patient has requested not to know or be involved in decision making
  • The patient has lost capacity to understand or participate in medical decision making.
100
Q

List 4 themes that generally recur in the various definitions of existential suffering.

A
  • hopelessness
  • meaninglessness
  • loss of autonomy
  • loss of identity
  • loss of connection to others
  • death anxiety
  • physical, social, psychological and spiritual distress
101
Q

List 4 classes of drugs that can be used to treat hiccups.

List one agent from each class.

A
  1. Neuroleptics - Prochlorperazine, chlorpromazine, haldol
  2. Antiepileptics - Gabapentin, carbamazepine, phenytoin
  3. Prokinetics - metoclopramide
  4. Antispasmodics - Baclofen (increases inhibitory effect of GABA)
  5. PPI - pantoloc
  6. Nifedipine
  7. LIdocaine
  8. TCA
102
Q

List the 4 stages of pressure wounds/pressure sores (4 points, but had 8 lines)

A

Stage 1

  • erythema, no open wounds, blanchable

Stage 2

  • broken skin, shallow ulcer, red-pink

Stage 3

  • crater sore, subcutaneous fat visible

Stage 4

  • deep sore with damage to bone, muscle, tendon
103
Q

Name classes of drugs that can cause xerostomia

A
  1. Anticholingerics
  2. Opioids
  3. Cannabis
  4. TCAs
  5. Neuroleptics
  6. Antihistamines
104
Q

List 6 measurable indications for effectiveness of an interprofessional team

A

Necessary for effective interprofessional teams:

  • Role clarification
  • team functioning
  • patient -client -family-community centred care
  • collaborative leadership
  • interprofessional communication
  • interprofessional conflict resolution

Measurable outcomes of interprofessional care:

  • patient outcomes
  • organizational outcomes
  • staff behaviour
  • patient behaviour
  • clearly worded goals
    *
105
Q

List non pharmacological strategies to prevent and treat delirium

A
  • frequent orientation
  • orientation board with date, clock, etc
  • consistent caregivers
  • window access
  • maintain routine
  • Mitigate sensory deficits (provide glasses, hearing aids, etc)
  • monitor bowel and bladder function
  • maintain sleep/wake cycle
  • early mobilization
  • reduce polypharmacy
106
Q

List 4 pharmacological treatments for hiccups

A

Pro Gabby is Bac at the Met

Receptors : D2 and GABA

  1. Antipsychotics - Procloperazine, Chlorpromazine
  2. Anticonvulsants - Gabapentin
  3. Anti-spasmodics - Baclofen
  4. Prokinetics - Metoclopramide

Other:

  • Nifedipine (CCB)
  • haldol
  • carbamazepine
  • midazolam
107
Q

List 2 classes of medications for first line treatment of neuropathic pain.

List 4 non pharmacological interventions

A

Neuropathic pain:

  1. Anticonvulsants (gabapentin, pregab)
  2. Opioids
  3. Antidepressants (TCAs, SNRIs)
  4. NMDA antagonists (methadone, ketamine)
  5. Topical lidocaine
  6. Steroids

Non-pharm approaches to neuropathic pain

  • TENS
  • CBT
  • Physiotherapy
  • Massage
  • Acupuncture
  • neurolysis (celiac plexus block)
  • neurosurgery (cordotomy)
108
Q

List the 6 categories of childhood illness

A
  1. Conditions in which treatment is exclusively palliative after diagnosis
  2. Conditions for which curative treatment exists, but fails
  3. Conditions of severe, non progressive disability with complications causing death.
  4. Conditions that are progressive and but have a treatment that allows them to live under treatment for a time.
  5. Neonates with limited life expectancy
  6. Unexpected loss from disease or trauma or in perinatal period.
109
Q

A 3 year old child is frequently reviewing the circumstances of a loved-one’s death. How do you respond to the child’s parent?

At what age do they begin to understand the concept of death?

A
  • Normal processing.
  • Elicit child’s understanding
  • Address any misunderstanding and feelings of guilt or causality child may have
  • Use concrete language about being dead.

What age do children begin to understand concept of death?

  • Age 6-7
110
Q

Benefits of early pediatric palliative care?

