HPM Questions Flashcards
1
Q
What are the components of Total Pain?
A
Physical, Psychological, Social, and Spiritual
2
Q
What is acute pain?
A
Occurs suddenly due to illness, injury, or surgery, that is generally short-lived that resolves as the acute illness heals
3
Q
What is chronic pain?
A
Pain that lasts longer than the expected healing process (3 months for IASP), and that affects a person’s activities of daily living
4
Q
What is nociceptive pain?
A
Arises from actual or threatened damage to non-neural tissues due to activation of nociceptors
5
Q
What are common symptoms of somatic nociceptive pain?
A
Arises from bone, joint, muscle, skin, or connective tissue that is well-localized, aching, and throbbing
6
Q
What are common cymptoms of visceral nociceptive pain?
A
Arsises from visceral organs (such as the GI tract), that is aching if related to capsular pain or poorly localized cramping if due to hollow viscus organ pain
7
Q
What are the stages of nociceptive pain?
A
Transduction -> Conduction -> Transmission -> Perception -> Modulation
8
Q
What are the characteristics of pain conducted by C-fibers?
A
C-fibers are small, unmyelinated, slow-conducting fibers that transmit dull, poorly localized, diffuse, burning/aching pain, and are sensitive to mechanical, thermal, or chemical stimuli
9
Q
What are the characteristics of pain conducted by A-delta fibers?
A
A-delta fibers are large, myelinated, fast-conducting fibers that transmit well-localized, sharp pain, and are sensitive to mechanical and thermal stimuli
10
Q
What are the characteristics of pain conducted by A-beta fibers?
A
A-beta fibers conduct non-noxious input (i.e., touch), and do not transmit pain signals
11
Q
Which of the stages of nociceptive pain is not responsive to drug therapy?
A
Perception
12
Q
What is an example of transduction of pain?
A
Nociceptors translate physical stimulus into an electrical signal and action potential
13
Q
What is an example of conduction of pain?
A
Pain impulse traveling up or up to the spinal cord
14
Q
What is an example of transmission of pain?
A
Transfer of an action potential from one neuron to the next
15
Q
What is an example of perception of pain?
A
The conscious experience of pain
16
Q
What is an example of modulation of pain?
A
Inhibiting descending pain impulses
17
Q
What medications help reduce the transduction of pain signals?
A
NSAIDs, anticonvulsants, Capsaicin, Lidocaine, and TCAs
18
Q
What medications help reduce the conduction/transmission of pain signals?
A
Opioids (endogenous and exogenous), Gabapentin, Pregabalin, Ketamine, and anticonvulsants
19
Q
What medications help reduce the perception of pain signals?
A
None
20
Q
What interventions help reduce the perception of pain signals?
A
Relaxation and guided imagery
21
Q
What medications help reduce modulation of pain signals?
A
Opioids, Tramadol, Tapentadol, TCAs, SNRIs, and Baclofen
22
Q
What processes lead to the development of neuropathic pain?
A
Abnormal nerve regeneration, increased expression of membrane sodium channels, disinhibition of the modulatory process, or decreased expression of mu-opioid receptors
23
Q
What is allodynia?
A
Pain from a non-painful stimulus, such as touch
24
Q
What pain assessment tool has been validated for patients with advanced dementia?
A
PAINAD – a 5 item observational tool
25
How long must pain be present in a day for it to be classified as persistent pain?
12 out of 24 hours in a day
26
What is the preferred route of administration for medications for most patients?
Oral
27
What are the FDA guidelines to starting transdermal Fentanyl in patients?
Patients must be receiving and tolerating at least 60mg of oral Morphine equivalents per day for no less than 7 days (1 week)
28
What is the maximum daily dose of Acetaminophen recommended by the FDA?
4 grams
29
What opiate should you avoid due to it being a strong CNS irritant with dysphoria, irritability, tremors, myoclonus, and seizures?
Meperidine (Demerol)
30
If a patient has a neurolytic procedure performed, when might they have return of pain sensation secondary to nerve regeneration?
3 to 6 months
31
What kind of nerve blocks help with visceral pain?
Sympathetic nerve blocks
32
What kind of nerve blocks help with focal pain?
Somatic nerve blocks
33
What are the main types of sympathetic nerve blocks?
```
Celiac plexus
Lumbar
Superior hypogastric
Stellate ganglion
Ganglion impars
```
34
What are the main types of somatic blocks?
Brachial plexus
Gasserian
Paravertebral
Epidural/Intrathecal
35
What is the indication for a superior hypogastric plexus block?
Visceral pelvic pain that is refractory to medical management
36
For what cancer type is a neurolytic procedure a first-line therapy for pain?
Upper abdominal cancers (i.e., pancreatic cancer)
37
What neurolytic intervention is indicated for pancreatic cancer?
Celiac plexus block
38
What are the side effects associated with a celiac plexus block?
