Palliative Care Practice Questions

Q: A 58-year-old woman with terminal breast cancer presents with severe nausea and vomiting due to hypercalcemia and gastroparesis. Which antiemetic would be most appropriate?

Haloperidol. ***Haloperidol*** - **Haloperidol** is highly effective for nausea caused by **metabolic derangements** such as **hypercalcemia** because it acts as a potent **D2 receptor antagonist** in the **chemoreceptor trigger zone (CTZ)** [1]. - It is a first-line agent in **palliative care** for chemical causes of vomiting and is generally preferred when multiple systemic factors are at play. *Cyclizine* - This is an **antihistamine** that primarily targets the **vestibular system** and the vomiting center, making it more suitable for **motion sickness** or raised intracranial pressure. - It lacks the specific action on the **CTZ** required to effectively manage nausea secondary to **hypercalcemia** [1]. *Ondansetron* - This **5-HT3 receptor antagonist** is primarily indicated for **chemotherapy-induced** or postoperative nausea and vomiting. - It is frequently associated with **constipation**, which can worsen the gastrointestinal distress already present in patients with **hypercalcemia** and gastroparesis. *Metoclopramide* - While it has **prokinetic** properties, its efficacy is limited in the context of **hypercalcemia-induced** nausea which is mediated chemically via the brain rather than just mechanically. - Although useful for mild **gastroparesis**, it is less effective than central dopamine antagonists for the systemic metabolic triggers seen in terminal malignancy cases.

Q: A 65-year-old man with metastatic lung cancer is receiving oral morphine 30 mg every 4 hours for pain control. He develops severe dysphagia and cannot take oral medications. What is the appropriate 24-hour subcutaneous morphine dose?

90 mg. ***90 mg*** - The patient's total daily dose of **oral morphine** is 180 mg (30 mg every 4 hours, which is 6 doses per day) [1]. - When converting from **oral to subcutaneous morphine**, a **conversion ratio of 2:1** is used due to the higher bioavailability of parenteral administration; thus, 180 mg oral / 2 = 90 mg subcutaneous [1]. *60 mg* - This dose would represent a **3:1 conversion ratio**, which is more commonly used for converting oral morphine to **intravenous/subcutaneous diamorphine** in some guidelines, not morphine to morphine. - Using this dose would result in **undermedication** and inadequate pain control for this patient with metastatic cancer. *180 mg* - This is a **1:1 conversion ratio**, which ignores the **first-pass metabolism** that oral morphine undergoes. - Administering the same dose subcutaneously would likely lead to **opioid toxicity**, characterized by respiratory depression and sedation, because parenteral morphine is much more potent [1]. *45 mg* - This dose represents a **4:1 conversion ratio**, which is significantly lower than the standard clinical recommendation for **opioid rotation** from oral to SC morphine [1]. - Such a low dose would likely cause a **pain crisis** or withdrawal symptoms due to insufficient analgesia for the patient's existing needs.

Q: Why is dexamethasone preferred over other corticosteroids for symptom management in terminal cancer patients?

It has the least mineralocorticoid activity. ***It has the least mineralocorticoid activity*** - **Dexamethasone** possesses negligible **mineralocorticoid activity**, which significantly reduces the risk of **fluid retention**, edema, and hypertension in fragile terminal patients. - Its high **glucocorticoid potency** and long **biological half-life** make it highly effective for managing **cerebral edema**, nausea, and cancer-related pain with once-daily dosing [1]. *It has maximum immunosuppressive effect* - While it is a potent immunosuppressant, this is generally a **side effect** or a secondary goal rather than the primary reason for its preference in **symptom palliation**. - Prednisone or other steroids could provide significant immunosuppression, but they carry a higher risk of **fluid-related complications**. *It has shorter half-life allowing better control* - This is incorrect; Dexamethasone has a **long half-life** (36-72 hours), which is preferred because it allows for **infrequent dosing** and maintains stable plasma levels. - **Hydrocortisone** has a shorter half-life but requires multiple doses daily, which increases the **treatment burden** for palliative patients. *It does not cross blood-brain barrier* - Dexamethasone **readily crosses** the **blood-brain barrier**, which is exactly why it is the drug of choice for treating **peritumoral brain edema**. - Its ability to penetrate the **central nervous system** helps alleviate symptoms like headaches and neurological deficits caused by **brain metastases**.

