Hospice Care — MCQs
In implementation of a health programme, best thing to do is -
How many medical practitioners' opinions are required for termination of pregnancy where gestational age exceeds 12 weeks but is within 20 weeks?
Patients who need surgery within 24 hours are categorized under which color category in a disaster management triage?
In the TRIAGE system for disaster management, which of the following color codes denotes "high-priority treatment and/or transfer"?
Dying declaration comes under?
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?
A 62-year-old woman with advanced ovarian cancer has been on oral morphine 90 mg BD for 3 months. She now reports reduced pain relief despite increasing doses, but experiences severe pain at specific sites of bone metastases. What is the best management strategy?
A 55-year-old man with terminal esophageal cancer develops respiratory secretions causing death rattle. Despite positioning and suctioning, the symptom persists. Which medication would be most appropriate and why?
A 70-year-old man with advanced pancreatic cancer on sustained-release morphine 60 mg BD develops breakthrough pain 3-4 times daily. His pain is otherwise well controlled. What should be the dose of immediate-release morphine for breakthrough pain?
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?
Hospice Care Indian Medical PG Practice Questions and MCQs
Question 1: In implementation of a health programme, best thing to do is -
- A. Discussion with leaders in community and implement accordingly
- B. Discussion with people in community and decide according to it
- C. Discussion and decision taken by the health ministry regarding implementation
- D. Discussion with doctors in PHC and implement accordingly (Correct Answer)
Explanation: ***Discussion with doctors in PHC and implement accordingly*** - **Primary Healthcare (PHC) doctors** possess critical hands-on knowledge of common health issues, local demographics, and daily health challenges faced by the community. - Their involvement ensures the program is **practically viable** and tailored to the specific needs and resources available at the grassroots level for effective implementation. *Discussion with leaders in community and implement accordingly* - While engaging community leaders is important for acceptance and dissemination, they may lack the **medical expertise** required to design effective and clinically sound health interventions. - Relying solely on leaders might lead to programs that are **socially acceptable but not medically optimal** or comprehensive. *Discussion with people in community and decide according to it* - Involving the community is crucial for program adherence and understanding local needs, but **laypersons** may not have the necessary medical knowledge to make informed decisions about complex health interventions. - Their input is valuable for relevance and acceptance, but medical and public health expertise is required for program design and implementation to ensure **efficacy and safety**. *Discussion and decision taken by the health ministry regarding implementation* - The health ministry sets policies and provides overall strategic direction, but they often lack direct, **on-the-ground understanding** of specific local health issues and implementation challenges. - A top-down approach without involving local healthcare providers can lead to programs that are **not feasible** or effective in the local context.
Question 2: How many medical practitioners' opinions are required for termination of pregnancy where gestational age exceeds 12 weeks but is within 20 weeks?
- A. Four
- B. Only one
- C. Two (Correct Answer)
- D. Three
Explanation: ***Two*** - According to the **Medical Termination of Pregnancy Act**, if the gestational age exceeds 12 weeks but is within 20 weeks, the opinion of **two registered medical practitioners** is required to perform an abortion. - This ensures a more robust review of the medical necessity and circumstances surrounding the decision to terminate a pregnancy at a later stage. *Four* - The requirement for four medical practitioners is not stipulated in the **Medical Termination of Pregnancy Act** for any gestational age. - Such a high number of opinions would create unnecessary logistical hurdles and delays for women seeking legal abortions. *Only one* - The opinion of only **one registered medical practitioner** is sufficient for terminations where the gestational age is up to **12 weeks**. - For gestational ages exceeding 12 weeks, the law mandates a more cautious approach, requiring additional medical consensus. *Three* - While multiple opinions are required for later-term abortions, the specific number mandated by the **Medical Termination of Pregnancy Act** for pregnancies between 12 and 20 weeks is two, not three. - The requirement shifts to a medical board for pregnancies exceeding **20 weeks** (and up to 24 weeks for specific categories of women), but this involves more than "three" individual opinions in a standard sense.
Question 3: Patients who need surgery within 24 hours are categorized under which color category in a disaster management triage?
- A. Green
- B. Yellow (Correct Answer)
- C. Blue
- D. Black
Explanation: ***Yellow*** - Patients in the **yellow category** are those who require **significant medical attention** and intervention, such as surgery, but whose condition is stable enough to withstand a delay of a few hours up to 24 hours without immediate threat to life or limb. - This category indicates a **delayed but urgent need** for treatment, distinguishing them from immediate (red) or minor (green) cases. *Blue* - The color **blue** is generally **not a standard triage category** in most commonly used disaster protocols (e.g., START, JumpSTART). - Triage systems typically use red, yellow, green, and black to prioritize patients based on immediate medical need and prognosis. *Green* - The **green category** is for patients with **minor injuries** who are considered "walking wounded" and can often wait for treatment for several hours, sometimes up to a few days. - These individuals are **stable** and do not require immediate intervention to preserve life or limb. *Black* - The **black category** is reserved for individuals who are **deceased** or have injuries so severe that survival is unlikely given the available resources, often implying **palliative care** rather than active life-saving interventions in a mass casualty event. - This category signifies that resources would be better allocated to patients with a higher chance of survival.
