Palliative care principles — MCQs

10 questions

A 76-year-old man is brought to the hospital after having a stroke. Head CT is done in the emergency department and shows intracranial hemorrhage. Upon arrival to the ED he is verbally non-responsive and withdraws only to pain. He does not open his eyes. He is transferred to the medical ICU for further management and intubated for airway protection. During his second day in the ICU, his blood pressure is measured as 91/54 mmHg and pulse is 120/min. He is given fluids and antibiotics, but he progresses to renal failure and his mental status deteriorates. The physicians in the ICU ask the patient’s family what his wishes are for end-of-life care. His wife tells the team that she is durable power of attorney for the patient and provides appropriate documentation. She mentions that he did not have a living will, but she believes that he would want care withdrawn in this situation, and therefore asks the team to withdraw care at this point. The patient’s daughter vehemently disagrees and believes it is in the best interest of her father, the patient, to continue all care. Based on this information, what is the best course of action for the physician team?

A 75-year-old woman with metastatic colon cancer comes to the physician requesting assistance in ending her life. She states: “I just can't take it anymore; the pain is unbearable. Please help me die.” Current medications include 10 mg oral hydrocodone every 12 hours. Her cancer has progressed despite chemotherapy and she is very frail. She lives alone and has no close family. Which of the following is the most appropriate initial action by the physician?

A 72-year-old woman with metastatic ovarian cancer is brought to the physician by her son because she is in immense pain and cries all the time. On a 10-point scale, she rates the pain as an 8 to 9. One week ago, a decision to shift to palliative care was made after she failed to respond to 2 years of multiple chemotherapy regimens. She is now off chemotherapy drugs and has been in hospice care. Current medications include 2 mg morphine intravenously every 2 hours and 650 mg of acetaminophen every 4 to 6 hours. The son is concerned because he read online that increasing the dose of morphine would endanger her breathing. Which of the following is the most appropriate next step in management?

A 69-year-old man with aggressive metastatic cholangiocarcinoma presents after the second round of chemotherapy. He has suffered a great deal of pain from the metastasis to his spine, and he is experiencing side effects from the cytotoxic chemotherapy drugs. Imaging shows no change in the tumor mass and reveals the presence of several new metastatic lesions. The patient is not willing to undergo any more chemotherapy unless he gets something for pain that will “knock him out”. High-dose opioids would be effective, in his case, but carry a risk of bradypnea and sudden respiratory failure. Which of the following is the most appropriate next step in management?

A 76-year-old woman is brought to the physician by her daughter for evaluation of progressive cognitive decline and a 1-year history of incontinence. She was diagnosed with dementia, Alzheimer type, 5 years ago. The daughter has noticed that in the past 2 years, her mother has had increasing word-finding difficulties and forgetfulness. She was previously independent but now lives with her daughter and requires assistance with all activities of daily living. Over the past year, she has had decreased appetite, poor oral intake, and sometimes regurgitates her food. During this time, she has had a 12-kg (26-lb) weight loss. She was treated twice for aspiration pneumonia and now her diet mainly consists of pureed food. She has no advance directives and her daughter says that when her mother was independent the patient mentioned that she would not want any resuscitation or life-sustaining measures if the need arose. The daughter wants to continue taking care of her mother but is concerned about her ability to do so. The patient has hypertension and hyperlipidemia. Current medications include amlodipine and atorvastatin. Vital signs are within normal limits. She appears malnourished but is well-groomed. The patient is oriented to self and recognizes her daughter by name, but she is unaware of the place or year. Mini-Mental State Examination score is 17/30. Physical and neurologic examinations show no other abnormalities. A complete blood count and serum concentrations of creatinine, urea nitrogen, TSH, and vitamin B12 levels are within the reference range. Her serum albumin is 3 g/dL. Urinalysis shows no abnormalities. Which of the following is the most appropriate next step in management?

A 28-year-old woman dies shortly after receiving a blood transfusion. Autopsy reveals widespread intravascular hemolysis and acute renal failure. Investigation reveals that she received type A blood, but her medical record indicates she was type O. In a malpractice lawsuit, which of the following elements must be proven?

