1 . Which of the following is TRUE about end-of-life care?

A) It is one aspect of palliative care.

B) It is synonymous with palliative care.
C) It is defined by a specified time period.
D) It does not include a focus on the family.
2 . Which of the following is NOT a priority for patients with a life-limiting illness receiving
palliative care?

A) Relieving burden
B) Prolonging life at all costs
C) Obtaining a sense of control
D) Strengthening relationships with loved ones
3 . Which of the following is TRUE regarding the interdisciplinary healthcare team
involved in palliative care?

A) A social worker is not usually part of the team.

B) The members of the team are the same across palliative care settings.
C) Team members' roles should be communicated to the patient and family.
D) The patient's primary care physician is not usually a member of the team.
4 . The greatest increase in survival during hospice has been associated with which of
the following diseases?

A) Heart failure
B) Breast cancer
C) Colorectal cancer
D) Chronic obstructive pulmonary disease
5 . Which of the following is NOT a barrier to the optimum use of palliative care at the end
of life?

A) Reimbursement policies
B) Easily determined prognoses
C) Lack of well-trained healthcare professionals
D) Attitudes of patients, families, and clinicians
6 . Which of the following is TRUE regarding the Medicare hospice benefit?

A) The policy requires a survival prognosis of nine months or less.

B) The policy excludes curative treatment of the terminal disease.
C) A financial penalty is assessed if the patient lives beyond the criterion for life
expectancy.
D) The policy accounts for palliative treatments that serve a dual purpose of palliating
symptoms and prolonging life.
7 . Which of the following is TRUE regarding prognostication for life-limiting illnesses?

A) Heart disease is associated with accurate prognostication.

 B) Physicians' predictions for prognoses are usually optimistic.
C) Determining the prognosis for cancer has improved over the past few years.
D) There have been no guidelines developed to help physicians determine prognoses.
8 . Which of the following is a clinician-related factor that contributes to the low rate of
end-of-life discussions?

A) Lack of time
B) Certainty about prognosis
C) Excessive confidence in curative therapies
D) Awareness of the patients' and/or families' concerns regarding prognosis
9 . Which of the following is TRUE regarding the discussion of palliative treatment
options and goals?

A) Discussion of treatment options and goals should not include the patient's family.
B) Most physicians engage in discussion about treatment options near the end of life.
C) Unrealistic expectations are a major contributor to an increased use of aggressive
treatment at the end of life.
D) Patients will not choose life-extending therapy if the consequences of aggressive
treatment are discussed.
10 . Which of the following is TRUE regarding advance directives?

A) Most individuals have prepared advance directives.

B) There are no cultural differences in the rates of advance directives.
C) Advance directives have been associated with a lower likelihood of in-hospital death.
D) The rate of advance directives is lower in the gay and lesbian community than the
general population.
11 . Evidence-based guidelines for palliative care interventions are available from the
American College of Physicians for which of the following symptoms?

A) Fatigue
B) Depression
C) Constipation
D) Nausea and vomiting
12 . Which of the following offers the best approach for the assessment of physical
symptoms?

A) Asking open-ended questions

B) Traditional systems approach
C) Asking which symptom is least troublesome
D) Systematic assessment of symptoms plus open-ended questions
13 . A patient's fear to take opioids might be related to a belief that

A) the side effects of opioids cannot be managed.

B) the increase of pain signifies that the disease is getting worse.
C) if he or she takes strong drugs now, no drugs will be effective in the future.
 D) All of the above
14 . Which of the following is FALSE regarding practitioner liability in pain management?

A) Undertreatment of pain carries a risk of malpractice liability.

B) Breach of duty is difficult to prove in cases of inadequate pain management.
C) Establishing malpractice requires evidence of breach of duty and proof of injury and
damages.
D) Careful documentation on the patient's medical record regarding the rationale for
opioid treatment is essential.
15 . Which of the following is TRUE regarding end-of-life care for patients with a history of
substance abuse?

A) Opioids should be avoided for pain relief.

