ACHPN - Advanced Certified Hospice and Palliative Nurse Examination Pharmacologic Interventions in Palliation Questions and Answers — Questions and Answers
Question 1: An 82-year-old male with end-stage COPD is admitted to hospice for worsening dyspnea. He is currently opioid-naïve. Which of the following is the most appropriate initial pharmacologic intervention for managing his dyspnea?
- Nebulized morphine every 4 hours as needed
- Lorazepam 0.5 mg sublingual every 6 hours as needed for anxiety
- Morphine sulfate immediate-release 2.5-5 mg orally every 4 hours as needed. (Correct answer)
- Oxygen at 4 L/min via nasal cannula continuously
Correct answer: Morphine sulfate immediate-release 2.5-5 mg orally every 4 hours as needed.
Low-dose oral opioids are the first-line pharmacologic treatment for refractory dyspnea in palliative care, even in opioid-naïve patients. Starting with a low dose of immediate-release morphine (2.5-5 mg) allows for safe and effective titration. Nebulized opioids have not been shown to be effective. While benzodiazepines can manage the anxiety component of dyspnea, they do not treat the sensation of breathlessness itself. Oxygen is only beneficial for patients who are hypoxemic.
Question 2: A patient with metastatic cancer to the bone reports severe, sharp, intermittent pain with movement, despite being on a stable long-acting opioid regimen. Which adjuvant medication would be most appropriate to target this type of incident bone pain?
- Gabapentin
- Dexamethasone. (Correct answer)
- Amitriptyline
- Baclofen
Correct answer: Dexamethasone.
Corticosteroids, such as dexamethasone, are recommended as an adjuvant analgesic for cancer-related bone pain due to their potent anti-inflammatory effects which can reduce pain from inflammation surrounding bone metastases. Gabapentin and amitriptyline are primarily used for neuropathic pain. Baclofen is a muscle relaxant and would be more appropriate for pain related to muscle spasms.
Question 3: A 65-year-old patient with advanced pancreatic cancer is experiencing persistent nausea and vomiting, suspected to be due to delayed gastric emptying. Which of the following antiemetics would be the most appropriate first-choice medication?
- Ondansetron
- Scopolamine
- Metoclopramide. (Correct answer)
- Lorazepam
Correct answer: Metoclopramide.
Metoclopramide is a prokinetic agent that enhances gastric emptying, making it a logical first choice for nausea and vomiting caused by gastroparesis or delayed gastric emptying. Ondansetron is a 5-HT3 antagonist, primarily used for chemotherapy-induced or post-operative nausea. Scopolamine is an anticholinergic used for motion sickness or excess secretions. Lorazepam is an anxiolytic that can help with anticipatory nausea but does not have a primary prokinetic effect.
Question 4: A patient in the terminal phase of life develops noisy, gurgling respirations ('death rattle') that are distressing to the family. Non-pharmacologic measures like repositioning have been ineffective. Which pharmacologic intervention is most appropriate to manage this symptom?
- Administering a diuretic like furosemide
- Prophylactic subcutaneous glycopyrrolate or scopolamine. (Correct answer)
- Increasing the dose of the patient's opioid
- Starting a nebulized bronchodilator
Correct answer: Prophylactic subcutaneous glycopyrrolate or scopolamine.
The 'death rattle' is caused by the accumulation of secretions in the upper airway. Anticholinergic medications like glycopyrrolate or scopolamine work by decreasing the production of these secretions. Evidence suggests that prophylactic administration, before the rattle becomes severe, is more effective than treating it once it is established. Diuretics, opioids, and bronchodilators do not target the underlying cause of this symptom.
Question 5: An ACHPN is caring for a patient with severe, refractory neuropathic pain from metastatic cancer. The patient has had inadequate relief and limiting side effects from high doses of morphine and a trial of gabapentin. Which of the following opioids would be a logical next choice due to its unique mechanism of action for neuropathic pain?
- Hydromorphone
- Fentanyl
- Oxycodone
- Methadone. (Correct answer)
Correct answer: Methadone.
Methadone is a unique opioid that not only acts as a mu-opioid agonist but also as an NMDA receptor antagonist and inhibits the reuptake of serotonin and norepinephrine. This dual mechanism makes it particularly effective for complex pain syndromes, including neuropathic pain, and it is often used when other opioids have failed. The other listed opioids are primarily mu-opioid agonists without this additional NMDA receptor antagonism.
Question 6: A hospice patient with advanced dementia develops hyperactive delirium with agitation that is distressing and poses a safety risk. Non-pharmacologic interventions have failed. Which of the following represents the most appropriate initial pharmacologic approach?
- Administering lorazepam as a standalone first-line agent
- Starting a scheduled dose of an antidepressant like sertraline
- Initiating a low-dose antipsychotic such as haloperidol. (Correct answer)
- Requesting a palliative sedation consultation immediately
Correct answer: Initiating a low-dose antipsychotic such as haloperidol.
For hyperactive delirium with agitation in palliative care, a low-dose antipsychotic (neuroleptic) such as haloperidol is recommended as the first-line pharmacologic treatment. Benzodiazepines like lorazepam can be used as adjuncts, particularly if anxiety is a major component or if antipsychotics are ineffective, but they can sometimes worsen confusion when used alone. Antidepressants are not indicated for acute delirium. Palliative sedation is a last resort for refractory symptoms.
ACHPN - Advanced Certified Hospice and Palliative Nurse Examination Pharmacologic Interventions in Palliation Questions and Answers
An 82-year-old male with end-stage COPD is admitted to hospice for worsening dyspnea.
He is currently opioid-naïve.
Which of the following is the most appropriate initial pharmacologic intervention for managing his dyspnea?