Orthostasis and diarrhea
39
What kind of nerve block is indicated for chest wall pain (e.g., breast cancer pain or rib metastases)?
Intercostal
40
What kind of nerve block is indicated for unilateral leg pain?
Lumbar subarachnoid
41
What is another kind of nerve block indicated for pelvic pain?
Phenol saddle
42
What is another kind of nerve block indicated for chronic pelvic pain (e.g., interstitial cystitis)?
Pudendal nerve
43
What is complex regional pain syndrome?
Regional pain that is associated with focal autonomic dysfunction
44
What kind of nerve block is indicated for spinal facet joint pain (e.g., malignant vertebral compression fractures)?
Medial branch of the primary dorsal ramus
45
When are nerve blocks for trigeminal neuralgia indicated?
As a last resort
46
What nerve block has the lowest risk for adverse effects when treating
Gasserian ganglion block
47
What is the life expectancy patients should generally have if they are being referred for an epidural catheter for pain management?
Days to weeks
48
What is a major risk of epidural catheter placement?
Catheter fibrosis
49
What is the life expectancy patients should generally have if they are being referred for an intrathecal catheter for pain management?
Weeks to months
50
How much oral morphine daily dose equivalents must a patient be taking before being referred for an intrathecal catheter for pain management?
Greater than or equal to 100mg
51
What medications can be used in neuraxial pain management?
Opiates - Morphine, Hydromorphone, Fentanyl
| Non-Opiates - Bupivacaine, Clonidine, Ziconotide, Baclofen
52
What are the common side effects seen with Bupivacaine neuraxial pain management?
Urinary retention, paresthesias, lower extremity weakness, gait impairment, and orthostatic hypotension
53
What is the most common side effect seen with Ziconotide neuraxial pain management?
Psychosis
54
What is the most emergent complication of an intrathecal pain pump?
Spinal cord and/or nerve injury
55
What are common non-emergent complications of intrathecal pain pumps?
CSF leaks, infection, migration, release of large concentrations of drug, and/or granulomas
56
What are the conversion ratios for Morphine?
```
PO = 30mg
IV = 10mg
Epidural = 1mg
Intrathecal = 0.1mg
```
57
What are the conversion ratios for Hydromorphone?
```
PO = 7.5mg
IV = 1.5mg
Epidural = 0.2mg
Intrathecal = 0.04mg
```
58
What are the conversion ratios for Fentanyl?
```
IV = 100mcg
Epidural = 33mcg
Intrathecal = 6-10mcg
```
59
When are vertebroplasty and/or kyphoplasty indicated?
Used for symptomatic compression fractures to reduce pain and stabilize the fracture, most often showing pain relief in cancer patients
60
What are the contraindications to vertebroplasty and/or kyphoplasty?
1. ) Epidural disease
2. ) Neurologic damage related to the fracture
3. ) Fracture with bone fragments extending into the spinal cord
4. ) Infection
5. ) Hypercoagulable state
6. ) Severe cardiopulmonary disease
61
How long after radiation therapy do patients typically experience pain relief?
2 to 4 weeks
62
What is a rhizotomy?
A surgical procedure to sever the nerve roots of a spinal cord
63
What is a cordotomy?
A surgical procedure that disables selected pain-conducting tracts in the spinal cord to achieve pain control
64
When is a cordotomy indicated?
Severe, uncontrolled, refractory cancer pain
65
What is the primary use for Ketamine?
Refractory neuropathic pain
66
What is a growing use for Ketamine?
Refractory depression
67
What are the most common side effects of Ketamine?
Vivid dreams, hallucinations, floating sensations, and visual-spatial disorders
68
What is a rare side effect seen with Ketamine abuse?
Ulcerative cystitis
69
What medication should you use if there are psychogenic side effects seen while administering Ketamine?
Lorazepam
70
What is the preferred steroid to use in cancer pain management?
Dexamethasone
71
Why is Dexamethasone the preferred steroid to use in cancer pain?
Low mineralocorticoid effect
72
Other than pain, when might a provider consider steroids for symptom control?
End-of-life fatigue, anorexia, and nausea
73
What is the primary indication for topical lidocaine?
Post-herpetic neuralgia
74
For which disease processes has acupuncture been shown to have promising benefits?
Chemotherapy-induced neuropathy and post-thoracotomy pain
75
Which pain disease state does Cognitive Behavioral Therapy best treat?
Chronic pain
76
What are known contraindications for acupuncture?
An active infection or known malignancy at the site of needle insertion
77
What are the known indications for St. John's Wort?
Depression and auto-inflammation
78
What are the side effects of St. John's Wort?
1. ) Interferes with the metabolism of opiates
2. ) Blood thinner
3. ) Increased risk of serotonin syndrome
79
What drug is ginger known to interact with?
Coumadin (Warfarin)
80
What is the most prevalent symptom in palliative care?
