I85PREP
⌘ K
CAQ-Palliative study materials
CAQ-Palliative study resources

CAQ-Palliative practice questions

One question at a time. Build your CAQ-Palliative understanding.

First 50 of 200 questions. Each one lists the choices, the correct answer, and an explanation. The checker at the top of this page saves progress in this browser when it is available.

Continue in the practice tool above to load more questions, 50 at a time.

Question 1Hospice and Palliative Medicine

A patient with advanced pancreatic cancer has severe pain despite scheduled morphine. Which opioid regimen change is most appropriate for managing baseline chronic cancer pain?

  1. Add a second short-acting opioid simultaneously for rescue
  2. Switch to a long-acting opioid given around the clock with a short-acting agent for breakthrough pain Correct answer.
  3. Give short-acting morphine only when the patient requests it
  4. Discontinue opioids and start a muscle relaxant

Explanation

Chronic cancer pain is best controlled with around-the-clock long-acting opioid dosing plus a short-acting rescue dose for breakthrough pain. This maintains steady analgesia and allows titration. Using only as-needed short-acting agents leads to fluctuating control.

Question 2Hospice and Palliative Medicine

Which bowel regimen should be started prophylactically when a hospice patient begins regular oral morphine?

  1. An antidiarrheal such as loperamide
  2. A stimulant laxative such as senna with or without a stool softener Correct answer.
  3. A proton pump inhibitor
  4. An oral iron supplement

Explanation

Opioids cause constipation through reduced gut motility, so a stimulant laxative (often with a stool softener) is started prophylactically. Laxatives are titrated to soft, regular stools. Waiting for constipation to develop is inappropriate.

Question 3Hospice and Palliative Medicine

A dying patient has loud gurgling respirations from pooled oral secretions. Which medication is most appropriate for this 'death rattle'?

  1. Haloperidol
  2. Glycopyrrolate Correct answer.
  3. Morphine
  4. Midazolam

Explanation

Death rattle is caused by accumulated secretions, so an anticholinergic such as glycopyrrolate or scopolamine reduces secretion production. It does not relieve the sound by drying existing fluid, so repositioning may help. Sedatives and opioids do not address secretions.

Question 4Hospice and Palliative Medicine

According to the Medicare hospice benefit, which statement about the prognosis requirement is correct?

  1. The patient must have a life expectancy of six months or less if the disease follows its normal course Correct answer.
  2. The patient must have a documented terminal diagnosis of cancer
  3. The patient must be imminently dying within days
  4. The patient must have exhausted curative treatment options

Explanation

Hospice eligibility requires a prognosis of six months or less if the illness runs its expected course, certified by physicians. Non-cancer diagnoses qualify when functional decline supports the prognosis. Imminent death and exhausted curative options are not required.

Question 5Hospice and Palliative Medicine

A family asks what 'goals of care' discussion means. Which description is most accurate?

  1. Clarifying what matters most to the patient and aligning treatment with those priorities Correct answer.
  2. Choosing the cheapest available treatment option
  3. Determining the patient's code status only
  4. Deciding which treatments insurance will cover

Explanation

Goals-of-care conversations elicit the patient's values, priorities, and acceptable outcomes, then align treatment choices with them. They are broader than code status alone. Cost and coverage are separate considerations.

Question 6Hospice and Palliative Medicine

Which finding most strongly suggests that a hospice patient with advanced dementia is approaching the final days of life?

  1. Stable weight over one month
  2. Mild ankle edema
  3. Intermittent confusion
  4. New onset of mottled skin and decreased urine output Correct answer.

Explanation

Mottling, cool extremities, and decreasing urine output reflect peripheral shutdown and are signs of active dying. They typically appear in the last days. Stable weight and mild edema are not imminent-death signs.

Question 7Hospice and Palliative Medicine

A patient on high-dose opioids develops myoclonus and hyperalgesia. Which phenomenon should be suspected?