A
  • Better symptom management
  • Improved QOL
  • Improved parental adjustment
  • Support pediatric care teams in their ability to communicate with families
  • Parents and families better prepared for end of life
  • Better care at time of death
  • coordination of services in community
  • support in decision making that fits with their values
  • perceived higher quality of care
111
Q

List 4 Properties of methadone which make it a good analgesic agent

A
  • may attenuate opioid tolerance via NMDA antagonism
  • NMDA anatagonism useful for neuropathic pain
  • long half life
  • no active metabolites , less toxicity
  • safe in renal failure
  • inexpensive
112
Q

Name 4 clinical conditions where you would use methadone

A
  • renal failure / dialysis
  • neuropathic pain
  • Opioid tolerance and toxicity
  • Opioid induced hyperalgesia from central sensitization
  • Chronic pain
113
Q

List 4 clinical situations where a fentanyl patch would not be good.

A
  • Cachexia
  • Unstable pain requiring titration
  • Excessive diaphoresis
  • Opioid naive
  • Acute, intermittent pain
  • Sepsis/ fever
114
Q

What conditions would change the pharmacokinetics of fentanyl?

A
  • fever
  • diaphoresis
  • cachexia
  • hepatic impairment
  • obesity
  • elderly age
115
Q

List 6 patient instructions when prescribing fentanyl patch?

A
  • clean hands and apply to clean, dry area
  • apply to non-moving body part
  • rotate locations each patch change
  • remove old patch q72 hours when new one is applied
  • clip hair if needed, but do not shave.
  • cover with tape or tegaderm dressing if needed.
  • avoid exposore to direct heat or cold
  • keep locked and out of reach of children.
116
Q

List indications for opioid rotation

A
  1. Opioid neurotoxicity
  2. Intolerable, non resolving side effects
  3. Ceiling effect of analgesia with escalating doses (inadqueate analgesia)
  4. Need to change to a different route (ie to fentanyl patch)
  5. Poor patient adherence
  6. Decline in renal function
  7. Dose of opioid required is impractical
117
Q

A patient decides to stop dialysis. List symptoms you may expect to occur

A
  • Pain
  • Agitation
  • Confusion
  • Pruritis
  • Nausea
  • Dyspnea
  • Myoclonus
  • Restless legs
  • Fatigue
  • Weakness
  • Depression
118
Q

List First Line Pharmacological treatmnet of spasticity and 2 additional alternatives

A
  1. Baclofen
  2. Tizanadine
  3. Diazepam
  4. Botox
  5. Cannabinoids
  6. Gabapentin
119
Q

What is the most important prognosticator for hospice?

List 3 prognostic tools

A

Most important prognosticator : Performance Status

3 tools:

  • PPI
  • PPS
  • PaP (palliative prognostic score)
  • BODE
  • MELD
  • ECOG
120
Q

You are asked to create a bowel management protocol for hospice. List 6 items you would include.

A
  • Assessment and documentation of bowel habits
  • regular laxative for patients on opioids
  • encourage mobility and fluids
  • Oral laxatives for mild constipation with 2 classes
  • Rectal options (enema, supp) if no BM > 3 days
  • Inform MD if refractory constipation
121
Q

You have a new consult and you’re not feeling up to it (Ie. burned out). List 3 things you would check with yourself before doing the consult.

A
  • Self reflection on contributors
  • Need to access support?
  • Need to debrief
  • Take time to address physical and emotional needs
    *
122
Q

List the three features that define burnout

A
  • Emotional exhaustion
  • Depersonalization
  • Lack of feeling of personal accomplishment
123
Q

List 8 things to share with a family to prepare them for the dying process, but do NOT include symptoms.

A
  • Ensure advanced directive in place
  • Who to contact at the time of death
  • Make preliminary funeral arrangement
  • Tell family what to expect as death approaches
  • Prepare the family if a crises is foreseen
  • Discourage monitoring of vital signs
  • Instruct family to administer meds (if at home)
  • Religious/culture considerations to be respected.
  • Review organ and tissue donation
  • Address any specific fears or concerns about around dying
  • Discuss access to additional psychological support if needed (spiritual care, grief counselling)
124
Q

What is the relationship between hope and prognosis?

