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Question 1
Incorrect
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A 68-year-old patient with advanced metastatic bowel cancer is experiencing symptoms of bowel obstruction and is currently suffering from nausea and vomiting. The patient has been informed that they have only a few days left to live. Upon examination, the patient's abdomen is tender and distended. Over the past 24 hours, the patient has been taking hyoscine butylbromide in an attempt to alleviate their symptoms, but there has been no improvement.
What is the most appropriate course of treatment to manage the patient's nausea and vomiting in this situation?Your Answer: Prochlorperazine
Correct Answer: Octreotide
Explanation:NICE recommends the use of octreotide for individuals in the final stages of life who are experiencing obstructive bowel disorders and have nausea or vomiting that does not improve within 24 hours of starting treatment with hyoscine butylbromide.
When managing nausea and vomiting in individuals nearing the end of life, it is important to assess the likely causes, such as certain medications, recent chemotherapy or radiotherapy, psychological factors, biochemical imbalances, raised intracranial pressure, gastrointestinal motility disorders, ileus, or bowel obstruction.
It is crucial to have discussions with the person who is dying and their loved ones about the available options for treating nausea and vomiting. Non-pharmacological methods should be considered as well.
When selecting medications to manage these symptoms, factors to consider include the likely cause and its reversibility, potential side effects (including sedation), other symptoms the person may be experiencing, the desired balance of effects when managing other symptoms, and compatibility and drug interactions with other medications the person is taking.
For individuals with obstructive bowel disorders who have nausea or vomiting, hyoscine butylbromide is recommended as the first-line pharmacological treatment. If symptoms do not improve within 24 hours of starting this treatment, octreotide should be considered.
For more information, please refer to the NICE guidance on the care of dying adults in the last days of life. https://www.nice.org.uk/guidance/ng31
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This question is part of the following fields:
- Palliative & End Of Life Care
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Question 2
Incorrect
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A 68-year-old patient with advanced metastatic prostate cancer is experiencing significant difficulty breathing and appears visibly distressed. Despite his discomfort, he remains mentally alert and reports moderate levels of pain. He has been informed that he has only a few days left to live. Currently, his oxygen saturation levels are at 95% when breathing regular air, and there are no specific signs of chest abnormalities.
What would be the most suitable course of action to alleviate his breathlessness in this situation?Your Answer: High-flow oxygen via a non-rebreather mask
Correct Answer: Oral morphine
Explanation:Here are some suggestions for managing breathlessness in the final days of life, as provided by NICE:
1. It is important to identify and treat any reversible causes of breathlessness in the dying person, such as pulmonary edema or pleural effusion.
2. Non-pharmacological methods can be considered for managing breathlessness in someone nearing the end of life. It is not recommended to start oxygen therapy as a routine measure. Oxygen should only be offered to individuals who are known or suspected to have symptomatic hypoxemia.
3. Breathlessness can be managed using different medications, including opioids, benzodiazepines, or a combination of both.
For more detailed information, you can refer to the NICE guidance on the care of dying adults in the last days of life. https://www.nice.org.uk/guidance/ng31
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This question is part of the following fields:
- Palliative & End Of Life Care
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Question 3
Incorrect
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A 65-year-old patient with advanced metastatic bowel cancer is experiencing symptoms of bowel obstruction and is currently suffering from nausea and vomiting. The patient has been informed that she has only a few days left to live. Upon examination, her abdomen is found to be tender and distended.
What is the most suitable course of action to address her nausea and vomiting in this situation?Your Answer: Prochlorperazine
Correct Answer: Hyoscine butylbromide
Explanation:According to NICE, hyoscine butylbromide is recommended as the initial medication for managing nausea and vomiting in individuals with obstructive bowel disorders who are in the last days of life. NICE provides guidance on how to handle these symptoms in the final days of life, which includes assessing the potential causes of nausea and vomiting in the dying person. This may involve considering factors such as certain medications, recent chemotherapy or radiotherapy, psychological causes, biochemical causes like hypercalcemia, raised intracranial pressure, gastrointestinal motility disorder, ileus, or bowel obstruction.
It is important to discuss the available options for treating nausea and vomiting with the dying person and their loved ones. Non-pharmacological methods should also be considered when managing these symptoms in someone in the last days of life. When selecting medications for nausea and vomiting, factors such as the likely cause and reversibility of the symptoms, potential side effects (including sedation), other symptoms the person may be experiencing, and the desired balancing of effects when managing other symptoms should be taken into account. Additionally, compatibility and potential drug interactions with other medications the person is taking should be considered.
For individuals in the last days of life with obstructive bowel disorders who have nausea or vomiting, hyoscine butylbromide is recommended as the first-line pharmacological treatment. If the symptoms do not improve within 24 hours of starting treatment with hyoscine butylbromide, octreotide may be considered as an alternative option.