Fatigue
81
What is the definition of fatigue?
Extreme tiredness, typically resulting from mental/physical exertion
82
What other diagnoses should be considered when patients present with fatigue?
Depression, hypoactive delirium, weakness, or demoralization
83
What has been shown to improve cancer-related fatigue in particular individuals?
Exercise
84
What is the most likely cause of cancer-related fatigue?
Elevation of pro-inflammatory cytokines such as TNF-alpha, IL-1, and IL-6
85
What are common risk factors for cancer-related fatigue?
Unmarried, lower household income, medical comorbidities, poor nutritional issues, deconditioning, polypharmacy
86
What two factors are not consistently associated with cancer-related fatigue?
1. ) Type of treatment
| 2. ) Dose intensity
87
What is the dosing for Methylphenidate for cancer-related fatigue?
Start at 5mg BID
| Max of 40mg/day
88
What is the dosing for Modafinil for cancer-related fatigue?
200mg/day
89
What is the dosing for Dexamethasone for cancer-related fatigue?
8mg, typically divided into BID dosing
| This is the medication of choice for fatigue at end-of-life
90
What patients are candidates for testosterone supplementation for fatigue?
HIV, ESRD, and COPD
91
What are the side effects for Megestrol?
Edema, thromboembolic events, increased mortality
92
What is a known independent risk factor for mortality?
Delirium
93
How often can delirium be reversed?
50%
94
What are the symptoms of hypoactive delirium?
Psychomotor retardation
Withdrawal/Apathy
Inattentive
Lethargy
95
What are the symptoms of hyperactive delirium?
Psychomotor agitation
Aggression
Hypervigilance
Sympathetic hyperactivity
96
What is the key difference between delirium and dementia?
Attention is impaired in delirium whereas it the patient is confused but does not have impaired attention in dementia
97
What are life-threatening causes of delirium?
Hypoxia, hyperglycemia, hypertension, Wernicke's encephalopathy, intracranial hemorrhage, meningitis/encephalitis, or poisoning
98
What is a severe side effect of antipsychotics used to treat delirium?
Neuroleptic malignant syndrome
99
What is the FDA Black Box Warning for antipsychotics used to treat delirium?
Sudden death in elderly patients with dementia
100
What is the first-line therapy for delirium?
Medical evaluation leading to treating the underlying cause
101
What is a strong contraindication for using Haloperidol?
QTc above 450msec, or if it increases by 25% while on Haloperidol
102
What antipsychotics are known to potentiate delirium through their anticholinergic side effects?
Chlorpromazine and Olanzapine
103
What is the safest antipsychotic to use in patients with Lewy-body dementia?
Quetiapine
104
What are the symptoms associated with xerostomia?
Malodorous breath, altered taste, difficulty chewing/swallowing, tooth decay, gum disease
105
When should you use sialagogues for patients with xerostomia?
If prognosis is greater than 3 to 6 months
106
What is a common under-reported cause of insomnia?
Restless leg syndrome
107
What is the first-line therapy for the treatment of insomnia?
Behavioral therapy
108
What are the CDC recommendations for the treatment of insomnia?
1. ) Consistent bed time
2. ) Quiet, dark, relaxing bedroom
3. ) No electronic media devices
4. ) No meals or alcohol before bed
5. ) Exercise during the day
109
What medications used commonly for insomnia cause an increased risk for accidental opiate overdose?
Zolpidem (Ambien)
110
What is the first-line therapy for opioid-induced pruritis?
Rotation
111
What is the second-line therapy for opioid-induced pruritis?
Sertraline, Paroxetine, or Mirtazapine
112
What is the treatment of choice for opioid-induced pruritis secondary to neuraxially-administered opiates?
Ondansetron
113
What are effective medications for pruritis associated with HIV?
Indomethicin
| Doxepin
114
What are effective medications for pruritis associated with chronic kidney disease?
Gabapentin
Pregabalin
Mirtazapine
Dronabinol
115
What are effective medications for pruritis associated with hepatic disease?
Rifampin
Sertraline
Mirtazapine
Dronabinol
116
What are effective medications for pruritis associated with inflammatory dermatoses?
Steroids
| Immunosuppressants
117
What are the characteristics of a stage I wound?
Intact skin with non-blanchable redness of a localized area, usually over a bony prominence
118
What are the characteristics of a stage II wound?
Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed without sloughing
119
What are the characteristics of a stage III wound?
Full thickness tissue loss, with visible subcutaneous fat but nonvisible bone/tendon/muscle
120
What are the characteristics of a stage IV wound?
Full thickness tissue loss with exposed bone/tendon/muscle
121
Generally, what should the maximum PPS level be for patients who are referred for hospice (or declared terminal)?
30%
122
What are the PPS breakdowns for ambulation?
```
80-100% - full
60-70% - reduced
40-50% - mainly site/lie
10-30% - totally bed bound
0% - death
```
123
What are the PPS breakdowns for activity and evidence of disease?
