AOCNP Palliative Care and Symptom Management 4 — Questions and Answers
Question 1: A patient with advanced lung cancer reports severe dyspnea at rest despite supplemental oxygen. Which intervention has the strongest evidence for relieving refractory dyspnea in this setting?
- Increase inspired oxygen concentration to 100%
- Low-dose systemic opioids (Correct answer)
- Nebulized furosemide
- Anxiolytics alone without opioids
Correct answer: Low-dose systemic opioids
Low-dose systemic opioids (e.g., oral morphine) are the most evidence-based pharmacologic intervention for refractory dyspnea in advanced cancer.
Question 2: When titrating opioids for cancer pain, a patient on oral morphine 60 mg/day has inadequate relief. What is the appropriate dose increase per standard palliative care guidelines?
- Increase by 10–15%
- Increase by 25–33% (Correct answer)
- Double the dose immediately
- Add a second opioid at the same dose
Correct answer: Increase by 25–33%
Standard practice recommends increasing the total daily opioid dose by 25–33% when pain is inadequately controlled.
Question 3: A hospice patient develops myoclonic jerks and hyperalgesia after high-dose morphine. Which action best addresses opioid-induced neurotoxicity?
- Add lorazepam to suppress myoclonus only
- Opioid rotation to a different agent such as hydromorphone (Correct answer)
- Increase morphine to overcome tolerance
- Discontinue all opioids and treat with NSAIDs
Correct answer: Opioid rotation to a different agent such as hydromorphone
Opioid rotation (switching to an equianalgesic dose of a different opioid) reduces neurotoxic metabolite accumulation and relieves opioid-induced neurotoxicity.
Question 4: Which of the following best describes the concept of 'total pain' as used in palliative care?
- The numeric pain rating on a 0–10 scale
- Pain that is unresponsive to opioid therapy
- The multidimensional suffering encompassing physical, psychological, social, and spiritual components (Correct answer)
- Pain experienced only in the final 48 hours of life
Correct answer: The multidimensional suffering encompassing physical, psychological, social, and spiritual components
Dame Cicely Saunders defined 'total pain' as the interplay of physical, psychological, social, and spiritual dimensions of suffering.
Question 5: A patient with malignant bowel obstruction is not a surgical candidate. Which combination is most appropriate for symptom management?
- High-dose laxatives and oral fluids only
- Opioids for pain, an antisecretory agent, and antiemetics (Correct answer)
- Parenteral nutrition and nasogastric suction indefinitely
- High-fiber diet and prokinetic agents
Correct answer: Opioids for pain, an antisecretory agent, and antiemetics
Malignant bowel obstruction is managed with opioids for pain/colic, antisecretory agents (e.g., octreotide or hyoscine) to reduce secretions, and antiemetics.
Question 6: An AOCNP is counseling the family of a dying patient about the 'death rattle.' Which statement is most accurate?
- The sound indicates the patient is in severe pain
- It is caused by retained secretions and is usually not distressing to the patient (Correct answer)
- Suctioning the throat is the most effective treatment
- It only occurs in patients who received opioids
Correct answer: It is caused by retained secretions and is usually not distressing to the patient
The death rattle results from retained oropharyngeal secretions in a semi-comatose patient and is typically not distressing to the patient, though it may distress families.
Question 7: Which tool is specifically validated for assessing symptom burden in patients with advanced cancer across multiple symptom domains?
- Numeric Rating Scale (NRS)
- Edmonton Symptom Assessment System (ESAS) (Correct answer)
- Palliative Performance Scale (PPS)
- Karnofsky Performance Status (KPS)
Correct answer: Edmonton Symptom Assessment System (ESAS)
The Edmonton Symptom Assessment System (ESAS) is a validated, multidimensional tool that rates nine common symptoms (pain, fatigue, nausea, depression, anxiety, drowsiness, appetite, wellbeing, dyspnea) in palliative patients.
AOCNP Palliative Care and Symptom Management 4
A patient with advanced lung cancer reports severe dyspnea at rest despite supplemental oxygen.
Which intervention has the strongest evidence for relieving refractory dyspnea in this setting?