For more information, refer to the NICE guidance on the care of dying adults in the last days of life. https://www.nice.org.uk/guidance/ng31
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This question is part of the following fields:
- Palliative & End Of Life Care
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Question 4
Incorrect
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A 60-year-old man who has recently undergone treatment for lymphoma presents with retrosternal pain, dysphagia, and difficulty swallowing. Despite unsuccessful treatment, he has been informed that he only has a few months left to live.
What is the SINGLE most probable diagnosis?Your Answer: Oesophageal cancer
Correct Answer: Oesophageal candidiasis
Explanation:This patient’s symptoms are consistent with a diagnosis of oesophageal candidiasis, which is commonly seen in patients undergoing treatment for haematopoietic or lymphatic malignancies.
The classic combination of symptoms associated with oesophageal candidiasis includes dysphagia, odynophagia, and retrosternal pain. This infection can be life-threatening and often requires hospital admission.
The recommended treatment for oesophageal candidiasis is as follows:
– First-line treatment involves taking oral fluconazole at a daily dose of 200-400 mg.
– If the patient is unable to tolerate oral treatment, intravenous fluconazole can be used instead.
– Second-line treatment options include oral itraconazole, oral posaconazole, or intravenous or oral voriconazole.It is important to seek medical attention promptly for oesophageal candidiasis, as timely treatment is crucial in managing this potentially serious infection.
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This question is part of the following fields:
- Palliative & End Of Life Care
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Question 5
Incorrect
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You review a 72-year-old woman with a diagnosis of lung cancer. You can see from her notes that she has an advanced decision in place.
Which SINGLE statement is true regarding an advanced decision?Your Answer: It can be used to give a relative ‘lasting power of attorney’
Correct Answer: It can be used by Jehovah’s witnesses to refuse blood transfusions
Explanation:An advance decision, also known as an advance directive in Scotland, is a statement made by a patient expressing their desire to refuse certain types of medical treatment or care in the event that they become unable to make or communicate decisions for themselves. These statements serve as a means of effectively communicating the patient’s wishes to healthcare professionals and family members, helping to avoid any confusion that may arise. If a patient reaches a point where they are no longer capable of making informed decisions about their care, an advance decision can provide clarity and guidance.
An advance decision can typically be utilized in the following situations: making decisions regarding CPR, determining the use of IV fluids and parenteral nutrition, deciding on specific procedures, and addressing the use of blood products for Jehovah’s Witnesses. However, it is important to note that advance decisions have their limitations and cannot be used to grant a relative lasting power of attorney, appoint a spokesperson to make decisions on the patient’s behalf, request a specific medical treatment, advocate for something illegal (such as assisted suicide), refuse treatment for a mental health condition, or authorize treatments that are not in the patient’s best interests.
A doctor is legally obligated to adhere to an advance decision unless certain circumstances arise. These circumstances include changes that invalidate the decision, advances or changes in treatment that alter the circumstances, ambiguity in the wording of the decision, or if the decision is unsigned or its authenticity is in doubt. If there are any doubts about the validity of an advance decision, it is advisable to seek legal advice. Unfortunately, there have been instances where advance decisions have been forged or signed under duress, and any suspicions of this nature should be raised.
It is important to note that there is no specific time period for which an advance decision remains valid.
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This question is part of the following fields:
- Palliative & End Of Life Care
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Question 6
Incorrect
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A 60-year-old man who has recently undergone treatment for prostate cancer presents with lower abdominal pain, urinary difficulties, and frequent urination. The treatment has not been effective, and he has been informed that he only has a few months left to live.
What is the most appropriate initial treatment for this patient?Your Answer: Oral morphine
Correct Answer: Oral fluconazole
Explanation:This patient’s symptoms are consistent with a diagnosis of oesophageal candidiasis, which is commonly seen in patients undergoing treatment for haematopoietic or lymphatic malignancies.
The classic combination of symptoms associated with oesophageal candidiasis includes dysphagia, odynophagia, and retrosternal pain. This infection can be life-threatening and often requires hospital admission.
The recommended treatment for oesophageal candidiasis is as follows:
– First-line treatment involves taking oral fluconazole at a daily dose of 200-400 mg.
– If the patient is unable to tolerate oral treatment, intravenous fluconazole can be used instead.
– Second-line treatment options include oral itraconazole, oral posaconazole, or intravenous or oral voriconazole.It is important to seek medical attention promptly for oesophageal candidiasis, as timely treatment is crucial in managing this potentially serious infection.
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This question is part of the following fields:
- Palliative & End Of Life Care
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Question 7
Correct
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A 68-year-old patient with advanced metastatic lung cancer is observed by his family to have a parched mouth and chapped lips. He confesses that he hasn't been consuming fluids regularly in the past few days. He is mentally clear and attentive and is presently at ease and free from pain. He has been informed that he has only a few days left to live.