100% - normal activity with no evidence of disease
90% - normal activity with some evidence of disease
80% - normal activity with effort
70% - abnormal work with significant disease
60% - unable to house work
50% - unable to any work
40% - unable to most activity
10-30% - unable to do any activity
0% - death
124
What are the PPS breakdowns for self-care?
```
70-100% - full
60% - occasional assistance needed
50% - considerable assistance needed
40% - mainly assistance
10-30% - total care
0% - death
```
125
What are the PPS breakdowns for intake?
```
90-100% - normal
30-80% - normal or reduced
20% - minimal to sips
10% - mouth care only
0% - death
```
126
What are the PPS breakdowns for conscious level?
70-100% - full
50-60% - full or confusion
20-50% - full or drowsy with or without confusion
10% - drowsy or coma with or without confusion
0% - death
127
What time period is defined as the active phase of dying?
48 hours prior to death
128
What are the findings seen in the early stages of dying?
```
Bed bound
Loss of interest and ability in drinking/eating
Cognitive changes
Increased sedation
Delirium
```
129
What are the findings seen in the late stages of dying?
```
Loss of swallowing reflex
Death rattle
Coma
Fever
Altered respiratory pattern
Skin color changes
```
130
What is the chance of CPR survival to ultimate discharge in terminally ill patients?
0%
131
What medication is the first-choice for hyperactive terminal delirium?
Benzodiazepines such as Lorazepam or Midazolam
132
What is the first line treatment for death rattle?
Repositioning
133
How long until death is likely in a fair-skinned patient who develops lower extremity mottling at the end of life?
Hours
134
What kind of nerve block might be recommended for an individual with severe pelvic pain secondary to malignancy and external beam radiation?
Superior hypogastric block
Ganglion impars block (rectum)
Phenol saddle block
135
For what patients is duloxetine a more appropriate starting medication than gabapentin?
Patients with heart failure (fluid retention), a history of falls, and depression
136
What is the most likely adverse effect seen with high doses of Ketamine?
Psychomimetic reactions
137
What medications are indicated to treat complex regional pain syndrome?
Bisphosphonates
| Ketamine
138
What non-pharmacologic intervention has the best evidence to support its use in pain management?
Cognitive-behavioral therapy
139
What is the difference between sarcopenia and cachexia?
Sarcopenia is age-related, whereas cachexia is illness-related
140
What is the definition of cachexia?
Weight loss greater than 5% over 6 months
141
If a patient has anorexia, dyspepsia, nausea, bloating, and early satiety, what medications would you prescribe?
1. ) Metoclopramide
| 2. ) Erythromycin
142
If a patient has AIDS, fatigue, nausea, pain, and anorexia, what medication would you prescribe?
Dronabinol
143
If a patient has cancer, fatigue, nausea, pain, and anorexia, what medication would you prescribe?
Dexamethasone
144
If a patient has insomnia, anxiety, depression, and anorexia, what medications would you prescribe?
1. ) Mirtazapine
2. ) Olanzapine
3. ) Methylphenidate
145
What appetite stimulant has the best evidence to support its use in an individual who would live weeks to months?
Megestrol Acetate
146
What kind of weight do people put on when they take Megestrol Acetate?
Fat and fluid -- not muscle
147
What are the risks of using Megestrol Acetate?
Increased risk of DVT, muscle catabolism, adrenal suppression, and hypogonadism
148
What receptors are important to target for vestibular-related vomiting?
Acetylcholine
| Histamine
149
What receptors are important to target for chemoreceptor trigger zone related vomiting?
Dopamine
Serotonin
Neurokinin
150
What receptors are important to target for peripherally related vomiting?
Serotonin
| Mechanoreceptors in the intestine
151
How does Metoclopramide work?
At low doses -- Dopamine receptors in GI tract
| At high doses -- Serotonin receptors in brain
152
How can Metoclopramide be administered?
PO, IV, SQ
153
How does Haloperidol work?
Dopamine
154
How can Haloperidol be administered?
PO, IV, IM, SQ
155
How does Prochlorperazine work?
Dopamine
156
How can Prochlorperazine be administered?
PO, PR
157
How does Chlorpromazine work?
Dopamine
158
How can Chlorpromazine be administered?
PO, IV, IM, PR
159
How does Promethazine work?
Histamine, Acetylcholine, and Dopamine
160
How can Promethazine be administered?
PO, PR
161
How does Olanzapine work?
Dopamine, Serotonin, and Acetylcholine
162
How can Olanzapine be administered?
PO, SQ
163
How does Mirtazapine work?
Serotonin
164
How can Mirtazapine be administered?
PO
165
What is a well known side effect of Ondansetron?
Constipation
166
What are two cannabinoid-receptor agonists that are FDA approved for chemotherapy-induced nausea and vomiting?