B) The issues are the same for past and active substance abusers.
C) Recurrence of addiction is high among recovered substance abusers.
D) Long-acting pain medications are preferred for active substance abusers.
16 . Which of the following is the most reliable indicator of pain?

A) Patients' self-report
B) Results of physical examination
C) Results of functional assessment
D) Results of multidimensional assessment
17 . Referred pain is usually an indicator of

A) bone pain.
B) visceral pain.
C) tissue damage.
D) central nervous system damage.
18 . Strong evidence supports pain management approaches for people with which of the
following life-limiting diseases?

A) Cancer
B) HIV/AIDS
C) Heart failure
D) Cardiovascular disease
19 . According to the World Health Organization (WHO) ladder, pain should be managed

A) with only nonopioids for Steps 1 and 2.

B) in every case, according to a stepwise progression from Step 1 to Step 3.
C) in an individualized manner according to the intensity of the pain.
D) with nonopioids given around the clock and opioids given on an as-needed basis.
20 . Which of the following is TRUE regarding pain medications?

A) Opioids have a ceiling effect.

B) Meperidine is a recommended pain reliever in Step 3 palliative care.
 C) Methadone is an option for first-line treatment of severe pain.
D) Intravenous administration of opioids is preferred over oral delivery.
21 . Which of the following is considered the first-line opioid for Step 3?

A) Fentanyl
B) Morphine
C) Methadone
D) Oxycodone
22 . Which of the following is TRUE regarding the management of fatigue?

A) Aerobic exercise has been shown to relieve fatigue.

B) Additional rest/sleep is an effective strategy for alleviating fatigue.
C) Fatigue should be aggressively treated in the last days or hours of life.
D) Causal treatment should be provided rather than symptomatic treatment.
23 . When managing dyspnea in patients with terminal illness,

A) nonpharmacologic interventions are generally ineffective.

B) the first step is treatment of symptoms rather than underlying cause.
C) evidence supports the use of opioids for patients with advanced lung disease.
D) providing supplemental oxygen should be the primary approach, even in patients
without hypoxemia.
24 . Which of the following is TRUE regarding constipation in the end of life?

A) Constipation should be reassessed at least every three days.

B) Polyethylene glycol and lactulose improve stool frequency.
C) Assessment includes determining what herbal remedies the patient may be taking.
D) All of the above
25 . Which of the following antiemetic agents is recommended for uremia-induced nausea
in people with end-stage chronic kidney disease?

A) Haloperidol
B) Ondansetron
C) Metoclopramide
D) Hyoscine hydrobromide
26 . The most widely used appetite enhancer for patients with life-limiting disease is

A) ondansetron.
B) dexamethasone.
C) megestrol acetate.
D) None of the above
27 . Among terminally ill patients, the highest rates of diarrhea have been associated with

A) cancer.
B) HIV/AIDS.
C) heart failure.
 D) end-stage renal disease.
28 . The most common contributor to sleep disturbances in patients at the end of life is

A) dyspnea.
B) hot flashes.
C) uncontrolled pain.
D) nocturnal hypoxia.
29 . Which of the following is NOT a precipitating factor of delirium at the end of life?

A) Overhydration
B) Decreased sensory input
C) Psychotropic medications
D) A change in environment
30 . Of the following, which has been shown to be bothersome to the greatest proportion
of individuals receiving palliative care?

A) Relationships
B) Loss of function and normalcy
C) Concerns about the dying process and death
D) Emotional, spiritual, existential, or non- specific distress
31 . Which of the following is TRUE regarding anxiety at the end of life?

A) Anxiety is rarely a side effect of a medication.

B) Pharmacologic approaches are essential for managing anxiety.
C) Anxiety manifests itself through only psychological and cognitive signs.
D) None of the above
32 . Which of the following is FALSE regarding depression at the end of life?

A) Polypharmacy can increase the risk of depression.