  1. Opioid-induced neurotoxicity Correct answer.
  2. Opioid tolerance
  3. Opioid withdrawal
  4. Serotonin syndrome

Explanation

Myoclonus, hyperalgesia, and sometimes delirium in the setting of high-dose or accumulating opioid metabolites suggest opioid-induced neurotoxicity. Management includes dose reduction or opioid rotation. Tolerance alone does not cause hyperalgesia.

Question 8Hospice and Palliative Medicine

A hospice patient with bone metastases reports pain that worsens with movement but is otherwise controlled. Which adjuvant is most appropriate?

  1. A stimulant laxative
  2. An antifungal
  3. An NSAID such as ibuprofen Correct answer.
  4. An anticholinergic

Explanation

Bone metastasis pain is often inflammatory and responsive to NSAIDs, which reduce prostaglandin-mediated pain. They are added to opioids with attention to renal and GI risk. They are not substitutes for opioid rescue.

Question 9Hospice and Palliative Medicine

A patient receiving morphine for dyspnea becomes drowsy but remains tachypneic and distressed. What is the most appropriate next step?

  1. Start a stimulant laxative
  2. Reassess the cause of dyspnea and consider adding a non-opioid intervention such as oxygen or anxiolysis Correct answer.
  3. Increase the morphine dose substantially
  4. Stop all opioids immediately

Explanation

Drowsiness without respiratory depression suggests the opioid is not fully addressing the cause of distress. Reassessing the cause and adding targeted measures like oxygen, positioning, or an anxiolytic is appropriate. Blindly escalating opioids risks toxicity.

Question 10Hospice and Palliative Medicine

A patient with terminal agitation and delirium near end of life is distressed. Which medication class is first-line for this agitation?

  1. An opioid
  2. A corticosteroid
  3. A neuroleptic such as haloperidol Correct answer.
  4. A benzodiazepine as monotherapy

Explanation

For terminal delirium with agitation, a neuroleptic such as haloperidol is first-line to reduce distress and perceptual disturbance. Benzodiazepines may be added but can worsen delirium as monotherapy. Opioids and steroids are not primary treatments.

Question 11Hospice and Palliative Medicine

A patient with end-stage COPD has refractory dyspnea despite optimal bronchodilators and oxygen. Which intervention is supported for palliation?

  1. Continuous antibiotics
  2. Low-dose opioids titrated to relieve breathlessness Correct answer.
  3. High-dose benzodiazepines as first-line
  4. Aggressive diuresis

Explanation

Low-dose opioids are established for refractory dyspnea in advanced COPD, reducing the sensation of breathlessness. Benzodiazepines are adjuncts for anxiety but not first-line. Antibiotics and diuresis target specific causes rather than refractory dyspnea.

Question 12Hospice and Palliative Medicine

A patient on regular opioids has new-onset confusion and myoclonus with preserved pain control. Which action best addresses the likely cause?

  1. Rotate to a different opioid with dose adjustment Correct answer.
  2. Discontinue all analgesia
  3. Double the current opioid dose
  4. Add a benzodiazepine

Explanation

Neurotoxicity from accumulating opioid metabolites is managed by opioid rotation, often to a different agent, with careful equianalgesic dosing. Escalating the dose worsens toxicity. Abrupt discontinuation causes withdrawal and pain.

Question 13Hospice and Palliative Medicine

A family is distressed watching a dying patient's irregular breathing with long pauses. What is the most appropriate explanation and intervention?

  1. Start antibiotics for pneumonia
  2. Tell them it indicates the patient is in pain and give a large opioid bolus
  3. Explain that irregular breathing is expected in dying and offer repositioning and reassurance Correct answer.
  4. Transfer to the intensive care unit

Explanation

Cheyne-Stokes and irregular breathing are expected in the dying process and are not inherently distressing to the patient. Explaining this and offering comfort measures reduces family distress. Reflexively treating with large opioid boluses risks hastening death.