Dronabinol
| Nabilone
167
What are the two agents you should not use in opioid induced constipation?
Docusate and bulk-forming agents
168
What are two newer agents introduced for opioid-induced constipation?
Lubiprostone and Linaclotide
169
For what patients is Naloxegol indicated?
Opioid-induced constipation in non-cancer patients on chronic opiates
170
What is the mechanism of action of Lubiprostone?
Selective chloride channel activator in the small intestine
171
What is one unique fact about Lubiprostone?
Seemingly ineffective for Methadone-induced constipation
172
What services does Medicare Part A cover?
Hospitalization
Skilled Nursing
Home Health
Hospice
173
What services does Medicare Part B cover?
Outpatient payment to providers
| DME
174
What is Medicare Part C?
Medicare Advantage -- minimum Medicare services for a fixed monthly payment with narrow networks; hospice is included
175
What does Medicare Part D cover?
Pharmacy
176
What Palliative Performance Scale score is associated with a prognosis of 6 months or less?
70% or less
177
What ECOG score is associated with a prognosis of 6 months or less?
2 or more
178
What are the Medicare hospice eligibility requirements?
1. ) Entitled to Medicare Part A
2. ) Certified as being terminally ill
3. ) Certified to have a prognosis of 6 months or less
179
What are the election periods of hospice?
An initial 90-day period
A subsequent 90-day period
An unlimited number of 60-day periods
180
What are the core services required for hospice?
Physician
Nurse
Social services
Counseling (bereavement, dietary, and spiritual)
181
What are the four levels of hospice care?
Routine home care
Continuous home care
Inpatient respite care
General inpatient care
182
What are the daily payments made by Medicare for routine home care level of care?
Day 1 to 60 -- $189.97
| Day 61+ -- $148.41
183
What are the requirements for continuous home care?
Minimum of 8 hours of direct care in a 24 hour period, more than 50% of which is provided by a licensed nurse
184
What is the per diem rate for continuous home care under Medicare?
$957.08
185
How often can the respite care benefit be accessed under Medicare?
Accessed occasionally and potentially more than once in a benefit period, but not for more than 5 consecutive days
186
What is the per diem rate for respite level of care under Medicare?
$169.36
187
What is the per diem rate for general inpatient care under Medicare?
$728.83
188
What are the reasons for discharge from hospice?
1. ) Patient moves to a new area
2. ) Patient is no longer terminally ill
3. ) Ability of hospice to operate is seriously impaired by the person(s) in the home
189
When must narratives and certifications be completed for recertification?
No earlier than 15 days prior to the start of the benefit period
190
When must the face-to-face encounters be completed for recertification?
No earlier than 30 days prior to the start of the benefit period
191
Who must do the hospice face-to-face encounter?
Hospice physician or Hospice Nurse Practitioner that is employed by the hospice
192
What patient-centered factors lead to patients being less likely to enroll into hospice?
1. ) African-American ethnicity
| 2. ) Fee-for-service Medicare
193
What are the predictors for a good survival outcome of an acute spinal cord compression secondary to cancer?
```
Ambulatory
Single metastasis
No visceral metastases
Radiosensitive cancer
Quickly engaging therapy
```
194
What kinds of cancers typically metastasize to the thoracic spine?
Breast and lung
195
What kinds of cancers typically metastasize to the lubmosacral spine?
Colon and pelvic cancers
196
What is the gold standard imaging study to evaluate for cord compression?
MRI of the entire spine
197
What is the recommended dose of Dexamethasone for cord compression?
10mg IV bolus followed by 4mg IV/PO 4 times a day with a 2 week taper
High dose is NOT necessary
198
For spinal compression, when is radiation alone indicated?
```
No spinal compression/instability
Prior spinal decompression
Subclinical cord compression
Known radiosensitive tumor
Poor surgical candidate
Multiple areas of compression
```
199
For spinal compression, when is neurosurgery with post-operative radiation indicated?
Spinal instability (needs neurosurgical evaluation)
Previous radiation to area limiting the dose
Disease progression despite radiation
Radioresistant tumor
Good baseline performance status
Lost ambulation within past 48 hours
Single area of compression
200
What is a key difference in outcomes in radiation alone versus combined with surgery for spinal cord compression?
Radiation alone will improve pain but will not restore function in individuals who have paralysis
201
What is the standard of care for hemoptysis associated with lung cancer?
Palliative radiotherapy after a sentinel bleed
202
What is the standard of care for bleeding associated with high-risk head and neck cancer?
Endovascular stenting of the carotid after a sentinel bleed
203
What is the most common life-threatening metabolic disorder in cancer patients?
Hypercalcemia
204
What is the mechanism of hypercalcemia in patients with breast cancer, myelomas, or lymphomas?
Osteolytic masses that cause an increase in bone resorption
205
What is the mechanism of hypercalcemia in patients with renal cell, ovarian, endometrial, or HIV-associated cancers?