A 57-year-old man presents to his oncologist to discuss management of small cell lung cancer. The patient is a lifelong smoker and was diagnosed with cancer 1 week ago. The patient states that the cancer was his fault for smoking and that there is "no hope now." He seems disinterested in discussing the treatment options and making a plan for treatment and followup. The patient says "he does not want any treatment" for his condition. Which of the following is the most appropriate response from the physician?

A 36-year-old man is admitted to the hospital for treatment of burn wounds on his upper extremities. Analgesic therapy with an opioid drug is begun. Shortly after, the patient develops chills, diaphoresis, nausea, and abdominal pain. On further questioning, the patient reports that he has been smoking opium at home to help him ""deal with the depression and pain.” This patient was most likely given which of the following opioid drugs?

A 72-year-old man is brought to the emergency department from hospice. The patient has been complaining of worsening pain over the past few days and states that it is no longer bearable. The patient has a past medical history of pancreatic cancer which is being managed in hospice. The patient desires no "heroic measures" to be made with regards to treatment and resuscitation. His temperature is 98.8°F (37.1°C), blood pressure is 107/68 mmHg, pulse is 102/min, respirations are 22/min, and oxygen saturation is 99% on room air. Physical exam reveals an uncomfortable elderly man who experiences severe pain upon abdominal palpation. Laboratory values reveal signs of renal failure, liver failure, and anemia. Which of the following is the best next step in management?

Q10

A 32-year-old man comes to the emergency department because of recurrent episodes of vomiting for 1 day. He has had over 15 episodes of bilious vomiting. During this period he has had cramping abdominal pain but has not had a bowel movement or passed flatus. He does not have fever or diarrhea. He was diagnosed with Crohn disease at the age of 28 years which has been well controlled with oral mesalamine. He underwent a partial small bowel resection for midgut volvulus at birth. His other medications include vitamin B12, folic acid, loperamide, ferrous sulfate, and vitamin D3. He appears uncomfortable and his lips are parched. His temperature is 37.1°C (99.3°F), pulse is 103/min, and blood pressure is 104/70 mm Hg. The abdomen is distended, tympanitic, and tender to palpation over the periumbilical area and the right lower quadrant. Rectal examination is unremarkable. A CT scan of the abdomen shows multiple dilated loops of small bowel with a transition zone in the mid to distal ileum. After 24 hours of conservative management with IV fluid resuscitation, nasogastric bowel decompression, promethazine, and analgesia, his condition does not improve and a laparotomy is scheduled. During the laparotomy, two discrete strictures are noted in the mid-ileum, around 20 cm apart. Which of the following is the most appropriate next step in management?

Palliative care principles US Medical PG Practice Questions and MCQs

Question 1: A 76-year-old man is brought to the hospital after having a stroke. Head CT is done in the emergency department and shows intracranial hemorrhage. Upon arrival to the ED he is verbally non-responsive and withdraws only to pain. He does not open his eyes. He is transferred to the medical ICU for further management and intubated for airway protection. During his second day in the ICU, his blood pressure is measured as 91/54 mmHg and pulse is 120/min. He is given fluids and antibiotics, but he progresses to renal failure and his mental status deteriorates. The physicians in the ICU ask the patient’s family what his wishes are for end-of-life care. His wife tells the team that she is durable power of attorney for the patient and provides appropriate documentation. She mentions that he did not have a living will, but she believes that he would want care withdrawn in this situation, and therefore asks the team to withdraw care at this point. The patient’s daughter vehemently disagrees and believes it is in the best interest of her father, the patient, to continue all care. Based on this information, what is the best course of action for the physician team?

