COCN COCN Palliative and End-of-Life Care 2 — Questions and Answers
Question 1: Which opioid rotation (equianalgesic conversion) consideration is most important when switching a cancer patient from morphine to hydromorphone?
- Hydromorphone requires a higher dose than morphine
- A 25–50% dose reduction from the calculated equianalgesic dose is recommended to account for incomplete cross-tolerance (Correct answer)
- No dose adjustment is needed since opioids are interchangeable
- Hydromorphone should only be used IV, never subcutaneously
Correct answer: A 25–50% dose reduction from the calculated equianalgesic dose is recommended to account for incomplete cross-tolerance
Incomplete cross-tolerance between opioids means the calculated equianalgesic dose should be reduced by 25–50% to prevent overdose.
Question 2: A cancer patient on chronic opioids develops constipation. The first-line treatment is:
- Bulk-forming laxatives (psyllium)
- Stimulant laxatives (senna) with or without stool softeners (Correct answer)
- Increased oral fluid intake alone
- Fiber supplements only
Correct answer: Stimulant laxatives (senna) with or without stool softeners
Stimulant laxatives are the recommended first-line treatment for opioid-induced constipation (OIC), as bulk agents may worsen the condition.
Question 3: Which medication is specifically FDA-approved for opioid-induced constipation in cancer patients who have not responded to standard laxatives?
- Metoclopramide
- Methylnaltrexone (Relistor) (Correct answer)
- Ondansetron
- Lactulose
Correct answer: Methylnaltrexone (Relistor)
Methylnaltrexone is a peripherally-acting mu-opioid receptor antagonist that relieves OIC without reversing central analgesia.
Question 4: A patient with advanced cancer is experiencing refractory dyspnea. The evidence-based pharmacologic treatment is:
- Benzodiazepines as monotherapy
- Low-dose systemic opioids (Correct answer)
- High-dose corticosteroids only
- Bronchodilators regardless of pulmonary cause
Correct answer: Low-dose systemic opioids
Low-dose systemic opioids have the strongest evidence for reducing the sensation of dyspnea in advanced cancer.
Question 5: Which advance directive specifically designates a person to make healthcare decisions if the patient becomes incapacitated?
- Living will
- Durable power of attorney for healthcare (DPAHC) (Correct answer)
- POLST/MOLST form
- DNR order
Correct answer: Durable power of attorney for healthcare (DPAHC)
A DPAHC appoints a healthcare proxy (surrogate decision-maker) to act on the patient's behalf when they cannot make decisions.
Question 6: Palliative sedation for refractory symptoms at end of life requires that other symptom management options have been:
- Not yet tried to conserve resources
- Exhausted or deemed inappropriate before sedation is initiated (Correct answer)
- Refused by the family but not the patient
- Only tried once each
Correct answer: Exhausted or deemed inappropriate before sedation is initiated
Palliative sedation is ethically justified only when all other reasonable symptom-relief options have failed or are inappropriate.
COCN COCN Palliative and End-of-Life Care 2
Which opioid rotation (equianalgesic conversion) consideration is most important when switching a cancer patient from morphine to hydromorphone?