Increase in PTHrP leading to increased bone resorption and decreased renal clearance of calcium
206
What is the mechanism of hypercalcemia in patients with Hodgkin and non-Hodgkin lymphomas?
Increased Calcitriol production leading to increased enteral calcium absorption and decreased renal clearance of calcium
207
What are the symptoms of hypercalcemia?
Hypovolemia, constipation, arrythmia, delirium, and lethargy
208
What is the primary treatment for patients with hypercalcemia?
Volume resuscitation (200-500mL/hour)
209
What is the primary medication intervention for hypercalcemia?
Parenteral Bisphosphonates (Pamidronate or Zoledronic Acid)
210
What is the indication for Denosumab?
Bisphosphonate-refractory hypercalcemia
211
What is the emergent presenting symptoms of SVC syndrome?
Stridor, confusion, AKI, or syncope
212
What is the treatment for emergent SVC?
Endovascular stenting with steroids followed by radiation
213
What is the mainstay of treatment for SVC syndrome?
Radiation with steroids
214
What is the standard treatment of increased intracranial pressure?
Steroids (Dexamethasone)
215
What is the standard of care in preventing a pathologic fracture in patients with known bony metastases?
Bisphosphonates (IV more than PO)
216
What is always an acceptable answer to treating dyspnea?
Treat any reversible cause, if possible
217
What is an effective treatment for dyspnea releated to COPD?
Pulmonary rehabilitation
218
What is the first-line medication therapy for dyspnea?
Opiates
219
What is the standard treatment for a COPD exacerbation?
Bronchodilators and steroids
220
What is an effective opioid-based strategy for managing refractory dyspnea?
MSER 10mg once daily, titrated weekly to a maximum of 30mg once daily
221
What is pulmonary rehabilitation for COPD?
PT and RT focused outpatient exercise and behavioral modification to improve walk distance and dyspnea
222
What is the median survival for an individual who develops a malignant pleural effusion?
4-6 months
223
How often do you need to treat asymptomatic pleural effusions?
Never
224
What is the indication for a thoracentesis?
A malignant pleural effusion with a short life expectancy
225
What is the most effective drug for cough?
Opiates
226
What is the medication indicated for radiation- or chemotherapy-induced pneumonitis?
Erlotinib
227
What is an accepted therapy for radiation-induced pneumonitis?
Steroids -- Prednisone 60mg tapered slowly over months
228
What are the symptoms of radiation pneumonitis?
Dry cough, dyspnea, and pleuritic pain
229
What are the two most common DSM5 anxiety disorders at the end of life?
Generalized Anxiety Disorder
| Anxiety secondary to a medical condition
230
What antidepressant medications should you avoid?
Paroxetine -- anti-cholinergic symptoms
Venlafaxine -- withdrawal symptoms
Bupropion -- lowers seizure threshold
231
What antidepressant helps with both sleep (at low doses) and appetite?
Mirtazapine
232
What class of medications could be helpful for depression if the patient also has co-morbid pain or hot flashes?
SNRIs
233
What is the most effective antidepressant to use with Tamoxifen?
Venlafaxine
| Sertraline and Citalopram are other options
234
What is the interaction with antidepressants and Tamoxifen?
There is a potential that it decreases the conversion of Tamoxifen to its active metabolite
235
What classes of medications are the best at helping the overall symptoms of PTSD?
SSRIs and SNRIs
236
What medications are helpful for PTSD associated nightmares?
Prazosin or Topiramate
237
What is the relationship between antipsychotics and smoking?
Smoking causes a decrease in antipsychotic drug levels
238
What are the Cluster A personality types?
-- Weird --
| Paranoid, Schizoid, Shizotypal
239
What are the Cluster B personality types?
-- Wild --
| Narcissistic, Histrionic, Borderline, Antisocial
240
What are the Cluster C personality types?
-- Worried --
| Avoidant, Dependent, Obsessive-Compulsive
241
What is the difference between grief, mourning, and bereavement?
Grief -- inward feelings
Mourning -- outward expression
Bereavement -- time for grief and mourning
242
What are the risk factors for complicated grief?
History of depression/anxiety, dependent relationships, kinship relationships, neglect in childhood, poor parental bonding, separation anxiety in childhood, alack of preparation of death, and loss of a child
243
What is the first basic HPM intervention?
Address physical symptoms/concerns
244
What is the second basic HPM intervention?
Address psychosocial concerns
245
What are the components of the second basic HPM intervention?
```
Physical symptoms
Emotive symptoms
Autonomy related issues
Communication
Economic burden
Transcendent issues
```
246
What is the third basic HPM intervention?
Communicate effectively
247
What is the fourth basic HPM intervention?
Provide an empathic presence
248
What is the fifth basic HPM intervention?
Foster hope
249
What is a very common cause of benign acute hiccups?