Question 4: In the TRIAGE system for disaster management, which of the following color codes denotes "high-priority treatment and/or transfer"?
- A. Red (Correct Answer)
- B. Black
- C. Yellow
- D. Green
Explanation: ***Red*** - The **red tag** in the TRIAGE system signifies critical injuries requiring **immediate intervention** and transport to save life or limb. - Patients tagged red have a high priority for treatment with a good chance of survival if attended to promptly. - This represents the **highest priority** category for "high-priority treatment and/or transfer." *Green* - The **green tag** indicates patients with **minor injuries** who can walk and care for themselves. - Also known as the "**walking wounded**," these patients require minimal or delayed medical attention. - They have the **lowest priority** in disaster triage and can wait hours for treatment. *Black* - A **black tag** indicates the patient is **deceased** or has injuries so severe that survival is unlikely given the available resources. - These patients are assigned a low priority for treatment to allocate resources to those with a better prognosis. - Also called "**expectant**" in some systems. *Yellow* - The **yellow tag** designates patients with **serious, but non-life-threatening injuries** who can wait for treatment for a few hours. - These patients are stable enough that they do not require immediate intervention but will need medical attention. - Examples include fractures, moderate burns, or stable abdominal injuries.
Question 5: Dying declaration comes under?
- A. Section 60 IEA
- B. 291 CrPC
- C. Section 32 IEA (Correct Answer)
- D. Section 32 IPC
Explanation: ***Section 32 IEA*** - This section of the **Indian Evidence Act (IEA)** specifically deals with cases in which a statement of a relevant fact by a person who is dead or cannot be found, etc., is relevant. - A **dying declaration** is a statement made by a person as to the cause of their death, or as to any of the circumstances of the transaction which resulted in their death when the cause of that person's death is in question. *Section 60 IEA* - This section refers to **oral evidence** and states that oral evidence must, in all cases whatever, be direct. - It does not specifically address the admissibility of statements made by deceased persons. *291 CrPC* - This section relates to the **Code of Criminal Procedure (CrPC)** and deals with the evidence of formal character, which can be proved by affidavit. - It is not concerned with the concept of dying declarations. *Section 32 IPC* - This refers to the **Indian Penal Code (IPC)**, which defines various offenses and their punishments. - Section 32 of the IPC states that words referring to acts include illegal omissions; it does not deal with evidence or dying declarations.
Question 6: 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?
- A. Continue morphine but add naloxone infusion
- B. Add haloperidol for delirium and continue morphine
- C. Switch to fentanyl as it has no active metabolites and dose adjust for renal function (Correct Answer)
- D. Stop all opioids and use only adjuvant analgesics
Explanation: ***Switch to fentanyl as it has no active metabolites and dose adjust for renal function*** - The patient is experiencing **opioid-induced neurotoxicity (OIN)** due to the accumulation of morphine metabolites, specifically **Morphine-3-glucuronide (M3G)** and **Morphine-6-glucuronide (M6G)**, which are cleared renally. - **Fentanyl** is the preferred opioid in renal impairment because it has no clinically significant active metabolites and does not undergo significant renal excretion [1]. *Continue morphine but add naloxone infusion* - Adding **naloxone** would reverse the analgesic effects and likely precipitate an acute **withdrawal syndrome** or uncontrolled cancer pain. - This does not address the underlying cause, which is the accumulation of **neuroexcitatory metabolites** in the setting of renal failure. *Add haloperidol for delirium and continue morphine* - **Haloperidol** may mask the symptoms of delirium but does not stop the progression of **myoclonus** or neurotoxicity caused by toxic metabolites. - Continuing morphine in a patient with a **creatinine of 2.8 mg/dL** will lead to further metabolite accumulation and potential seizures. *Stop all opioids and use only adjuvant analgesics* - Abruptly stopping opioids in a patient on a high dose (240 mg/day) will lead to severe **withdrawal** and a massive **pain crisis**. - Terminal lung cancer pain requires effective opioid management; switching to a safer agent (opioid rotation) is the standard of care rather than complete discontinuation [1].
Question 7: A 62-year-old woman with advanced ovarian cancer has been on oral morphine 90 mg BD for 3 months. She now reports reduced pain relief despite increasing doses, but experiences severe pain at specific sites of bone metastases. What is the best management strategy?