Question 14Hospice and Palliative Medicine

A patient with severe cancer pain is converting from oral morphine to parenteral morphine. What is the approximate oral-to-parenteral morphine ratio used for equianalgesic conversion?

  1. 10:1
  2. 3:1 Correct answer.
  3. 1:10
  4. 1:1

Explanation

The standard equianalgesic ratio for oral to parenteral morphine is roughly 3:1, so parenteral doses are about one-third of the oral dose. This reflects reduced first-pass metabolism with parenteral administration. Ratios must be adjusted for individual patient factors.

Question 15Hospice and Palliative Medicine

A patient receiving high-dose opioids for cancer pain develops severe constipation despite a stimulant laxative. Which addition is most appropriate?

  1. A second opioid
  2. A stool softener such as docusate combined with continued stimulant therapy Correct answer.
  3. Oral iron
  4. An antidiarrheal agent

Explanation

Adding a stool softener to a stimulant laxative addresses both hard stool and reduced motility. Persistent symptoms warrant reassessment for impaction or obstruction. Antidiarrheals and iron worsen constipation.

Question 16Hospice and Palliative Medicine

Which statement best describes the role of palliative care consultation alongside disease-directed treatment?

  1. It requires discontinuation of all disease-directed therapy
  2. It is appropriate only after curative options are exhausted
  3. It can be provided concurrently with curative or life-prolonging therapy to improve quality of life Correct answer.
  4. It is limited to patients enrolled in hospice

Explanation

Palliative care is appropriate at any stage of serious illness and can be delivered alongside disease-directed treatment. It focuses on symptom burden and goals, not on a required transition away from treatment. Hospice is a separate benefit with a prognosis requirement.

Question 17Hospice and Palliative Medicine

A patient with advanced illness has severe nausea with a known vestibular component. Which antiemetic is most appropriate?

  1. Metoclopramide
  2. Meclizine Correct answer.
  3. Dexamethasone
  4. Ondansetron

Explanation

Vestibular-mediated nausea responds to anticholinergic or antihistaminergic agents such as meclizine. Metoclopramide targets gastric stasis, ondansetron targets serotonin pathways, and steroids help raised intracranial pressure or inflammation. Matching the antiemetic to the mechanism improves control.

Question 18Hospice and Palliative Medicine

A patient with a malignant bowel obstruction and vomiting is not a surgical candidate. Which combination is most appropriate for symptom control?

  1. High-dose oral laxatives
  2. An antiemetic plus a corticosteroid and antisecretory agent Correct answer.
  3. Prokinetic agents in complete obstruction
  4. Large-volume oral fluids

Explanation

For inoperable malignant bowel obstruction, symptom control uses antiemetics, corticosteroids to reduce peritumoral edema, and antisecretory agents such as octreotide to reduce secretions. Oral laxatives and large oral fluid loads worsen distension and vomiting.

Question 19Hospice and Palliative Medicine

A patient with severe cancer pain on high-dose morphine has declining renal function. Which concern most directly affects opioid choice?

  1. Morphine is excreted unchanged with no metabolite activity
  2. Morphine causes hypertension in renal failure
  3. Morphine becomes ineffective in renal impairment
  4. Accumulation of active morphine metabolites increases risk of neurotoxicity and sedation Correct answer.

Explanation

Morphine metabolites, especially morphine-6-glucuronide, accumulate in renal impairment and can cause sedation and neurotoxicity. Rotation to an opioid less dependent on renal clearance, such as fentanyl, is often considered. The issue is metabolite accumulation, not loss of efficacy.

Question 20Hospice and Palliative Medicine

A patient with ALS has worsening breathlessness and anxiety, and noninvasive ventilation is no longer tolerated. Which approach best integrates symptom palliation?

  1. High-dose opioids to sedate to unconsciousness immediately
  2. Aggressive hydration to thin secretions
  3. Discontinuation of all symptom medications
  4. Low-dose opioids for breathlessness with a benzodiazepine for anxiety, titrated to comfort Correct answer.