A
  • Hope changes and evolves as prognosis changes.
  • When the prognosis is longer, people may hope for cure, more time, additional treatments etc
  • When the prognosis becomes much shorter, some patients may hope for different things such as better symptom relief, quality time with family, or surviving until a certain significant date (like a wedding) for example.
125
Q

A patient makes a MAID request. As a palliative care physician, what should be your first response?

A
  • Empathetic listening and acknowledgement of suffering
  • Exploration of the sources of their suffering
126
Q

List 6 non pharmacological pain management strategies for infants

A
  • Rocking
  • Singing
  • Pacifier
  • Bubbles
  • Carrying
  • Swaddling
  • Massage
  • Lullabies, Rhymes
127
Q

An adolescent is experiencing an adverse reaction following metoclopramide infusion.

Name the diagnosis.

List 2 management options

A
  • Extrapyramidal Side Effects
  • Acute dystonic reaction (EPS)
    • torticollis, forced neck extension, trismus, spasticity, extraorbital muscle spasm
  • Parkinsonism
  • Akasthisa
  • Tardive dyskinesia

2 Treatment options

  • Discontinue metoclopramide
  • Cogentin (Benztropine)
  • Benadryl - Diphenhydramine
  • Benzo - midazolam
128
Q

List organizational strategies to prevent team burnout

A
  • Provision of adequate resources to do the job
  • Support of work life balance
  • Provide physical settings are are comforting and soothing
  • Encouraging choice and control.
  • Appropriate recognition and reward
  • Developing supportive work community
  • Adequate supervision and mentoring
  • Developing an atmosphere
129
Q

What 4 things must a patient have for decision making capacity?

A
  • Does the patient understand the information?
  • Does the patient appreciate the implications of the information?
  • Can the patient use the information to make a decision? Reasoning.
  • Can the patient express their choice? (Communication)

UNDERSTAND
APPRECIATE

REASONING
COMMUNICATE

130
Q

List 8 vulnerable populations

A
  • homeless
  • disabled
  • elderly
  • indigenous
  • children
  • incarcerated
  • LGBTQ2S / gender identity
  • Immigrants
  • addictions
  • rural communities/northern communities
  • poverty
131
Q

A caregiver is experiencing grief.

What 2 symptoms would prompt you to be concerned?

A
  • Complicated grief:
    • Symptoms > 12 months
    • Out of proportion to cultural norms
    • Intense anger
    • Non acceptance of death
    • Suicidality
    • Yearning for person
    • Interferes with function more days than not
    • substance misuse
    • Not otherwise explained by a mental health disorder
132
Q

List strategies to have culturally sensitive goals of care discussions

A
  • Use medical interpreters when necessary
  • Do not make any assumptions based on culture
  • Ask patient/family about most important aspects
  • Approach with curiosity, ask permission
  • Ask who they would like to be present
  • Ask how they would prefer to receive information
133
Q

List 2 indications for ketamine for pain (outside of procedural sedation)

A
  • Neuropathic pain
  • Attentuate opioid tolerance
  • Opioid refractory pain
  • Intolerable opioid side effects
134
Q

List indications and contraindications for parenteral hydration at the end of life.

A

Indications:

  • if delirium felt to be reversible and that is aligned with goals of care
  • family and patient preference
  • symptomatic hypercalcemia
  • symptomatic dehydration

Contraindications:

  • pulmonary edema
  • severe peripheral edema
  • patient / family request
  • death is imminent
  • excessive airway secretions
135
Q

How do children express pain with their behaviour. List 6 ways.

A
  • facial grimacing
  • crying
  • crying before painful procedure
  • withdrawal
  • irritability
  • anger
  • inconsolability
  • abnormal posture
  • fear of being moved
  • quietness
  • sleep disruption
  • change in appetite
136
Q

List risk factors for bleeding in the oncology setting

A
  • gastric or colorectal cancer
  • anticoagulation for PE/DVT
  • Thrombocytopenia
  • Diffuse pulmonary metastases
  • NSAIDS, ASA
  • Steroid use
  • head and neck cancer
  • large central lung cancers
  • acute and chronic leukemias
  • liver disease / liver metastases
  • Radiation therapy
137
Q

What is the main mechanism of action of acetaminophen?