A. Call other family members and consult them for their opinions
B. Listen to the patient’s daughter’s wishes and continue all care
C. Compromise between the wife and daughter and withdraw the fluids and antibiotics but keep the patient intubated
D. Listen to the patient’s wife’s wishes and withdraw care (Correct Answer)
E. Consult the hospital ethics committee and continue all care until a decision is reached

Explanation: ***Listen to the patient’s wife’s wishes and withdraw care*** - The **durable power of attorney for healthcare** legally designates the wife as the patient's surrogate decision-maker when the patient lacks capacity, overriding other family opinions. - In the absence of a living will, the **surrogate's interpretation of the patient's best interests** and previously expressed wishes is legally and ethically binding. *Call other family members and consult them for their opinions* - While involving family is good practice in general, the presence of a **legally appointed durable power of attorney** means that other family members' opinions do not supersede the designated surrogate's decisions. - Consulting other family members could **create more conflict and delay** crucial decisions, as the wife holds the legal authority. *Listen to the patient’s daughter’s wishes and continue all care* - The daughter's wishes, while understandable, **do not hold legal authority** over the decisions of the legally appointed durable power of attorney. - Disregarding the wife's authority would be a **breach of ethical and legal obligations** in patient care. *Compromise between the wife and daughter and withdraw the fluids and antibiotics but keep the patient intubated* - A compromise that goes against the legal surrogate's explicitly stated decision (to withdraw all care) is **ethically problematic and legally unsound**. - Healthcare decisions should be based on the patient's best interest as interpreted by the **authorized surrogate**, not on attempting to please all family members. *Consult the hospital ethics committee and continue all care until a decision is reached* - While an ethics committee consult is appropriate if there's **disagreement over the interpretation of the patient's wishes** *among legally designated surrogates* or concerns about the surrogate's decision-making capacity, it's not the first step when a clear legal surrogate with documentation is present and makes a decision. - Continuing all care against the wishes of the **legal proxy** would be contrary to patient autonomy and the principles of substituted judgment.

Question 2: A 75-year-old woman with metastatic colon cancer comes to the physician requesting assistance in ending her life. She states: “I just can't take it anymore; the pain is unbearable. Please help me die.” Current medications include 10 mg oral hydrocodone every 12 hours. Her cancer has progressed despite chemotherapy and she is very frail. She lives alone and has no close family. Which of the following is the most appropriate initial action by the physician?

A. Consult with the local ethics committee
B. Submit a referral to psychiatry
C. Submit a referral to hospice care
D. Increase her pain medication dose (Correct Answer)
E. Initiate authorization of physician-assisted suicide

Explanation: ***Increase her pain medication dose*** - The patient's request to end her life is directly linked to "unbearable pain" and her current pain regimen (10 mg hydrocodone every 12 hours) is **sub-therapeutic** for metastatic cancer, indicating inadequate pain control. - Addressing the **underlying cause** of her distress, which is severe pain, with appropriate analgesia is the immediate and most ethical first step in palliative care. *Consult with the local ethics committee* - While ethical considerations are paramount in end-of-life care, this is not the **initial action** as the patient's pain, a modifiable factor, needs to be addressed first. - An ethics committee consultation would be more appropriate if adequate pain control has been attempted and the patient's request persists or if there are complex ethical dilemmas beyond immediate symptom management. *Submit a referral to psychiatry* - Although patients with severe illness may experience depression, the primary stated reason for her request is **unbearable pain**, which is a physical symptom requiring immediate medical attention. - A psychiatric referral might be warranted if, after adequate pain management, the patient continues to express persistent desires for death or exhibits symptoms of a treatable mood disorder, but it is not the *initial* step. *Submit a referral to hospice care* - This is an appropriate step for a patient with metastatic colon cancer and frailty, as hospice provides **comprehensive palliative care**. - However, the **immediate priority** is addressing her acute and inadequately treated pain, which is the stated reason for her distress and request for assistance in dying. *Initiate authorization of physician-assisted suicide* - Physician-assisted suicide is **illegal** in most jurisdictions and ethically controversial, and palliative care principles prioritize relieving suffering rather than ending life. - The patient's request stems from **unmanaged pain**, which is a treatable condition, making physician-assisted suicide an inappropriate and premature consideration.

Question 3: A 72-year-old woman with metastatic ovarian cancer is brought to the physician by her son because she is in immense pain and cries all the time. On a 10-point scale, she rates the pain as an 8 to 9. One week ago, a decision to shift to palliative care was made after she failed to respond to 2 years of multiple chemotherapy regimens. She is now off chemotherapy drugs and has been in hospice care. Current medications include 2 mg morphine intravenously every 2 hours and 650 mg of acetaminophen every 4 to 6 hours. The son is concerned because he read online that increasing the dose of morphine would endanger her breathing. Which of the following is the most appropriate next step in management?

