CHPN Non-Pain Symptom Management 4 — Questions and Answers
Question 1: A terminally ill patient is experiencing agitated delirium with hallucinations and combativeness. Which medication is FIRST-LINE for managing hyperactive delirium in hospice?
- Lorazepam (benzodiazepine)
- Haloperidol (antipsychotic) (Correct answer)
- Morphine (opioid)
- Diphenhydramine (antihistamine)
Correct answer: Haloperidol (antipsychotic)
Haloperidol is the first-line agent for hyperactive delirium in palliative care due to its efficacy in reducing psychotic symptoms with minimal sedation.
Question 2: Which of the following is a REVERSIBLE cause of delirium that should be assessed in a hospice patient experiencing acute confusion?
- Advanced age
- Urinary retention or fecal impaction (Correct answer)
- History of dementia
- Terminal prognosis
Correct answer: Urinary retention or fecal impaction
Urinary retention and fecal impaction are common, treatable causes of delirium in palliative patients that should be assessed before attributing confusion to disease progression.
Question 3: A patient in the last days of life develops terminal restlessness unresponsive to haloperidol. What is the NEXT appropriate intervention?
- Increase IV fluids to treat presumed dehydration
- Add a benzodiazepine such as midazolam for refractory agitation (Correct answer)
- Apply physical restraints to prevent injury
- Discontinue all opioids as they may be causing the agitation
Correct answer: Add a benzodiazepine such as midazolam for refractory agitation
Midazolam is added for refractory terminal restlessness when haloperidol alone is insufficient, providing anxiolysis and sedation.
Question 4: When educating a family about terminal delirium, which statement BEST reflects evidence-based understanding?
- Delirium always indicates that the patient is in severe pain
- Delirium is common near death and may represent a transitional state; the patient is often unaware of their behavior (Correct answer)
- Sedating the patient will shorten their life
- Delirium can always be reversed with adequate hydration
Correct answer: Delirium is common near death and may represent a transitional state; the patient is often unaware of their behavior
Terminal delirium is a normal part of the dying process; patients are typically unaware of their behavior, and families need reassurance that it does not mean suffering.
Question 5: A hospice patient on chronic opioids develops myoclonus (muscle twitching). Which is the MOST likely cause?
- Opioid underdosing causing breakthrough pain
- Accumulation of opioid metabolites, particularly morphine-6-glucuronide (Correct answer)
- Hypoglycemia from decreased oral intake
- Seizure activity from brain metastases
Correct answer: Accumulation of opioid metabolites, particularly morphine-6-glucuronide
Opioid-induced myoclonus results from accumulation of neuroexcitatory metabolites (e.g., morphine-3-glucuronide) especially in renal impairment.
Question 6: A patient with terminal cancer develops anxiety and existential distress. Which combination approach is MOST consistent with palliative care philosophy?
- Prescribe a benzodiazepine only and minimize psychological interventions to avoid distressing the patient
- Combine pharmacologic treatment (e.g., lorazepam) with psychosocial support, chaplaincy, and dignity therapy (Correct answer)
- Refer exclusively to psychiatry and discharge from hospice
- Avoid discussing existential concerns to maintain hope
Correct answer: Combine pharmacologic treatment (e.g., lorazepam) with psychosocial support, chaplaincy, and dignity therapy
Palliative care addresses total suffering through an integrated approach combining medications, psychosocial support, and spiritual care.
Question 7: Which assessment tool is specifically designed to identify delirium in palliative care patients?
- Edmonton Symptom Assessment System (ESAS)
- Confusion Assessment Method (CAM) (Correct answer)
- Mini-Mental State Examination (MMSE)
- Pittsburgh Sleep Quality Index (PSQI)
Correct answer: Confusion Assessment Method (CAM)
The CAM is the gold-standard validated tool for detecting delirium and distinguishing it from dementia or depression.
CHPN Non-Pain Symptom Management 4
A terminally ill patient is experiencing agitated delirium with hallucinations and combativeness.
Which medication is FIRST-LINE for managing hyperactive delirium in hospice?