Q: Which of the following is the most appropriate opioid for initiation of pain management in a patient with moderate to severe cancer pain who is opioid-naive?

Morphine immediate release. ***Morphine immediate release*** - **Morphine immediate release (IR)** is the gold standard for initiating opioid therapy in **opioid-naive** patients because it allows for rapid **dose titration** to achieve effective analgesia. [1] - It has a predictable **pharmacokinetic profile**, making it safer and easier to adjust based on the patient's individual pain requirements and response. [1] *Fentanyl transdermal patch* - **Fentanyl patches** are contraindicated in **opioid-naive** patients due to the high risk of **respiratory depression** from a slow-onset, potent dose. [1] - These patches have a long **half-life** and take 12-24 hours to reach steady-state, making them unsuitable for acute dose escalation. [1] *Buprenorphine sublingual* - **Buprenorphine** is a **partial mu-opioid agonist** and has a "ceiling effect" for analgesia, which may limit its utility in severe escalating cancer pain. - While useful in certain settings, it is generally not the first choice for **initial titration** when compared to pure agonists like morphine. *Methadone* - **Methadone** has a very long and **unpredictable half-life**, which increases the danger of accumulation and **toxicity** in patients not already accustomed to opioids. [1] - It requires sophisticated titration due to its complex **pharmacokinetics** and potential to cause **QT interval prolongation**.

Q: A terminally ill patient with Ca pancreas is on IV diamorphine 10 mg/day. The patient is being discharged from the hospital and wishes to convert to oral morphine. What is the approximate oral morphine dose needed for this patient?

30 mg. ### Explanation The core concept in this question is the **opioid conversion ratio** between parenteral diamorphine and oral morphine. **1. Why Option B (30 mg) is Correct:** In palliative care, converting between different opioids or routes requires specific conversion factors. [1] * **Diamorphine to Morphine:** Diamorphine is approximately **3 times** more potent than oral morphine when given parenterally. * **Calculation:** 10 mg (IV Diamorphine) × 3 = **30 mg (Oral Morphine)**. * *Note:* In the UK and certain palliative guidelines, the standard conversion for Parenteral Diamorphine to Oral Morphine is a ratio of **1:3**. **2. Why Incorrect Options are Wrong:** * **Option A (20 mg):** This assumes a 1:2 ratio. While the IV to Oral ratio for *Morphine* itself is 1:2 or 1:3, Diamorphine is more potent, making 20 mg an under-dose. [1] * **Option C (40 mg):** This assumes a 1:4 ratio, which would over-sedate the patient and increase the risk of respiratory depression. * **Option D (5 mg):** This suggests oral morphine is more potent than IV diamorphine, which is pharmacologically incorrect. Oral medications undergo first-pass metabolism, generally requiring higher doses than parenteral routes. **3. High-Yield Clinical Pearls for NEET-PG:** * **Potency Hierarchy:** Fentanyl > Diamorphine > Morphine > Codeine. * **Morphine IV to Oral Ratio:** Usually **1:2 or 1:3** (e.g., 10 mg IV Morphine ≈ 20–30 mg Oral Morphine). * **Breakthrough Pain:** Always prescribe a "PRN" (as needed) dose for breakthrough pain, typically calculated as **1/6th to 1/10th** of the total 24-hour dose. [1] * **Side Effects:** When starting or increasing doses, always co-prescribe a **stimulant laxative** (e.g., Senna) and an **anti-emetic**, as constipation and nausea are nearly universal side effects.

Q: Which of the following is a method of breaking bad news?