A
  • unknown
  • possible COX inhibitor
  • preventing prostaglandin synthesis
138
Q

What is the main mechanism of action : NSAIDS

A
  • COX1 and COX 2 inhibition
  • inhibits prostaglandin synthesis from arachadonic acid
  • Can be general or selective
139
Q

What is the MOA? : Glucocorticoids

A
  • anti inflammatory
  • suppression of inflammatory mediator and neutrophils.
140
Q

What is the MOA? : Ketamine

A
  • NMDA antagonism
141
Q

What is the MOA : TCA?

A
  • Tricyclics
  • Serotonin and norepinephrine reuptake inhibitors
142
Q

What is the MOA? Bisphosphonates

A
  • inhibit osteoclast mediated bone resorption
  • don’t work well if no bony mets
  • caution in RF
143
Q

Patient with ALS complains of excessive drooling.

List 3 pharmacological and 3 nonpharmacological interventions

A

Pharmacologic:

  • glycopyrrolate/scopolamine
  • TCA
  • Botox

Non pharmacologic

  • suction
  • radiation
  • neurectomy (parasympathetic)
  • salivary duct relocation
144
Q

Non invasive positive pressure ventilation for a patient with ALS.

List 2 evidence based benefits

A
  • Improved survival
  • Improved quality of life
  • (Improved dyspnea)
145
Q

Name the 4 principles of medical ethics

A
  • Autonomy
  • Beneficience
  • Non maleficence
  • Justice
146
Q

List the 3 core dimensions of burnout syndrome

A
  • Emotional exhaustion
  • Depersonalization
  • Low feeling of personal accomplishment
147
Q

List 4 reasons why medications need to be dose adjusted by age and weight in pediatrics

A

Infants

  • increased fat to muscle ratio
  • increased surface area
  • increased volume of distribution
  • deceased glycoprotein (binding)
  • decreased renal clearance
  • decreased hepatic clearance

Children > 2

  • increased CYP450 dependent metabolism until adolescence
  • reduced body fat in school aged children
  • greated volume of distribution
  • greater renal elimination
148
Q

List 6 risk factors for depression (excluding any pathologies)

A
  • female sex
  • younger age or > 60
  • past history of depression
  • family history of depression
  • poor social support
  • poor pain control
  • declining functional status
  • unaddressed existential concerns
149
Q

Patient says I don’t want to die. I am afraid.

List 2 communication strategies to respond.

A
  • Open ended questions.
  • Wish, wonder, worry statements
  • Empathetic silence to encourage exploration
  • NURSE :
    • Name the emotion
    • Understand it
    • Respect for all they have done/shared
    • Support
    • E ?
150
Q

List 3 management strategies of non malignant pleural effusion at the end of life

A
  • Thoracentesis (prognosis < 2 weeks)
  • Indwelling pleural catheter
  • Symptomatic treatment (opioids, benzos, oxygen)
  • Treat underlying cause (CHF - diuretics)
  • Talc pleurodesis
151
Q

List 3 criteria for palliative sedation that are not found in the criteria for MAID

A
  • symptoms must be refractory to standard palliative care interventions
  • Prognosis must be hours to short days (death must be imminent)
  • informed consent can be from SDM if patient not capable
  • intention is not to hasten death
  • pall sedation is acceptable for pediatric patients (Not yet for MAID)
152
Q

Dysphagia is a common symptom at the end of life.

List categories of interventions.

A
  • Dietary changes :
    • pureed, thickened fluids
  • Lifestyle :
    • SLP, positioning, oral care
  • Procedural :
    • tube feeding, PEG tubes, stenting, surgery
  • Disease modifying treatments :
    • chemotherapy
  • Radiation
  • Medications :
    • PPI, H2, prokinetic, baclofen, sucralfate, botox
    • diltiazem, TCA, sildafenil, nitro spray
153
Q

List management for diabetic gastroparesis

A
  • optimize glycemic control
  • dietary modification
  • Prokinetics
  • Antiemetics
  • Reduce secretions (PPI, H2, octreotide)
  • artifical hydration, nutrition during acute episode
154
Q

32 year old female with history of cocaine and alcohol use disorder has tonsillar cancer. She used 100 tabs of 5 mg morphine in 5 days. List 6 reasons for this.