What is the most suitable course of action at this point?Your Answer: Encourage frequent sips of fluids
Explanation:When dealing with a terminally ill patient who is still lucid and alert and able to drink oral fluids, it is sensible to encourage them to take frequent sips of fluids to maintain hydration and alleviate symptoms of a dry mouth. According to NICE guidelines, it is important to support the dying person in their desire to drink if they are capable and willing. However, it is crucial to assess any difficulties they may have with swallowing or the risk of aspiration. It is recommended to have a discussion with the dying person and those involved in their care to weigh the risks and benefits of continuing to drink.
In addition, it is essential to provide regular care for the dying person’s mouth and lips, including managing dry mouth if necessary. This can involve assisting with teeth or denture cleaning if desired, as well as offering frequent sips of fluid. It is also encouraged to involve important individuals in the dying person’s life in providing mouth and lip care or giving drinks, if they are willing. Necessary aids should be provided, and guidance on safe drink administration should be given.
The hydration status of the dying person should be assessed on a daily basis, and the potential need for clinically assisted hydration should be reviewed while respecting the person’s wishes and preferences. It is important to discuss the risks and benefits of clinically assisted hydration with the dying person and their loved ones. It should be noted that while clinically assisted hydration may relieve distressing symptoms related to dehydration, it may also cause other problems. The impact on life extension or the dying process is uncertain whether hydration is provided or not.
Before initiating clinically assisted hydration, any concerns raised by the dying person or their loved ones should be addressed. An individualized approach should be taken into account, considering factors such as the person’s expressed preferences, cultural or religious beliefs, level of consciousness, swallowing difficulties, thirst level, risk of pulmonary edema, and the possibility of temporary recovery.
If the person exhibits distressing symptoms or signs associated with dehydration, such as thirst or delirium, and oral hydration is insufficient, a therapeutic trial of clinically assisted hydration may be considered. Monitoring for changes in symptoms or signs of dehydration, as well as any evidence of benefit or harm, should be conducted at least every 12 hours for those receiving clinically assisted hydration. If there are signs of clinical benefit, the hydration should be continued. However, if there are indications of potential harm, such as fluid overload, or if the person no longer desires it, the clinically assisted hydration should be stopped.
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This question is part of the following fields:
- Palliative & End Of Life Care
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Question 8
Incorrect
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A 65-year-old patient with advanced metastatic lung cancer is experiencing discomfort in his limbs and chest. Despite taking the maximum dosage of paracetamol, codeine phosphate, and ibuprofen regularly, his symptoms are no longer being adequately managed. You determine that it is necessary to discontinue the use of codeine phosphate and initiate stronger opioids.
What would be the most suitable initial dosage regimen in this situation?Your Answer: 30-60 mg oral morphine daily in divided doses
Correct Answer: 20-30 mg oral morphine daily in divided doses
Explanation:When starting treatment with strong opioids for pain relief in palliative care, it is recommended to offer patients regular oral sustained-release or oral immediate-release morphine, depending on their preference. In addition, provide rescue doses of oral immediate-release morphine for breakthrough pain. For patients without renal or hepatic comorbidities, a typical total daily starting dose schedule of 20-30 mg of oral morphine is suggested, along with 5 mg of oral immediate-release morphine for rescue doses during the titration phase. It is important to adjust the dose until a good balance is achieved between pain control and side effects. If this balance is not reached after a few dose adjustments, it is advisable to seek specialist advice. Patients should be reviewed frequently, especially during the titration phase. For patients with moderate to severe renal or hepatic impairment, it is recommended to consult a specialist before prescribing strong opioids.
For maintenance therapy, oral sustained-release morphine is recommended as the first-line treatment for patients with advanced and progressive disease who require strong opioids. Transdermal patch formulations should not be routinely offered as first-line maintenance treatment unless oral opioids are not suitable. If pain remains inadequately controlled despite optimizing first-line maintenance treatment, it is important to review the analgesic strategy and consider seeking specialist advice.
When it comes to breakthrough pain, oral immediate-release morphine should be offered as the first-line rescue medication for patients on maintenance oral morphine treatment. Fast-acting fentanyl should not be offered as the first-line rescue medication. If pain continues to be inadequately controlled despite optimizing treatment, it may be necessary to seek specialist advice.
In cases where oral opioids are not suitable and analgesic requirements are stable, transdermal patches with the lowest acquisition cost can be considered. However, it is important to consult a specialist for guidance if needed. Similarly, for patients in whom oral opioids are not suitable and analgesic requirements are unstable, subcutaneous opioids with the lowest acquisition cost can be considered, with specialist advice if necessary.