Spike. The correct answer is **C. SPIKES**. In palliative care and clinical practice, the **SPIKES protocol** is the gold-standard, six-step strategy designed to assist physicians in delivering bad news (such as a terminal diagnosis or poor prognosis) in a structured, empathetic, and effective manner. Developed by Baile and colleagues, the acronym stands for: * **S – Setting:** Arrange for a private, comfortable environment and involve significant others. * **P – Perception:** Assess what the patient already knows ("Ask before you tell"). * **I – Invitation:** Ask how much information the patient wants to receive [1]. * **K – Knowledge:** Give the information in small chunks, avoiding medical jargon [2]. * **E – Emotions/Empathy:** Address the patient’s emotional reaction with empathetic responses [3]. * **S – Strategy/Summary:** Lay out a clear plan for the next steps and summarize the discussion. **Why other options are incorrect:** * **A, B, and D (Burst, Spread, Dive):** These are not recognized medical protocols or mnemonics for communication skills. They are distractors and do not exist in the context of palliative care or medical ethics. **High-Yield Clinical Pearls for NEET-PG:** * **ABCDE Mnemonic:** Another alternative for breaking bad news (Advance preparation, Build a therapeutic relationship, Communicate well, Deal with patient/family reactions, Encourage emotions). * **NURSE Mnemonic:** Used specifically for responding to emotions (Name, Understand, Respect, Support, Explore). * **The Goal:** The primary aim of SPIKES is to reduce the "psychological impact" on the patient while ensuring they understand the clinical reality to make informed decisions [1].

Question 1

A 68-year-old man with terminal lung cancer develops confusion, myoclonus, and hallucinations after being on high-dose morphine (240 mg/day oral) for 2 weeks. His renal function shows creatinine 2.8 mg/dL. What is the most appropriate management considering the pathophysiology?

Accepted Answer

Switch to fentanyl as it has no active metabolites and dose adjust for renal function

Answer

Continue morphine but add naloxone infusion

Answer

Add haloperidol for delirium and continue morphine

Answer

Stop all opioids and use only adjuvant analgesics

Question 2

A 58-year-old woman with terminal breast cancer presents with severe nausea and vomiting due to hypercalcemia and gastroparesis. Which antiemetic would be most appropriate?

Accepted Answer

Haloperidol

Answer

Cyclizine

Answer

Ondansetron

Answer

Metoclopramide

Question 3

A 65-year-old man with metastatic lung cancer is receiving oral morphine 30 mg every 4 hours for pain control. He develops severe dysphagia and cannot take oral medications. What is the appropriate 24-hour subcutaneous morphine dose?

Accepted Answer

90 mg

Answer

60 mg

Answer

180 mg

Answer

45 mg

Question 4

Why is dexamethasone preferred over other corticosteroids for symptom management in terminal cancer patients?

Accepted Answer

It has the least mineralocorticoid activity

Answer

It has maximum immunosuppressive effect

Answer

It has shorter half-life allowing better control

Answer

It does not cross blood-brain barrier

Question 5

Which of the following is the most appropriate opioid for initiation of pain management in a patient with moderate to severe cancer pain who is opioid-naive?

Accepted Answer

Morphine immediate release

Answer

Fentanyl transdermal patch

Answer

Buprenorphine sublingual

Answer

Methadone

Question 6

A 40-year-old divorced mother of four school-age children is hospitalized with metastatic cancer of the ovary. The nurse finds the patient crying, and she tells the nurse that she does not know what will happen to her children when she dies. What is the most appropriate nursing response?

Accepted Answer

Many patients with cancer live for a long time, so there is time to plan for your children.

Answer

Why don’t we talk about the options you have for the care of your children?

Answer

For now you need to concentrate on getting well, not worry about your children.

Answer

Perhaps your ex-husband will take the children when you can’t care for them.

Question 7

A terminally ill patient with Ca pancreas is on IV diamorphine 10 mg/day. The patient is being discharged from the hospital and wishes to convert to oral morphine. What is the approximate oral morphine dose needed for this patient?

Accepted Answer

30 mg

Answer

20 mg

Answer

40 mg

Answer

5 mg

Question 8

Which of the following is a method of breaking bad news?

Accepted Answer

Spike

Answer

Burst

Answer

Spread

Answer

Dive

Question 9

In a patient with carcinoma of the lung suffering from dyspnea, how is palliation of dyspnea achieved?

Accepted Answer

Morphine patch

Answer

Diazepam

Answer

Clobazam

Answer

Haloperidol

Question 10

What factors should be considered for optimal pain management in a middle-aged patient with metastatic prostate cancer to the bone who is experiencing significant pain?

Accepted Answer

Combination of radiation therapy, chemotherapy, and palliative care consultation

Answer

Surgical intervention as a primary treatment

Answer

Use of experimental treatments as a first-line option

Answer

Long-term opioid therapy without additional modalities

Palliative Care — MCQs

Palliative Care — MCQs

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