A. Counsel patient and continue same opioid dose
B. Increase dosage of morphine (Correct Answer)
C. Change morphine to a non-opioid analgesic
D. Initiate palliative radiotherapy
E. Initiate cognitive behavioral therapy

Explanation: ***Increase dosage of morphine*** - The patient is experiencing severe, **uncontrolled pain** (8-9/10), indicating her current morphine dose is inadequate. In palliative care, the goal is to provide maximum comfort, and **opioid dose escalation** is appropriate to achieve this. - While respiratory depression is a concern with opioids, in patients with chronic pain who are already on opioids, **tolerance to respiratory depressant effects** develops more quickly than tolerance to analgesic effects. Careful titration and monitoring can safely increase pain relief. *Counsel patient and continue same opioid dose* - The patient's pain is severe and unmanaged, so simply counseling her without addressing the **inadequate analgesia** would be inappropriate and unethical. - Continuing the same dose would perpetuate her suffering, as the current regimen is clearly **insufficient for pain control**. *Change morphine to a non-opioid analgesic* - For severe cancer pain (8-9/10), **non-opioid analgesics** alone are typically ineffective. - Switching to a non-opioid would likely lead to even poorer pain control and increased suffering, as opioids are the **cornerstone of severe cancer pain management**. *Initiate palliative radiotherapy* - While **radiotherapy** can be effective for localized pain caused by bone metastases, its onset of action is not immediate, and the primary issue here is urgent, **uncontrolled systemic pain**. - It is not an appropriate initial step for immediate pain relief in a patient already in hospice with widespread metastatic disease and severe current pain. *Initiate cognitive behavioral therapy* - **Cognitive behavioral therapy (CBT)** can be a useful adjunct in chronic pain management to help with coping strategies and psychological distress. - However, it does not directly address the severe, acute physical pain the patient is experiencing and is not a substitute for **pharmacological pain control** in this context.

Question 4: A 69-year-old man with aggressive metastatic cholangiocarcinoma presents after the second round of chemotherapy. He has suffered a great deal of pain from the metastasis to his spine, and he is experiencing side effects from the cytotoxic chemotherapy drugs. Imaging shows no change in the tumor mass and reveals the presence of several new metastatic lesions. The patient is not willing to undergo any more chemotherapy unless he gets something for pain that will “knock him out”. High-dose opioids would be effective, in his case, but carry a risk of bradypnea and sudden respiratory failure. Which of the following is the most appropriate next step in management?

A. Put him in a medically-induced coma during chemotherapy sessions
B. Stop chemotherapy
C. Continue another round of chemotherapy without opioids
D. Give the high-dose opioids (Correct Answer)
E. Give a lower dose even though it has less efficacy

Explanation: ***Give the high-dose opioids*** - Given the patient's **aggressive metastatic cholangiocarcinoma**, lack of response to chemotherapy, severe pain, and desire for effective pain relief, providing **high-dose opioids** aligns with the principles of **palliative care** and patient autonomy at the end of life. - In a situation where cure is not possible and the patient prioritizes pain relief, even with the risk of **bradypnea** or **respiratory failure**, the focus shifts to maximizing comfort and quality of life. - The **principle of double effect** applies here: the intent is to relieve suffering, not to hasten death, making this ethically appropriate end-of-life care. *Put him in a medically-induced coma during chemotherapy sessions* - A medically-induced coma is an extreme measure usually reserved for conditions like severe brain injury or intractable seizures, not for managing pain during **chemotherapy** or preventing awareness of side effects. - This option does not address the underlying issue of the **chemotherapy's ineffectiveness** and adds significant risks and complications without clear benefit in this scenario. *Stop chemotherapy* - While chemotherapy has been ineffective and caused side effects, the decision to **stop chemotherapy** solely based on patient symptoms or ineffective treatment should be a shared decision, but the question specifically asks for the next step regarding pain management. - Stopping chemotherapy without addressing the patient's severe pain and his direct request for effective pain relief would be incomplete in this context. *Continue another round of chemotherapy without opioids* - The patient has expressed unwillingness to continue chemotherapy without effective pain relief, stating he needs "something for pain that will knock him out," making this option directly contradictory to his wishes. - Continuing ineffective chemotherapy while denying proper pain management would cause further suffering without benefit, violating principles of **palliative care** and **patient autonomy**. *Give a lower dose even though it has less efficacy* - The patient explicitly stated his desire for pain relief that will "knock him out," indicating dissatisfaction with current or sub-therapeutic pain management. - Providing a **lower, less effective dose of opioids** would go against the patient's expressed wishes and would likely fail to alleviate his severe pain adequately, diminishing his quality of life in his final days.