Explanation

In advanced ALS, low-dose opioids palliate breathlessness and benzodiazepines address associated anxiety, titrated to comfort. Immediate deep sedation is reserved for refractory distress after proportional titration. Aggressive hydration may worsen secretions.

Question 21Hospice and Palliative Medicine

A hospice patient with advanced cancer develops severe agitation and myoclonus after a recent opioid dose increase. Which sequence of actions is most appropriate?

  1. Stop all medications abruptly
  2. Start an antipsychotic alone and continue the same opioid dose
  3. Assess for other causes, reduce or rotate the opioid, and treat residual agitation cautiously Correct answer.
  4. Increase the opioid and add a benzodiazepine

Explanation

New neuroexcitation after an opioid increase suggests opioid-induced neurotoxicity, but other causes such as metabolic derangement must be excluded. Reducing or rotating the opioid addresses the mechanism, with cautious treatment of residual symptoms. Escalation worsens toxicity.

Question 22Hospice and Palliative Medicine

A patient with end-stage heart failure has refractory dyspnea and is on maximal diuretics. Which palliative measure is most appropriate to add?

  1. Routine high-dose benzodiazepines as first-line
  2. Aggressive intravenous fluids
  3. Continuous positive inotropes
  4. Low-dose opioids titrated to breathlessness Correct answer.

Explanation

Low-dose opioids are effective for refractory dyspnea in advanced heart failure when other measures are maximized. Benzodiazepines are adjuncts for anxiety, and inotropes or fluids are not comfort-focused in this setting. Titration balances breathlessness relief against sedation.

Question 23Hospice and Palliative Medicine

Which communication approach best supports a family meeting about transitioning to comfort-focused care?

  1. Explore the patient's values and understanding, then summarize and confirm a shared plan Correct answer.
  2. Present a single predetermined decision and ask for agreement
  3. Avoid discussing prognosis to prevent distress
  4. Focus only on medication lists

Explanation

Effective family meetings elicit the patient's values and current understanding, then summarize and confirm a shared plan. This shared decision-making respects autonomy and reduces conflict. Withholding prognosis can leave families unprepared.

Question 24Hospice and Palliative Medicine

A patient reports that morphine no longer relieves pain at the same dose that previously worked. Which concept best explains this?

  1. Tolerance Correct answer.
  2. Pseudoaddiction
  3. Addiction
  4. Physical dependence

Explanation

Tolerance is a reduced response to a drug requiring dose escalation for the same effect, common with chronic opioid use. It is distinct from addiction (compulsive use) and physical dependence (withdrawal on cessation). Pseudoaddiction reflects undertreated pain.

Question 25Hospice and Palliative Medicine

A patient on long-term opioids wishes to travel and asks about rescue dosing. Which statement is most accurate?

  1. A short-acting opioid should be available for breakthrough pain in addition to the long-acting baseline Correct answer.
  2. No rescue medication is needed if baseline dosing is stable
  3. Rescue dosing should replace baseline dosing during travel
  4. Rescue doses should be given only by injection

Explanation

Patients on long-acting opioids should have a short-acting rescue agent for breakthrough pain, dosed as a fraction of the total daily dose. Travel planning includes ensuring adequate supply. Rescue dosing supplements, not replaces, baseline therapy.

Question 26Hospice and Palliative Medicine

A patient with advanced cancer and a prognosis of months asks what palliative care would add to their ongoing chemotherapy. Which statement most accurately describes the role of palliative care in this setting?

  1. It can be provided alongside disease-directed therapy to relieve symptoms and support goals Correct answer.
  2. It focuses primarily on caregiver bereavement after the patient dies
  3. It requires stopping all curative-intent treatment before it can begin
  4. It is limited to patients expected to die within days to weeks

Explanation

Palliative care is defined by symptom relief and goal-concordant support at any stage of serious illness, and it is delivered concurrently with disease-directed treatment rather than as a replacement for it. Hospice eligibility, by contrast, is tied to a limited prognosis and a shift away from curative intent.

