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  • Question 1 - A 65-year-old patient with advanced metastatic bowel cancer is experiencing symptoms of bowel...

    Incorrect

    • 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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      • Palliative & End Of Life Care
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  • Question 2 - A 60-year-old man who has recently undergone treatment for lymphoma presents with retrosternal...

    Correct

    • 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 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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      • Palliative & End Of Life Care
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  • Question 3 - A 65-year-old patient with advanced metastatic lung cancer is experiencing severe pain in...

    Correct

    • A 65-year-old patient with advanced metastatic lung cancer is experiencing severe pain in his limbs and chest. Despite taking the maximum dose of paracetamol, codeine phosphate, and ibuprofen regularly, his symptoms are no longer being adequately controlled. You decide to discontinue the use of codeine phosphate and initiate stronger opioids.
      What is the most suitable course of action at this point?

      Your Answer: Sustained-release oral 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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      • Palliative & End Of Life Care
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  • Question 4 - You are caring for a seriously ill middle-aged patient. As part of the...

    Incorrect

    • You are caring for a seriously ill middle-aged patient. As part of the diagnostic process, you have requested an MRI scan to investigate the cause of their symptoms. The results of the scan reveal extensive cancer of unknown origin. The prognosis for this patient is extremely grim. You have a conversation with the patient's family to inform them of the findings and plan to disclose this information to the patient, who is still conscious. The family insists that you should not inform the patient, as they believe he wouldn't want to know.

      What is the most appropriate course of action in this situation?

      Your Answer: Ask the nurse looking after the patient to deal with it, she has a much better rapport with the patient and family anyway.

      Correct Answer: Inform the family that whilst you sympathise with their point of view, you cannot reasonably withhold this information from the patient. You would like to speak with her to explore how much information she'd like to know.

      Explanation:

      This question revolves around the challenge of delivering difficult news. The family involved in this situation have good intentions as they aim to shield their loved one from the distress of understanding the true nature of their underlying condition.

      However, if the patient possesses the mental capacity to comprehend, it is important to disclose the details of their condition if they express a desire to know. Engage in an open and sensitive conversation with the patient, allowing them to determine the extent of information they wish to receive about their condition.

      For further information, refer to the GMC Guidance on the topic of utilizing and divulging patient information for direct care.
      https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/confidentiality/using-and-disclosing-patient-information-for-direct-care

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      • Palliative & End Of Life Care
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  • Question 5 - A 45-year-old smoker with a diagnosis of advanced lung cancer with spinal metastases...

    Incorrect

    • A 45-year-old smoker with a diagnosis of advanced lung cancer with spinal metastases experiences a severe, shooting pain in his left leg. He is currently using a fentanyl patch, but it is not providing relief for the pain.
      What would be the most appropriate next course of treatment for this patient?

      Your Answer: Radiotherapy

      Correct Answer: Gabapentin

      Explanation:

      This patient is currently experiencing neuropathic pain due to spinal metastases from their lung malignancy.

      The first line of treatment for neuropathic pain includes options such as amitriptyline, duloxetine, gabapentin, or pregabalin. If the initial treatment is not effective or well-tolerated, one of the remaining three drugs can be considered. If the second and third drugs tried also prove to be ineffective or not well-tolerated, it may be necessary to switch to a different medication. Tramadol should only be considered as a last resort for acute rescue therapy.

      For more information on the pharmacological management of neuropathic pain in adults, please refer to the NICE guidance.

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      • Palliative & End Of Life Care
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  • Question 6 - A 65-year-old patient with advanced metastatic lung cancer is experiencing discomfort in his...

    Correct

    • 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: 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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      • Palliative & End Of Life Care
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  • Question 7 - You review a middle-aged man who has a non-operable brain tumor and is...

    Incorrect

    • You review a middle-aged man who has a non-operable brain tumor and is experiencing severe nausea. He has received prior radiotherapy and chemotherapy but is now solely under the care of the palliative team. During your review, he mentions that he also experiences vertigo and struggles to keep his food down due to the intensity of his nausea. His current medications only include basic pain relief.
      What is the MOST appropriate anti-emetic to prescribe for this patient?

      Your Answer: Ondansetron

      Correct Answer: Cyclizine

      Explanation:

      All of the mentioned medications are antiemetics that can be used to treat nausea. However, cyclizine would be the most appropriate choice as it also possesses anti-histamine properties, which can help alleviate symptoms of vertigo. Ondansetron is a specific 5HT3 antagonist that is particularly effective for patients undergoing cytotoxic treatment. Domperidone acts on the chemoreceptor trigger zone and is also highly beneficial for patients receiving cytotoxic treatment. Metoclopramide directly affects the gastrointestinal tract and is a useful anti-emetic for individuals with gastro-duodenal, hepatic, and biliary diseases. Haloperidol may be considered in end-of-life care situations where other medications have not yielded successful results.

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      • Palliative & End Of Life Care
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  • Question 8 - A 68-year-old patient with advanced metastatic prostate cancer is experiencing significant difficulty breathing...

    Incorrect

    • 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:

      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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      • Palliative & End Of Life Care
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  • Question 9 - You review a 72-year-old woman with a diagnosis of lung cancer. You can...

    Incorrect

    • 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:

      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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      • Palliative & End Of Life Care
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  • Question 10 - A 65-year-old patient with advanced metastatic lung cancer is experiencing discomfort in his...

    Incorrect

    • 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:

      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

    • This question is part of the following fields:

      • Palliative & End Of Life Care
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Palliative & End Of Life Care (3/7) 43%
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