Question 5: A 76-year-old woman is brought to the physician by her daughter for evaluation of progressive cognitive decline and a 1-year history of incontinence. She was diagnosed with dementia, Alzheimer type, 5 years ago. The daughter has noticed that in the past 2 years, her mother has had increasing word-finding difficulties and forgetfulness. She was previously independent but now lives with her daughter and requires assistance with all activities of daily living. Over the past year, she has had decreased appetite, poor oral intake, and sometimes regurgitates her food. During this time, she has had a 12-kg (26-lb) weight loss. She was treated twice for aspiration pneumonia and now her diet mainly consists of pureed food. She has no advance directives and her daughter says that when her mother was independent the patient mentioned that she would not want any resuscitation or life-sustaining measures if the need arose. The daughter wants to continue taking care of her mother but is concerned about her ability to do so. The patient has hypertension and hyperlipidemia. Current medications include amlodipine and atorvastatin. Vital signs are within normal limits. She appears malnourished but is well-groomed. The patient is oriented to self and recognizes her daughter by name, but she is unaware of the place or year. Mini-Mental State Examination score is 17/30. Physical and neurologic examinations show no other abnormalities. A complete blood count and serum concentrations of creatinine, urea nitrogen, TSH, and vitamin B12 levels are within the reference range. Her serum albumin is 3 g/dL. Urinalysis shows no abnormalities. Which of the following is the most appropriate next step in management?

A. Prescribe oxycodone
B. Short-term rehabilitation
C. Home hospice care (Correct Answer)
D. Inpatient palliative care
E. Evaluation for alternative methods of feeding

Explanation: ***Home hospice care*** - This patient exhibits advanced **dementia** with significant decline in function, frequent aspiration events, and substantial **weight loss**, indicating a prognosis of less than six months. **Hospice care** focuses on comfort and dignity during the end-of-life stage. - The daughter's recollection of the patient's wishes to avoid life-sustaining measures, combined with the current medical complexity and poor prognosis, supports the transition to **hospice services** to manage symptoms and provide support to both the patient and family. *Prescribe oxycodone* - There is no mention of pain in the patient’s presentation; therefore, prescribing an **opioid** like oxycodone is not indicated and could cause adverse effects such as **sedation** and **constipation**, which would further complicate her care. - While patients with advanced dementia may experience pain, it must be assessed and confirmed before prescribing **analgesics**. *Short-term rehabilitation* - Given the patient's advanced dementia, severe functional decline, recurrent aspiration pneumonia, and malnourishment, **short-term rehabilitation** to improve functional status is unlikely to be effective. - The patient's underlying condition is progressive and irreversible, making restoration of independent function an unrealistic goal. *Inpatient palliative care* - While **palliative care** focuses on symptom management and quality of life, **inpatient palliative care** is typically reserved for patients with severe symptoms requiring constant medical attention that cannot be managed at home. - In this case, the patient's symptoms, while serious, appear amenable to management in a home setting with the comprehensive support offered by **hospice**. *Evaluation for alternative methods of feeding* - In advanced dementia, **percutaneous endoscopic gastrostomy (PEG) tube feeding** does not improve survival, reduce aspiration risk, or enhance quality of life. - Given the patient's advanced stage of disease and the recalled wishes to avoid life-sustaining measures, initiating **artificial feeding** would be contrary to comfort-focused care.