- A. Add ketamine infusion for opioid resistance
- B. Switch to fentanyl patch and continue dose escalation
- C. Add gabapentin and consider palliative radiotherapy to metastatic sites (Correct Answer)
- D. Rotate to hydromorphone at equianalgesic dose
Explanation: ***Add gabapentin and consider palliative radiotherapy to metastatic sites*** - Bone metastases often cause **neuropathic pain** and inflammatory response; adding a **gabapentinoid** treats the nerve-related component that opioids may not fully cover [1]. - **Palliative radiotherapy** is highly effective for localized bone pain, often allowing for **reduced opioid requirements** and improved quality of life. *Add ketamine infusion for opioid resistance* - While **ketamine** is an NMDA antagonist used for refractory pain, it is generally reserved for specialists when common adjuncts and localized treatments fail. - It is a more invasive and complex intervention compared to **radiotherapy** and oral adjuvants like **gabapentin** for focal bone pain. *Switch to fentanyl patch and continue dose escalation* - Increasing the dose of a different opioid (dose escalation) is unlikely to resolve **opioid-insensitive** bone pain and may increase the risk of **opioid-induced hyperalgesia** [2]. - Transdermal **fentanyl** is more suitable for stable pain control and does not address the localized, metastatic nature of the patient's pain [1]. *Rotate to hydromorphone at equianalgesic dose* - **Opioid rotation** to hydromorphone is helpful if the patient is experiencing side effects, but it does not address the underlying pathology of **bone metastases** [1]. - Rotation alone does not provide the specific **neuropathic** or **anti-tumor** benefits offered by the combination of gabapentin and radiotherapy.
Question 8: A 55-year-old man with terminal esophageal cancer develops respiratory secretions causing death rattle. Despite positioning and suctioning, the symptom persists. Which medication would be most appropriate and why?
- A. Morphine - reduces respiratory drive and secretions
- B. Hyoscine butylbromide - antimuscarinic action reduces secretions without sedation (Correct Answer)
- C. Midazolam - sedates patient reducing awareness of secretions
- D. Furosemide - reduces fluid overload causing secretions
Explanation: Hyoscine butylbromide - antimuscarinic action reduces secretions without sedation - **Hyoscine butylbromide** is the preferred medication for the **death rattle** because its **antimuscarinic properties** effectively dry up salivary and bronchial secretions. - Unlike hyoscine hydrobromide, it does not cross the **blood-brain barrier**, meaning it reduces secretions with minimal risk of **sedation** or **delirium**. *Morphine - reduces respiratory drive and secretions* - While **morphine** is excellent for managing **dyspnea** and pain at the end of life, it does not possess **antisecretory** properties to manage a death rattle [1]. - Overuse of opioids for secretions can lead to unnecessary **respiratory depression** or decreased level of consciousness without fixing the noisy breathing. *Midazolam - sedates patient reducing awareness of secretions* - **Midazolam** is a benzodiazepine used for **terminal agitation** or anxiety but does not affect the production of **respiratory secretions**. - Although it might reduce patient awareness, it does not address the **audible noise** which is often distressing for the family members observing the patient [2]. *Furosemide - reduces fluid overload causing secretions* - **Furosemide** is indicated for **pulmonary edema** caused by congestive heart failure, not for the terminal accumulation of oropharyngeal secretions. - Using diuretics in a terminal patient with a death rattle is generally **ineffective** as the noise is caused by pooled saliva rather than **systemic fluid overload**.
Question 9: A 70-year-old man with advanced pancreatic cancer on sustained-release morphine 60 mg BD develops breakthrough pain 3-4 times daily. His pain is otherwise well controlled. What should be the dose of immediate-release morphine for breakthrough pain?
- A. 6 mg
- B. 12 mg (Correct Answer)
- C. 20 mg
- D. 30 mg
Explanation: ***12 mg*** - The standard dose for **breakthrough pain** is calculated as **one-sixth (approx 16%) or 10%** of the **total daily dose** (TDD) of the regular opioid. - Since the patient takes 60 mg twice daily, the **TDD is 120 mg**; 10% of 120 mg is **12 mg**, providing a safe and effective immediate-release dose [1]. *6 mg* - This dose represents only **5%** of the TDD, which is typically insufficient to manage moderate-to-severe **breakthrough pain**. - Using a dose this low may lead to **inadequate analgesia** and multiple repeat doses, which is not clinically optimal [1]. *20 mg* - This dose exceeds the standard **10-16% recommendation** for breakthrough medication in a patient whose pain is otherwise and normally **well controlled**. - High breakthrough doses relative to the TDD increase the risk of **opioid toxicity**, such as excessive sedation or **respiratory depression**. *30 mg* - This is **25%** of the daily dose, which is significantly higher than the recommended safety margin for **palliative care** breakthrough protocols [1]. - Such a high dose would typically only be considered if the **background pain** was also poorly controlled and the oral dose was being titrated upward.
Question 10: 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?
- A. Cyclizine
- B. Ondansetron
- C. Haloperidol (Correct Answer)
- D. Metoclopramide
Explanation: ***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.
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