Question 27Hospice and Palliative Medicine

In hospice eligibility under the Medicare hospice benefit, which element is required in addition to a prognosis of six months or less if the disease runs its usual course?

  1. Completion of at least one palliative care consultation
  2. A choice to forgo curative treatment for the terminal condition Correct answer.
  3. A surrogate decision-maker with legal power of attorney
  4. A signed do-not-resuscitate order

Explanation

The Medicare hospice benefit requires the patient to elect the hospice benefit, which entails waiving curative treatment for the terminal diagnosis, along with physician certification of a prognosis of six months or less. A DNR order, a legal power of attorney, and prior palliative care consultation are not statutory requirements.

Question 28Hospice and Palliative Medicine

A hospice patient with advanced illness reports continuous, aching pain that is present at rest and has been stable for weeks. Which analgesic approach is most appropriate as the foundation of management?

  1. A scheduled long-acting opioid with a short-acting agent for breakthrough pain Correct answer.
  2. As-needed short-acting opioid taken only when pain becomes severe
  3. Nonsteroidal anti-inflammatory drugs alone as monotherapy
  4. Intermittent intramuscular opioid injections given in clinic

Explanation

Continuous nociceptive pain that is present at rest is best managed with around-the-clock dosing of a long-acting opioid, plus a short-acting agent for breakthrough episodes. As-needed dosing alone leaves the patient in cycles of uncontrolled pain, and intramuscular injections are impractical and painful in hospice care.

Question 29Hospice and Palliative Medicine

A patient with far-advanced illness is in the last days of life and has audible gurgling respirations from pooled oral secretions. Which intervention is most appropriate?

  1. Aggressive intravenous fluid resuscitation
  2. Nebulized saline treatments around the clock
  3. Suctioning the airway deeply every hour
  4. Anticholinergic medication such as glycopyrrolate or scopolamine Correct answer.

Explanation

Terminal secretions arise from the loss of swallow and cough reflexes, and anticholinergic agents reduce secretion production. Deep suctioning is distressing, does not address secretion production, and can injure the airway; fluid loading may worsen the pooling.

Question 30Hospice and Palliative Medicine

Which statement best characterizes delirium in a patient with advanced cancer near the end of life?

  1. It rarely causes distress to family members
  2. It is best managed with physical restraints to prevent falls
  3. It is uncommon and usually indicates a new structural brain lesion
  4. It is often multifactorial and potentially reversible contributors should be sought Correct answer.

Explanation

Delirium is common in advanced illness and usually has multiple contributors, including medications, metabolic derangements, infection, and organ failure, so a focused search for reversible causes is warranted. Restraints generally worsen agitation, and delirium is highly distressing to families.

Question 31Hospice and Palliative Medicine

A family member asks why the hospice team discusses goals of care repeatedly rather than once at enrollment. Which rationale is most accurate?

  1. Goals often shift as illness progresses and as the patient's experience changes Correct answer.
  2. Goals of care must be re-documented each time a medication is changed
  3. Only physicians may set goals, so each new physician repeats the conversation
  4. Repeated discussion is required to justify continued hospice billing

Explanation

Preferences are not fixed; they evolve as patients experience functional decline, symptom burden, and caregiving realities, so goals should be revisited at key transitions. The other options describe administrative or logistical rationales rather than the clinical reason for ongoing dialogue.

Question 32Hospice and Palliative Medicine

Which finding in a patient with advanced illness most suggests that death may be imminent, within days?

  1. Occasional mild ankle edema
  2. New-onset mottling of the extremities with cool skin Correct answer.
  3. Reported fatigue after a short walk
  4. A single episode of emesis after a meal

Explanation

Peripheral mottling and cool extremities reflect diminishing peripheral perfusion and are recognized signs of active dying in the last days. Fatigue, isolated emesis, and mild edema are common earlier in the illness trajectory and are not specific to imminent death.