A
  • Disease progression and uncontrolled pain
  • Opioid neurotoxicity / hyperalgesia
  • Diversion (selling or being stolen)
  • Opioid use disorder
  • Confusion about medication regimen
  • Self medicating underlying psychiatric illness
  • Hoarding drugs
155
Q

89 year old female with metastatic esophageal cancer. Besides pain crisis, list possible emergencies at the end of life.

List 2 medications you would use to deal with the emergencies, including route of administration.

A

Possible emergencies:

  • GI bleed / hemorrhage
  • PE
  • bowel obstruction
  • delirium
  • hypercalcemia
  • nausea
  • dyspnea
  • seizure
  • SCC
  • airway obstruction

Treatment medications:

  • midazolam subcutaneous
  • hydromorphone subcutaneous
156
Q

Patient has severe short gut syndrome (1 hour gut transit time).

List 3 analgesic options for this patient without disrupting his desire to remain asleep at night.

A
  1. Fentanyl patch
  2. Methadone (buccal)
  3. HM or opioids infusion with CADD pump
  4. (Transdermal buprenorphine)
157
Q

List 4 clinical scenarios of appropriatenes of having a goals of care conversation around ICD.

A
  • time of insertion
  • after decline in clinical status
  • after multiple firings of ICD
  • need for inotropic support
  • patient or family desires to discuss it.
  • actively dying
  • recurrent hospitalization for CHF
158
Q

Patient with acute dyspnea and hypoxemia.

List 4 possible causes, and the ONE best investigation

A
  1. PE
  2. Pleural effusion
  3. Aspiration
  4. CHF
  5. Pnemonia
  6. SVC syndrome

Single best investigation:

CT CHEST

Cxray to start.

159
Q

List steps for conducting a confusion assessment without performing any investigations

A
  • CAM
  • Changes in attention
  • Acute onset, fluctuating course of confusion
  • And one of:
    • altered LOC
    • disorganized thinking
  • Complete history
  • Complete physical
160
Q

About to deliver bad news. Set up is done in a room with patient and family members. List the 6 steps for delivering bad news.

A
  • Setting
  • Perception
  • Invitation
  • Knowledge
  • Emotion / empathy
  • Summary/strategy
161
Q

List 3 reasons you would not recommend CPR in an elderly patient with dementia

A
  • Dementia is a terminal illness
  • CPR ineffectivef or patients with advanced incurable illness
  • May cause prolonged suffering
  • traumatic to patient and survivors
  • advanced age and poor function are predictors of poor outcomes with CPR
  • CPR does not allow for a natural death
162
Q

Patient with dementia. Family wants feeding.

List factors to consider

A
  • does not improve survival
  • does not prevent aspiration
  • does not improve malnutrition.
  • does not improve patient comfort
  • high rate of complications
  • may require restraints after placement
  • consider modifiable factors (depression, side effects of meds)
  • consult cultural beliefs.
163
Q

List 6 factors for the perception of a good death

A
  • Multidimensionality
    • physical experience
    • psychological experience
    • social experience
    • spiritual experience
  • Importance of role
  • Importance of culture
  • Importance of timing
  • Developmental stage
  • Importance of the diagnosis
  • Location of death
  • Opportunity for growth
164
Q

Woman with remote breast cancer, status post mastectomy and lymph node dissection with no radiation. Has unilateral upper limb swelling.

List 3 causes

A
  • DVT
  • Lymphedema
  • Metastatic disease.
  • Recurrent disease
165
Q

List 4 organ systems and their respective adverse effects to immunotherapy

A
  1. GI - colitis
  2. Hepatic - hepatitis
  3. Resp - pneumonitis
  4. Skin - dermatitis
  5. CNS - encephalitis
  6. Thyroid - hyper/hypo thyroidism
  7. Endocrine - hyroid and hypophysitis, adrenal insufficiency, type 1 diabetes
166
Q

Spinal cord compression patient.

List factors to consider for radiation and surgery versus radiation alone.