Question 6: A 28-year-old woman dies shortly after receiving a blood transfusion. Autopsy reveals widespread intravascular hemolysis and acute renal failure. Investigation reveals that she received type A blood, but her medical record indicates she was type O. In a malpractice lawsuit, which of the following elements must be proven?

A. Duty, breach, causation, and damages (Correct Answer)
B. Only duty and breach
C. Only breach and causation
D. Duty, breach, and damages

Explanation: ***Duty, breach, causation, and damages*** - In a medical malpractice lawsuit, all four elements—**duty, breach, causation, and damages**—must be proven for a successful claim. - The healthcare provider had a **duty** to provide competent care, they **breached** that duty by administering the wrong blood type, this breach **caused** the patient's death and renal failure, and these injuries constitute **damages**. *Only duty and breach* - While **duty** and **breach** are necessary components, proving only these two is insufficient for a malpractice claim. - It must also be demonstrated that the breach directly led to the patient's harm and resulted in legally recognized damages. *Only breach and causation* - This option omits the crucial elements of professional **duty** owed to the patient and the resulting **damages**. - A claim cannot succeed without establishing that a duty existed and that quantifiable harm occurred. *Duty, breach, and damages* - This option misses the critical element of **causation**, which links the provider's breach of duty to the patient's injuries. - Without proving that the breach *caused* the damages, even if a duty was owed and breached, and damages occurred, the claim would fail.

Question 7: A 57-year-old man presents to his oncologist to discuss management of small cell lung cancer. The patient is a lifelong smoker and was diagnosed with cancer 1 week ago. The patient states that the cancer was his fault for smoking and that there is "no hope now." He seems disinterested in discussing the treatment options and making a plan for treatment and followup. The patient says "he does not want any treatment" for his condition. Which of the following is the most appropriate response from the physician?

A. "You seem upset at the news of this diagnosis. I want you to go home and discuss this with your loved ones and come back when you feel ready to make a plan together for your care."
B. "It must be tough having received this diagnosis; however, new cancer therapies show increased efficacy and excellent outcomes."
C. "It must be very challenging having received this diagnosis. I want to work with you to create a plan." (Correct Answer)
D. "We are going to need to treat your lung cancer. I am here to help you throughout the process."
E. "I respect your decision and we will not administer any treatment. Let me know if I can help in any way."

Explanation: ***"It must be very challenging having received this diagnosis. I want to work with you to create a plan."*** - This response **acknowledges the patient's emotional distress** and feelings of guilt and hopelessness, which is crucial for building rapport and trust. - It also gently **re-engages the patient** by offering a collaborative approach to treatment, demonstrating the physician's commitment to supporting him through the process. *"You seem upset at the news of this diagnosis. I want you to go home and discuss this with your loved ones and come back when you feel ready to make a plan together for your care."* - While acknowledging distress, sending the patient home without further engagement **delays urgent care** for small cell lung cancer, which is aggressive. - This response might be perceived as dismissive of his immediate feelings and can **exacerbate his sense of hopelessness** and isolation. *"It must be tough having received this diagnosis; however, new cancer therapies show increased efficacy and excellent outcomes."* - This statement moves too quickly to treatment efficacy without adequately addressing the patient's current **emotional state and fatalism**. - While factual, it **lacks empathy** for his personal feelings of blame and hopelessness, potentially making him feel unheard. *"We are going to need to treat your lung cancer. I am here to help you throughout the process."* - This response is **too directive and authoritarian**, which can alienate a patient who is already feeling guilty and resistant to treatment. - It fails to acknowledge his stated feelings of "no hope now" or his disinterest in treatment, which are critical to address before discussing the necessity of treatment. *"I respect your decision and we will not administer any treatment. Let me know if I can help in any way."* - While respecting patient autonomy is vital, immediately accepting a patient's decision to refuse treatment without exploring the underlying reasons (e.g., guilt, hopelessness, lack of information) is **premature and potentially harmful**. - The physician has a responsibility to ensure the patient is making an informed decision, especially for a rapidly progressing condition like small cell lung cancer.