Question 33Hospice and Palliative Medicine

A patient with advanced illness reports a dry mouth and thirst despite adequate fluid intake. Which intervention is most appropriate for comfort?

  1. Starting intravenous fluids to correct the symptom
  2. Encouraging large volumes of ice water at once
  3. Restricting oral intake to reduce secretions
  4. Frequent oral care with moistened swabs and lip balm Correct answer.

Explanation

Thirst and dry mouth in advanced illness are often relieved by meticulous oral care, including moistening, lip care, and small sips, rather than by volume expansion. Fluid restriction worsens the symptom, and large boluses may cause discomfort or aspiration risk.

Question 34Hospice and Palliative Medicine

A patient with advanced cancer has severe pain inadequately controlled by oral morphine. The team is considering switching to a different opioid. Which principle best guides an opioid rotation?

  1. Use a conservative dose accounting for incomplete cross-tolerance and reassess frequently Correct answer.
  2. Add a second long-acting opioid rather than switching
  3. Keep the same dose regardless of route or agent
  4. Start the new opioid at the full equianalgesic dose and titrate upward

Explanation

Because of incomplete cross-tolerance, rotation typically uses a reduced dose of the new opioid, often 50 to 75 percent of the calculated equianalgesic dose, with close reassessment and titration. Starting at the full calculated dose risks oversedation and respiratory depression.

Question 35Hospice and Palliative Medicine

A patient with advanced illness and a history of chronic kidney disease needs an opioid for severe pain. Which agent is most appropriate because its active metabolites are less likely to accumulate?

  1. Morphine
  2. Meperidine
  3. Fentanyl Correct answer.
  4. Codeine

Explanation

Fentanyl has no renally cleared active metabolites of clinical concern and is generally preferred in renal impairment. Morphine and codeine accumulate active metabolites that can cause neurotoxicity, and meperidine accumulates normeperidine, which lowers the seizure threshold.

Question 36Hospice and Palliative Medicine

A patient with advanced illness has severe nausea and vomiting with a prominent vestibular component. Which antiemetic is most appropriate?

  1. Ondansetron
  2. Dexamethasone
  3. Scopolamine Correct answer.
  4. Metoclopramide

Explanation

Vestibular-mediated nausea responds best to anticholinergic or antihistaminergic agents such as scopolamine or meclizine. Metoclopramide targets gastric stasis, ondansetron targets serotonergic pathways, and dexamethasone is used for raised intracranial pressure or tumor-related edema.

Question 37Hospice and Palliative Medicine

A patient with advanced illness has severe dyspnea at rest with a respiratory rate of 32 and is anxious and air hungry. Which initial pharmacologic approach is most appropriate?

  1. Nebulized lidocaine
  2. A benzodiazepine alone as first-line therapy
  3. An opioid titrated to relieve the sensation of breathlessness Correct answer.
  4. High-dose corticosteroids

Explanation

Opioids are the first-line pharmacologic treatment for refractory dyspnea in advanced illness because they reduce the sensation of breathlessness. Benzodiazepines treat associated anxiety but do not relieve dyspnea and are used adjunctively rather than alone.

Question 38Hospice and Palliative Medicine

A patient with advanced cancer and a malignant bowel obstruction has persistent vomiting and is not a surgical candidate. Which management strategy is most appropriate?

  1. Octreotide with dexamethasone and a proton pump inhibitor, plus symptom-directed antiemetics Correct answer.
  2. Routine enemas to relieve obstruction at all levels
  3. Aggressive oral fluid challenge to flush the obstruction
  4. High-dose prokinetic agents to overcome the obstruction

Explanation

For inoperable malignant bowel obstruction, antisecretory therapy with octreotide, often combined with dexamethasone to reduce tumor edema, and acid suppression reduces vomiting. Prokinetics are contraindicated in complete obstruction and oral fluid challenges may worsen symptoms.