For more information, please refer to the NICE Clinical Knowledge Summary: Opioids for pain relief in palliative care. https://www.nice.org.uk/guidance/cg140
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This question is part of the following fields:
- Palliative & End Of Life Care
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Question 9
Incorrect
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A 65-year-old patient with advanced metastatic lung cancer is experiencing discomfort in his limbs and chest. He is started on regular maintenance treatment with potent opioids for his pain.
According to NICE, what is the recommended initial rescue medication for breakthrough pain?Your Answer: Subcutaneous morphine
Correct Answer: Oral immediate-release morphine
Explanation:When starting treatment with strong opioids for pain relief in palliative care, it is recommended to offer patients regular oral sustained-release or oral immediate-release morphine, depending on their preference. In addition, provide rescue doses of oral immediate-release morphine for breakthrough pain. For patients without renal or hepatic comorbidities, a typical total daily starting dose schedule of 20-30 mg of oral morphine is suggested, along with 5 mg of oral immediate-release morphine for rescue doses during the titration phase. It is important to adjust the dose until a good balance is achieved between pain control and side effects. If this balance is not reached after a few dose adjustments, it is advisable to seek specialist advice. Patients should be reviewed frequently, especially during the titration phase. For patients with moderate to severe renal or hepatic impairment, it is recommended to consult a specialist before prescribing strong opioids.
For maintenance therapy, oral sustained-release morphine is recommended as the first-line treatment for patients with advanced and progressive disease who require strong opioids. Transdermal patch formulations should not be routinely offered as first-line maintenance treatment unless oral opioids are not suitable. If pain remains inadequately controlled despite optimizing first-line maintenance treatment, it is important to review the analgesic strategy and consider seeking specialist advice.
When it comes to breakthrough pain, oral immediate-release morphine should be offered as the first-line rescue medication for patients on maintenance oral morphine treatment. Fast-acting fentanyl should not be offered as the first-line rescue medication. If pain continues to be inadequately controlled despite optimizing treatment, it may be necessary to seek specialist advice.
In cases where oral opioids are not suitable and analgesic requirements are stable, transdermal patches with the lowest acquisition cost can be considered. However, it is important to consult a specialist for guidance if needed. Similarly, for patients in whom oral opioids are not suitable and analgesic requirements are unstable, subcutaneous opioids with the lowest acquisition cost can be considered, with specialist advice if necessary.
For more information, please refer to the NICE Clinical Knowledge Summary: Opioids for pain relief in palliative care. https://www.nice.org.uk/guidance/cg140
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This question is part of the following fields:
- Palliative & End Of Life Care
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Question 10
Incorrect
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A 65-year-old patient with advanced metastatic lung cancer is experiencing discomfort in his limbs and chest. He is currently prescribed 15 mg sustained-release morphine twice daily for pain management, but is now encountering breakthrough pain.
According to NICE guidelines, what is the recommended first-line rescue medication for breakthrough pain?Your Answer: Oral sustained-release morphine
Correct Answer: Oral immediate-release morphine
Explanation:When starting treatment with strong opioids for pain relief in palliative care, it is recommended to offer patients regular oral sustained-release or oral immediate-release morphine, depending on their preference. In addition, provide rescue doses of oral immediate-release morphine for breakthrough pain. For patients without renal or hepatic comorbidities, a typical total daily starting dose schedule of 20-30 mg of oral morphine is suggested, along with 5 mg of oral immediate-release morphine for rescue doses during the titration phase. It is important to adjust the dose until a good balance is achieved between pain control and side effects. If this balance is not reached after a few dose adjustments, it is advisable to seek specialist advice. Patients should be reviewed frequently, especially during the titration phase. For patients with moderate to severe renal or hepatic impairment, it is recommended to consult a specialist before prescribing strong opioids.
For maintenance therapy, oral sustained-release morphine is recommended as the first-line treatment for patients with advanced and progressive disease who require strong opioids. Transdermal patch formulations should not be routinely offered as first-line maintenance treatment unless oral opioids are not suitable. If pain remains inadequately controlled despite optimizing first-line maintenance treatment, it is important to review the analgesic strategy and consider seeking specialist advice.
When it comes to breakthrough pain, oral immediate-release morphine should be offered as the first-line rescue medication for patients on maintenance oral morphine treatment. Fast-acting fentanyl should not be offered as the first-line rescue medication. If pain continues to be inadequately controlled despite optimizing treatment, it may be necessary to seek specialist advice.
In cases where oral opioids are not suitable and analgesic requirements are stable, transdermal patches with the lowest acquisition cost can be considered. However, it is important to consult a specialist for guidance if needed. Similarly, for patients in whom oral opioids are not suitable and analgesic requirements are unstable, subcutaneous opioids with the lowest acquisition cost can be considered, with specialist advice if necessary.
For more information, please refer to the NICE Clinical Knowledge Summary: Opioids for pain relief in palliative care. https://www.nice.org.uk/guidance/cg140
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This question is part of the following fields:
- Palliative & End Of Life Care
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