Question 8: A 36-year-old man is admitted to the hospital for treatment of burn wounds on his upper extremities. Analgesic therapy with an opioid drug is begun. Shortly after, the patient develops chills, diaphoresis, nausea, and abdominal pain. On further questioning, the patient reports that he has been smoking opium at home to help him ""deal with the depression and pain.” This patient was most likely given which of the following opioid drugs?

A. Butorphanol (Correct Answer)
B. Oxycodone
C. Morphine
D. Fentanyl
E. Hydrocodone

Explanation: ***Butorphanol*** - **Butorphanol** is a **mixed opioid agonist-antagonist** that acts as a **kappa (κ) receptor agonist** and **mu (μ) receptor antagonist/partial agonist**. - In opioid-dependent patients who use **mu receptor agonists** (like opium), butorphanol can precipitate **acute opioid withdrawal** by displacing full agonists from mu receptors and blocking their effects. - The patient's symptoms of chills, diaphoresis, nausea, and abdominal pain are classic signs of **acute opioid withdrawal syndrome**. *Oxycodone* - **Oxycodone** is a **full mu opioid receptor agonist** and would not precipitate withdrawal in an opioid-dependent patient. - Administering oxycodone would provide continued mu receptor stimulation, potentially alleviating withdrawal symptoms or maintaining the patient's opioid dependence. *Morphine* - **Morphine** is a **full mu opioid receptor agonist** and would not cause withdrawal in an opioid-dependent individual. - It would continue to stimulate mu opioid receptors, providing analgesia and preventing withdrawal symptoms. *Fentanyl* - **Fentanyl** is a potent **full mu opioid receptor agonist** and would provide continued opioid receptor stimulation. - Its administration would prevent withdrawal and provide effective analgesia in an opioid-tolerant patient. *Hydrocodone* - **Hydrocodone** is a **full mu opioid receptor agonist** and would not induce withdrawal symptoms. - Like other full agonists, it would continue mu receptor activation, providing analgesia without precipitating withdrawal.

Question 9: A 72-year-old man is brought to the emergency department from hospice. The patient has been complaining of worsening pain over the past few days and states that it is no longer bearable. The patient has a past medical history of pancreatic cancer which is being managed in hospice. The patient desires no "heroic measures" to be made with regards to treatment and resuscitation. His temperature is 98.8°F (37.1°C), blood pressure is 107/68 mmHg, pulse is 102/min, respirations are 22/min, and oxygen saturation is 99% on room air. Physical exam reveals an uncomfortable elderly man who experiences severe pain upon abdominal palpation. Laboratory values reveal signs of renal failure, liver failure, and anemia. Which of the following is the best next step in management?

A. Ketorolac and fentanyl
B. Ketorolac
C. Morphine (Correct Answer)
D. No intervention warranted
E. Morphine and fentanyl patch

Explanation: ***Morphine*** - This patient is in **hospice** with **acute, unbearable pain** requiring **immediate relief** in the emergency department. **Intravenous or subcutaneous morphine** is the **best next step** as it provides **rapid onset of analgesia** (within 5-10 minutes for IV, 15-30 minutes for SC). - In the **ED setting**, the priority is to achieve **immediate pain control** for this acute exacerbation. Once stabilized, a comprehensive long-acting regimen can be coordinated with hospice, but the question asks for the **best next step**, which is immediate-acting opioid administration. - Morphine is appropriate despite renal failure in end-of-life care where **comfort is the primary goal**. Doses may need adjustment, but pain relief takes precedence in hospice patients. *Ketorolac and fentanyl* - **Ketorolac (NSAID)** is **contraindicated** in patients with **renal failure** and carries risk of **gastrointestinal bleeding**, especially concerning in advanced cancer with anemia. - While fentanyl is appropriate for pain management, a **fentanyl patch** takes **12-24 hours** to reach therapeutic levels and is unsuitable for **acute pain** requiring immediate relief. *Ketorolac* - **Ketorolac (NSAID)** is contraindicated due to **renal failure** and would be insufficient for severe cancer-related pain. - NSAIDs are generally avoided in hospice patients with multi-organ dysfunction and do not provide adequate analgesia for unbearable pain. *Morphine and fentanyl patch* - While this represents a comprehensive pain management approach, it is **not the best next step** in the **emergency department** for **acute pain**. - **Fentanyl patches** have a **delayed onset** (12-24 hours to reach steady state) and are designed for **chronic, stable pain management**, not acute exacerbations. - The immediate priority is rapid pain relief with short-acting opioids; long-acting formulations should be coordinated with hospice after acute stabilization. *No intervention warranted* - This is **unethical and inappropriate** given the patient's explicit complaint of unbearable pain. - **Comfort and symptom management** are the primary objectives of hospice care, making pain relief an absolute necessity.