Question 39Hospice and Palliative Medicine

A patient with advanced illness and severe, treatment-refractory dyspnea requests relief and understands that proportional sedation may be required for comfort. Which ethical framework best supports this intervention?

  1. Futility, which permits overriding the patient's stated wish
  2. Euthanasia, which is illegal in most jurisdictions
  3. Paternalism, in which the clinician determines the goal
  4. The principle of double effect, where the intent is symptom relief Correct answer.

Explanation

Palliative sedation for refractory symptoms is justified by the principle of double effect when the intent is relief of suffering, the sedation is proportional to the symptom, and the patient or surrogate consents. It is distinct from euthanasia because the intent is not to end life.

Question 40Hospice and Palliative Medicine

A patient with advanced illness has severe, recurrent vomiting due to raised intracranial pressure from brain metastases. Which medication is most appropriate?

  1. Ondansetron
  2. Dexamethasone Correct answer.
  3. Metoclopramide
  4. Scopolamine

Explanation

Corticosteroids such as dexamethasone reduce peritumoral edema and are the treatment of choice for vomiting due to raised intracranial pressure. The other agents address different mechanisms, such as gastric stasis, vestibular pathways, or serotonin-mediated nausea.

Question 41Hospice and Palliative Medicine

A family is struggling with conflicting opinions about whether to continue artificial nutrition for a patient with advanced dementia who is no longer eating. Which approach best supports decision-making?

  1. Recommend feeding tube placement as the default to relieve family guilt
  2. Explore the patient's previously expressed values and the goals of care with the family Correct answer.
  3. Avoid discussing prognosis to prevent distress
  4. Defer the decision entirely to the attending physician

Explanation

Decisions about artificial nutrition are best guided by the patient's known values and the goals of care, elicited through structured family discussion. In advanced dementia, feeding tubes have not been shown to prolong survival or improve comfort and may add burden.

Question 42Hospice and Palliative Medicine

A patient with terminal illness has severe dyspnea refractory to opioids and oxygen and is highly distressed. Which intervention is most appropriate after a goals-of-care discussion confirms comfort as the priority?

  1. Proportional palliative sedation with a benzodiazepine or other sedating agent Correct answer.
  2. Increasing oxygen flow to the maximum tolerated
  3. Neuromuscular blockade to stop respiratory effort
  4. Starting high-dose stimulants to improve respiratory drive

Explanation

When dyspnea remains refractory despite optimized treatment and comfort is the agreed goal, proportional palliative sedation can relieve suffering. Neuromuscular blockade without sedation for comfort is not acceptable, and maximal oxygen or stimulants do not address refractory air hunger.

Question 43Hospice and Palliative Medicine

A patient with advanced cancer reports pain that is well controlled at rest but severe on movement. Which adjuvant approach is most appropriate?

  1. Adding a nonsteroidal anti-inflammatory drug or corticosteroid for bone-related movement pain Correct answer.
  2. Increasing the long-acting opioid to cover movement-related pain
  3. Adding a benzodiazepine before any activity
  4. Switching to a fentanyl patch for predictable movement pain

Explanation

Movement-related pain from bone metastases often responds to adjuvants such as NSAIDs or corticosteroids, which reduce inflammation and peritumoral edema. Increasing the long-acting opioid to cover episodes would cause excessive sedation at rest, and benzodiazepines do not treat nociceptive pain.

Question 44Hospice and Palliative Medicine

A patient receiving high-dose opioids for cancer pain develops severe constipation despite a stimulant laxative. Which additional measure is most appropriate?

  1. Adding an opioid antagonist that crosses the blood-brain barrier
  2. Stopping the opioid entirely to relieve constipation
  3. Adding an osmotic laxative such as polyethylene glycol and reviewing the bowel regimen Correct answer.
  4. Increasing dietary fiber alone

Explanation

Opioid-induced constipation often requires a combination of a stimulant and an osmotic laxative, along with review of contributing medications. Stopping analgesia is not appropriate, and centrally acting antagonists can precipitate withdrawal.