List 2 adjuvants in the treatment of SCC

A

Radiation vs rad + surgery depends on:

  • radiosensitivity
  • stability of spine
  • extent of disease
  • prognosis > 3 months - surgery more likely
  • performance status before SCC
  • progression despite radiation
  • number of vertebral levels involved.
  1. Adjuvants
  • Dexamethasone
  • Opioids
  • Bisphosphonates? prevention, not treatment
167
Q

You are tasked to set up a new palliative care program in your health authority.

List 6 considerations to include in your plan

A
  1. Determine delivery model
  2. Describe the goals of the program
  3. Establish the interdisciplinary team
  4. Ensure communication between professionals within and outside of program
  5. Identify palliative care needs of the population through assessment tools
  6. Measure to audit and evaluate new program
168
Q

List symptoms for duloxetine withdrawal

A
  • Headache
  • Anxiety
  • Nausea/vomiting
  • Gait ataxia
  • Malaise / flu like sx
  • Fatigue
  • Paresthesias
  • Tremor
  • Diaphoresis
  • Insomnia
169
Q

List indications for an intrathecal pump

A
  • refractory pain
  • chronic pain
  • somatic pain preferably
  • intolerable side effects from systemic opioids
  • localized abdominal /pelvic pain that is dermatomal.
170
Q

List contraindications for an intrathecal pump

A
  • short prognosis
  • infection
  • bacteremia
  • coagulopathy
  • inability to communicate
171
Q

List 3 most common solid tumours and 1 most common hematoligic malignancy associated with hypercalemia

A

Solid Tumour

  • Breast
  • Lung
  • Renal
  • Prostate
  • Bladder

Hematologic

  • Multiple myeloma
  • (Lymphoma)
172
Q

List decubitus ulcer management strategies

A
  • frequent repositioning
  • frequent skin care - cleansing, hydration
  • pressure mattress
  • wound care - debridement
  • continence management (catheter, ostomy bags, pads)

DIMES

  • Debridement
  • Infection and inflammation
  • Moisture balance
  • Edge effects
173
Q

List factors that would influence whether home palliative care could be provided

A
  • Pharmacy support : sc meds,
  • Access to 24/7 support
  • training in sc administration
  • Access to speciality palliative care
  • Access to primary care physician
  • lab access
  • Illness factors (prognosis, functional status)
  • patient factors (personal preference, sociocultural factors
  • Environmental factors (health care availability, social support)
174
Q

Opioid equivalency

A

ORAL :

  • Morphine 10 mg
  • Codeine 100 mg
  • Tramadol 100 mg
  • Oxycodone 5 -7.5 mg
  • Hydromorphone 2 mg
  • Methadone 1 mg (see ratios)

PARENTERAL

  • Morphine 10 mg
  • Fentanyl 0.1 mg
175
Q

How do opioids improve dyspnea?

A
  • Decreased ventilatory drive
  • Decreased sensitivity to hypercapnia and hypoxia
  • Decreased oxygen consumption
  • Decreased perception of dyspnea and anxiety
176
Q

What is the MOA of octreotide?

What are the adverse effects?

A
  • Somatostatin analogue
  • MOA:
    • inhibits gi hormones
    • reduces gastric, pancreatic, biliary and intestinal secretions
    • slows intestinal motility
    • reduces splanchnic and portal blood flow (and thus ascites)
    • increases reuptake of water and electrolytes in intestines
  • Adverse effects:
    • bradycardia
    • hypertension
    • pain at injection site
    • hypo or hyperglycemia
    • hot flashes
    • diarrhea
    • nausea and vomiting
    • abdominal cramps
177
Q

What receptors do phenothiazines work on?

Methotrimeprazine, Prochlorperazine, Chlorpromazine

A
  • D2, H1, Ach, alpha adrenergic
178
Q

List an approach to nausea and vomiting

A
  • Identify likely causes
  • Identify pathway
  • Identify neurotransmitter receptor
  • Choose most potent antagonist
  • Choose route of administration
  • Titrate dose carefully
  • Give regularly
  • Reassess
  • Look for drug-drug interactions
179
Q

Nausea: Which receptors act on which components of nausea pathway

A

Vomiting centre :

  • M1, H1, 5HT2

CRTZ:

  • D2, 5HT3

Vagal afferents/ GIT/sympathetic afferents

  • 5HT4, D2

Vestibular Nuclei

  • M1, H1

Cortex:

  • H1
  • GABA
  • CB1
180
Q

Pruritis management in ESRD

A
  • Non pharmacological measures
  • Gabapentin
  • Oral antihistamines (hydroxyzine)
  • Sertraline (SSRI)
  • Ondansetron
181
Q

Neuropathic pain in ESRD

A
  • First line : Gabapentin
  • Second line : TCA
  • Third line: Methadone
  • NO SNRI (renally excreted)
182
Q

Analgesics in ESRD

A
  • Acetaminophen
  • AVOID morphine, meperidine, codeine
  • Extreme caution with oxycodone, tramadol

Best options:

  • Hydromorphone
  • Fentanyl
  • Methadone
  • Buprenorphine
  • Acetaminophen
183
Q

Pruritis : topicals

A
  • Steroids
  • dilute phenol
  • menthol
  • capsaicin
  • topica lidocaine
  • topical TCA
  • topical ketamine
184
Q

Systemic medications for pruritis

A

Malignancy related or NYD:

  • SSRI/SNRI
  • Gabapentin
  • Steroids
  • naltrexone

Cholestasis:

  • biliary stent
  • Sequestrant : cholesytramine
  • Rifampin
  • Naltrexone
  • SSRI/SNRI

Opioids

  • rotation to lower histamine releasing one (fentanyl, oxycodone, methadone)
  • nalbuphine (mixed agonist-antagonist)
  • antihistamine
185
Q

HFrEF

A
  • EF < 40%
  • Systolic dysfunction
  • Tx:
    • ARNI/ACE
    • BB
    • Spironolactone
    • SGLT2 inhibitor (even if no DM)
186
Q

HFpEF

A
  • EF > 50%
  • diastolic dysfunction
  • HTN/DM/obesity/RF/THyroid
  • Poor evidence for all treatment:
    • Loop diuretics
    • HTN treatment
    • ARB
    • ACE
    • BB
    • MRA (Spironolactone)
187
Q

Medications to avoid in Heart Failure

A
  • NSAIDS
  • Carbamazepine (negative inotropy)
  • Venlafaxine (HTN)
  • TCA (Qtc)
  • Any QT prolonging agents
188
Q

Treatment of dyspnea and edema in heart failure

A

Dypsnea:

  • 02 little evidence, only if hypoxic
  • opioids
  • benzos
  • antipyschotics (anxiety)
  • thoracentesis
  • sl nitro
  • diuresis

Depression:

  • SSRI
  • SNRI duloxetine
  • Psychosocial support
  • NO TCA, NO VENLAFAXINE, NO stimulants

Edema:

  • limit fluid/salt
  • diuretics
  • leg elevation
  • supports for testicular edema
189
Q

BODE Index for COPD prognostication

A
  • BMI
  • Obstruction (FEV1)
  • Dyspnea (MMRC score)
  • Exercise capacity (distance walked in 6 min)

Higher the score, the higher risk of death

190
Q

COPD Management goals

A
  • improve symptoms
  • prevent complications
  • maintain function
191
Q

COPD treatment stable

A
  • If high risk (> 2 hospitalizations / year)
  • Triple therapy:
    • LABA/LAMA/ICS
  • If ineffective:
    • PDE4 inhibitor
    • NAC orally
    • Azithro daily
192
Q

AECOPD Mx

A

AECOPD: SOB/Wheeze/Increased purulence/ increased volume sputum

Simple:

  • Steroids
  • SABA
  • Amoxicillin / Doxycycline / Septra

Complicated:

  • SABA
  • Steroids
  • Amox/Clav
  • Levofloxacin
193
Q

COPD Medications

A

SABA (short acting B agonist)

  • Ventolin
  • bronchodilation B2 receptors in airways

LABA (long acting B agonist)

  • salmeterol
  • serevent

SAMA (short acting muscarinic antagonist)

  • anticholinergics
  • bronchodilation via inhibiting cholingeric bronchomotor tone
  • Atrovent / ipratropium

LAMA (long acting muscarinic antagonist)

  • Spiriva /titroprium

RC Study (80 decks)

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