Question 10: A 32-year-old man comes to the emergency department because of recurrent episodes of vomiting for 1 day. He has had over 15 episodes of bilious vomiting. During this period he has had cramping abdominal pain but has not had a bowel movement or passed flatus. He does not have fever or diarrhea. He was diagnosed with Crohn disease at the age of 28 years which has been well controlled with oral mesalamine. He underwent a partial small bowel resection for midgut volvulus at birth. His other medications include vitamin B12, folic acid, loperamide, ferrous sulfate, and vitamin D3. He appears uncomfortable and his lips are parched. His temperature is 37.1°C (99.3°F), pulse is 103/min, and blood pressure is 104/70 mm Hg. The abdomen is distended, tympanitic, and tender to palpation over the periumbilical area and the right lower quadrant. Rectal examination is unremarkable. A CT scan of the abdomen shows multiple dilated loops of small bowel with a transition zone in the mid to distal ileum. After 24 hours of conservative management with IV fluid resuscitation, nasogastric bowel decompression, promethazine, and analgesia, his condition does not improve and a laparotomy is scheduled. During the laparotomy, two discrete strictures are noted in the mid-ileum, around 20 cm apart. Which of the following is the most appropriate next step in management?

A. Small bowel resection with ileostomy
B. Abdominal closure and start palliative care
C. Small bowel resection and primary anastomosis
D. Strictureplasty of individual strictures (Correct Answer)
E. Ileocolectomy

Explanation: ***Strictureplasty of individual strictures*** - This patient presents with **multiple strictures** in the mid-ileum causing a small bowel obstruction in the setting of **Crohn's disease**. Strictureplasty is the preferred surgical approach for *short, multiple (up to four), or recurrent Crohn's disease strictures* as it preserves bowel length. - While small bowel resection is an option, **strictureplasty** is favored in Crohn's disease to *avoid short bowel syndrome*, especially if multiple strictures are present, as seen here. *Small bowel resection with ileostomy* - An ileostomy is typically created when a primary anastomosis is not safe due to high risk of leak (e.g., severe inflammation, peritonitis, patient instability) or when there is extensive disease not amenable to strictureplasty with primary anastomosis. - Performing an ileostomy when primary anastomosis is possible unnecessarily creates a stoma, which can lead to complications and impact quality of life. *Abdominal closure and start palliative care* - This patient, while acutely unwell, has a surgically correctable cause for his obstruction and is not described as having an incurable or end-stage condition necessitating only palliative care. - Palliative care would be considered for patients with widespread untreatable disease or severe comorbidities, which is not indicated here given the localized, treatable strictures. *Small bowel resection and primary anastomosis* - While small bowel resection is a valid treatment for isolated, non-recurrent strictures, strictureplasty is generally preferred in Crohn's disease when multiple strictures are present. - **Resection of multiple segments** can lead to significant **short bowel syndrome**, especially in a patient with a history of prior small bowel resection, making strictureplasty a more bowel-sparing and appropriate choice. *Ileocolectomy* - **Ileocolectomy** involves resection of the terminal ileum and a portion of the colon. This would be indicated if the disease involves the *ileocecal valve region* or the *colon*, which is not the case in this patient, whose strictures are in the mid-ileum. - This procedure is excessive for mid-ileal strictures and would result in unnecessary removal of healthy bowel given the location of the strictures.

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