Question 45Hospice and Palliative Medicine

A patient with advanced illness and severe anxiety near the end of life has not responded to nonpharmacologic measures. Which pharmacologic approach is most appropriate?

  1. A benzodiazepine such as lorazepam, titrated to effect Correct answer.
  2. An antipsychotic used alone as first-line therapy
  3. A selective serotonin reuptake inhibitor started at a high dose
  4. A stimulant to counter fatigue

Explanation

Benzodiazepines provide rapid relief of acute anxiety and are appropriate for short-term management near the end of life. SSRIs have a delayed onset of weeks, and antipsychotics are used primarily for delirium or as adjuncts rather than as first-line anxiolytics.

Question 46Hospice and Palliative Medicine

A patient with advanced illness and severe pain has been stable on a long-acting opioid. Which statement best describes the role of a rescue dose?

  1. It should be given only if the patient requests it after several hours of pain
  2. It should be avoided because it increases the risk of addiction
  3. It should equal the entire daily dose to ensure adequate relief
  4. It is typically 10 to 20 percent of the total daily dose, given as needed for breakthrough pain Correct answer.

Explanation

A rescue dose of roughly 10 to 20 percent of the total daily opioid dose, given as needed, addresses breakthrough pain while the long-acting agent provides baseline control. Frequent rescue use signals the need to reassess and adjust the baseline regimen.

Question 47Hospice and Palliative Medicine

A patient with advanced illness has severe pain that is poorly controlled and is admitted to hospice. Which factor most directly determines whether the patient can be safely managed at home?

  1. The number of medications the patient is taking
  2. The patient's insurance type
  3. The availability of a capable caregiver and a plan for after-hours support Correct answer.
  4. The patient's preference for a specific hospice agency

Explanation

Safe home management depends on a reliable caregiver, an appropriate home environment, and access to after-hours clinical support. Insurance type, medication count, and agency preference do not determine clinical safety.

Question 48Hospice and Palliative Medicine

A patient with advanced cancer has severe pain and is receiving a long-acting opioid. The patient develops new confusion and myoclonus with preserved pain control. Which action best addresses the likely cause?

  1. Add a benzodiazepine to treat the myoclonus
  2. Increase the opioid dose to improve comfort
  3. Start a stimulant to improve alertness
  4. Reduce or rotate the opioid and reassess for accumulation of active metabolites Correct answer.

Explanation

New confusion and myoclonus with preserved analgesia suggest opioid neurotoxicity from accumulation of active metabolites, so reducing the dose or rotating to a different opioid is appropriate. Adding sedatives or stimulants does not address the underlying toxicity.

Question 49Hospice and Palliative Medicine

A patient with end-stage heart failure has refractory dyspnea despite maximal diuretics and optimal medical therapy. Which palliative measure is most appropriate?

  1. Starting a beta-blocker at a high dose
  2. Low-dose opioid titrated to relieve breathlessness Correct answer.
  3. Restricting all oral fluids
  4. Increasing the diuretic dose beyond the maximum tolerated

Explanation

Low-dose opioids reduce the sensation of breathlessness and are appropriate for refractory dyspnea in advanced heart failure. Escalating diuretics beyond tolerance risks renal injury and hypotension, and fluid restriction does not reliably relieve the symptom.

Question 50Hospice and Palliative Medicine

A patient with advanced illness reports that the same dose of morphine no longer relieves pain as it once did. Which concept best explains this observation?

  1. Tolerance Correct answer.
  2. Addiction
  3. Physical dependence
  4. Pseudoaddiction

Explanation

Tolerance is a pharmacologic decrease in response to a drug over time, requiring dose adjustment or rotation. It is distinct from addiction, which involves compulsive use, and from physical dependence, which is expected with chronic opioid use.