GERD
250
What is a common medication cause of hiccups?
Dexamethasone
251
What is a common medication used to treat hiccups?
Proton-pump inhibitor to treat GERD
252
What are other medication treatments for refractory hiccups?
Chlorpromazine (dopaminergic)
Haloperidol (dopaminergic)
Metoclopramide (dopaminergic)
Baclofen (caution in renal failure)
253
What is the best treatment for worsening dementia-related behaviors?
Non-pharmacologic interventions such as creating a care plan around improving the environment around the individual
254
What are several common medication causes of dysphagia?
NSAIDS
Antibiotics
Anticholinergics
Bisphosphonates
255
What is the most common complication of transjugular intrahepatic portosystemic shunting (TIPS)?
Encephalopathy
256
What is one of the most constipating anti-hypertensive medications?
Verapamil
257
What herbal extract is associated with progressive liver failure?
Kava extract
258
In addition to starting Dexamethasone, what two consultants should be called shortly after a patient is admitted with a spinal cord compression?
Neurosurgery and Radiation Oncology
259
What medication is indicated to treat restless leg syndrome?
Pramipexole
| Benzodiazepines are an appropriate second-line therapy
260
What medications (in order) are often effective for cholestatic pruritis?
1. ) Cholestyramine
2. ) Rifampin
3. ) Naltrexone
261
What medication is often effective for uremic pruritis?
Gabapentin
262
What antidepressant is a long-acting medication with a long half-life and comes as a liquid?
Fluoxetine
263
What opioid preparation is the least constipating?
Fentanyl patch (by approximately 50%)
264
What is the average total daily dose of Dexamethasone for cord compression?
15-30mg/day
265
What do toddlers (0-2 years) understand about death?
No conceptualization
266
What do children aged 3-5 years understand about death?
Cannot perceive universality of death
| Do not understand irreversible nature of death
267
What do children aged 5-10 years understand about death?
Death is irreversible and final
Can escape death if they do not talk about it
Magical thinking
268
What do children aged 10-13 years understand about death?
Understand that death is universal
Pre-occupied with death
Psychosomatization of feelings around death
269
What do children aged 13-18 years understand about death?
Risk of impaired grief if death occurs in adolescence
| "Death is not fair"
270
What interventions are helpful for children aged 0-2 with grief responses?
Cuddling
| Simple music
271
What are the typical grief responses for a child aged 3-4 years?
Intense but brief
| Asks questions repeatedly
272
What interventions are helpful for children aged 3-4 with grief responses?
Play therapy
273
What interventions are helpful for children aged 5-9 with grief responses?
Answer questions honestly
| Help with memorials/goodbyes
274
What is the general trend of the Karnofsky scale?
Normal (100) Dead (0)
| 50 -- considerable assistance with frequent medical care
275
What is the general trend of the Palliative Performance Scale?
Normal (100) Dead (0)
276
What is the general trend of the ECOG scale?
Normal (0) Dead (5)
| 3 - limited self-care or bed-to-chair less than 50% of waking hours
277
What is the life expectancy of an individual who develops malignant hypercalcemia?
8 weeks
278
What is the life expectancy of an individual who develops a malignant pericardial effusion?
8 to 12 weeks
279
What is the life expectancy of an individual who develops carcinomatous meningitis?
8 to 12 weeks
280
What is the life expectancy of an individual who develops multiple brain metastases?
4 to 8 weeks without radiation therapy
| 12 to 24 weeks with radiation therapy
281
What is the New York Heart Association level 4?
Symptomatic cardiac disease at rest (hospice appropriate)
282
What are the hospice criteria for COPD?
```
--- BODE criteria ---
BMI < 21
Obstruction (FEV1 < 30% -- Gold 4)
Dyspnea
Exercise capacity
```
283
What are the hospice criteria for liver disease?
PT > 5 or INR > 1.5
| Serum Albumin < 2.5
284
What does the MELD score calculate?
```
Liver disease 3 month prognosis using INR, Bilirubin, and Creatinine
< 9 -- 4% death
10-19 -- 27% death
20-29 -- 76% death (Hospice)
30-39 -- 83% death
> 40 -- 100% death
```
285
What does the MELD-NA look at?
Likelihood of death for hepatocellular carcinoma
286
What is the hospice criteria for renal failure?
GFR < 15 in diabetics or < 10 in non-diabetics
| Not pursuing dialysis
287
What is the median length of hospice stay after discontinuing dialysis?
9.6 days
288
What factors are associated with a worse outcome for patients with ALS?
Older age at diagnosis
Bulbar features
Frontotemporal dementia
289
What is the average survival after diagnosis of ALS?
24 to 36 months
290
What is the hospice criteria for admitting patients with dementia?
FAST 7c or worse
291
What two events are associated with a greater than 50% risk of mortality in 6 months in patients with dementia?
Hospitalized with either pneumonia or hip fracture
292
What does a midarm circumference of 22.5 equivalent to in BMI?
18.5
293
What are the four disciplines required in a hospice?
Physician
RN
SW
Chaplain (or other counselor)
294
What is compassion fatigue?
Secondary trauma from caring for those who are suffering
| Characterized by fatigue, emotional exhaustion, and apathy
295
What is the definition of Palliative Sedation?
The monitored use of medications intended to induce a state of decreased or absent awareness in order to relieve the burden of otherwise intractable suffering
296
When a person shows neck hyperextension, nonreactive pupils, decreased responsiveness to verbal stimuli, and an inability to close the eyelids, how soon is death most likely?
Within 3 days (typically hours)
297
What tool is useful in identifying changes in particular sources of suffering over time?
The Herth Hope Index
298
What is a brief, empirically supported, individualized psychotherapy designed for adults at the end of life?
Dignity Therapy
299
What are the effects of Dignity Therapy?
Improved dignity and quality of life
| Decreased depression and anxiety
300
What is a psychotherapy designed for the individual or groups that is applicable for patients with cancer?
Meaning-Centered Psychotherapy
301
What are the effects of Meaning-Centered Psychotherapy?
Improved meaning, spiritual well-being, and quality of life
302
What is a widely used self-reporting scale for depression in patients with advanced illness?
Hospital Anxiety and Depression Scale
303
What is a widely used scale that tracks mood and detects depression in patients and caregivers?
Center for Epidemiologic Studies Depression Scale
304
What is the first-line antidepressant of choice for a patient with major depressive disorder if a their life expectancy is 6 months or less?
Psychostimulants (i.e., Methylphenidate)
305
What SSRI is the most associated with QTc prolongation?
Citalopram (greater than 40mg daily)
306
What SSRI does not need to be tapered due to its long half life?
Fluoxetine
307
What SSRI can have a very significant sudden discontinuation syndrome secondary to its very short half life?
Paroxetine
308
What is a pain scale that is not copyrighted, valiated, reliable, and measures symptoms over time?
Edmonton Symptom Assessment Scale (ESAS)
309
What is cachexia's effect on oxycodone?
Cachexia lowers oxycodone clearance
| Use lower doses
310
What is cahexia's effect on transdermyl fentanyl?
Cachexia lowers fentanyl absorption
| Use higher doses
311
What is the methadone dose of choice for daily morphine doses of 60mg or less?
No more than 2.5mg Q8hours
312
What is the methadone dose of choice for daily morphine doses between 60 and 199mg?
10:1 conversion
313
What is the methadone dose of choice for daily morphine doses greater than 200mg?
20:1, and no more than 30mg daily
314
What QTc is a relative contraindication for methadone?
450msec
315
What QTc is an absolute contraindication for methadone?
>500msec
316
What supplement can decrease serum methadone levels?
St. John's Wort
317
What spinal analgesic is associated with dizziness, nausea, and psychiatric symptoms?
Ziconotide (calcium channel blogger)
318
What are the cardiovascular risks of long-term opiates?
Myocardial infarction
| Heart failure
319
Low doses of what opiate is found to be protective against depression?
Buprenorphine
320
Which NSAID is linked to higher cardiovascular adverse events?
Celecoxib
321
What pain types can Dexamethasone treat?
Neuropathic, bone, bowel obstruction, and headache
322
What disease process is treated by topical capsaicin patches?
Post-herpetic neuralgia
323
What is Denosumab?
Osteoclast inhibitor that has less skeletal events than Zoledronic acid
Used as an adjuvant agent in early breast cancer
324
What is an effective modality for multifocal bone pain?
Bone-seeking radionucleotides
325
What is the duration of effect of bone-seeking radionucleotides on pain?
Analgesia generally achieved at 4 days and lasting up to 7 weeks
326
What are the four principles of ethics?
Autonomy
Beneficence
Non-maleficence
Justice
327
What are the components that make up patient capacity?
Does the patient understand their medical condition, the recommended treatment, risks of treatment, treatment alternatives, and the implications of accepting/denying the treatment
328
What are the clinical findings of a minimally conscious state?
Fixes gaze
| Follows simple commands
329
What are the clinical findings of a persistent vegetative state?
Non-intentional actions
Remains in such a state for more than 4 weeks
Must have intact complex reflexes
330
For bony cancer lesions, what intervention results in durable symptom relief in nearly two-thirds of patients?
Radiation therapy to the lesion
331
How long does it take for radiation therapy to result in pain relief?
Generally 3 to 4 weeks, but often sooner
332
What is the current recommended regimen for palliative radiation therapy?
8 Gy in a single fraction that may be repeated in the future
333
When is radiation isotope therapy indicated?
Widespread osteoblastic disease (i.e., prostate cancer)
334
When are Strontium and Samarium radiation therapy indicated?
For pain control in patients with a good performance scale and prognosis