B) Cognitive therapy alone is recommended as treatment.
C) Distraction therapy has been effective for mild-to-moderate depression.
D) A diagnosis requires at least five depression- related symptoms within a two-week
period.
urse #97384 - $90-
15

SELF-ASSESSMENT QUESTIONS
1 . Which of the following is TRUE about end-of-life care?

A) It is one aspect of palliative care.

B) It is synonymous with palliative care.
C) It is defined by a specified time period.
 D) It does not include a focus on the family.

CONCEPT OF PALLIATIVE CARE

The term "palliative care" was first used by Balfour Mount, a Canada-trained physician and
visiting professor at St. Christopher's Hospice, the first program of its kind. Dr. Mount
subsequently established a palliative care program at Royal Victoria Hospital in Montreal, the
first such program to be integrated in an academic teaching hospital [3]. Since that time, many
attempts have been made to craft a definition of palliative care that represents its unique focus
and goals. The challenge in defining palliative care has been encompassing all that such care
refers to while specifying the timing of it (Table 1) [4,5,6,7,8]. The timing of palliative care
remains an important point of discussion. As a result of its roots in hospice care, the term
"palliative care" has often been considered to be synonymous with "end-of-life care." However,
the current emphasis is to integrate palliative care earlier in the overall continuum of care
(Figure 1) [6,9].
As the definition of palliative care has evolved, end-of-life care has become one aspect of
palliative care. The time period assigned to "end of life" has not been defined, with the phrase
being used to describe an individual's last months, weeks, days, or hours [10,11]. Designating a
specific time period as the "end of life" is further challenged by disease trajectories that differ
depending on the underlying life-limiting disease, a problem discussed in detail later in this
course.
Click to Review

2 . Which of the following is NOT a priority for patients with a life-limiting illness receiving
palliative care?

A) Relieving burden

B) Prolonging life at all costs

C) Obtaining a sense of control
D) Strengthening relationships with loved ones

CONCEPT OF PALLIATIVE CARE

Because palliative care focuses on the physical and psychosocial needs of the patient and his or
her family, the patient's and family's perspectives are vital considerations in developing high-
quality palliative care programs. An early survey of patients with life-limiting diseases identified
five priorities for palliative care: receiving adequate treatment for pain and other symptoms,
avoiding inappropriate prolongation of life, obtaining a sense of control, relieving burden, and
strengthening relationships with loved ones [16]. In another study, a spectrum of individuals
involved with end-of-life care (physicians, nurses, social workers, chaplains, hospice volunteers,
patients, and recently bereaved family members) echoed these findings, with the following
factors being noted as integral to a "good death:" pain and symptom management, clear
decision making, preparation for death, completion, contributing to others, and affirmation of the
whole person [17].
Click to Review

3 . Which of the following is TRUE regarding the interdisciplinary healthcare team

involved in palliative care?

A) A social worker is not usually part of the team.

B) The members of the team are the same across palliative care settings.
C) Team members' roles should be communicated to the patient and family.
D) The patient's primary care physician is not usually a member of the team.

CONCEPT OF PALLIATIVE CARE

MEMBERS OF THE PALLIATIVE CARE TEAM

Figure 2
Source: [15,25,26,27]
Click to Review

4 . The greatest increase in survival during hospice has been associated with which of
the following diseases?

A) Heart failure

B) Breast cancer
C) Colorectal cancer
D) Chronic obstructive pulmonary disease

CONCEPT OF PALLIATIVE CARE

The most surprising finding is the apparent survival advantage conferred by palliative and
hospice care. One study showed that hospice care extended survival for many patients within a
population of 4,493 patients with one of five types of cancer (lung, breast, prostate, pancreatic,
or colorectal cancer) or heart failure [51]. For the population as a whole, survival was a mean of
29 days longer for patients who had hospice care than for those who did not. With respect to the
specific diseases, heart failure was associated with the greatest increase in survival (81 days),
followed by lung cancer (39 days), colorectal cancer (33 days), and pancreatic cancer (21
days) [51]. There was no survival benefit for patients with breast or prostate cancer. In a study of
patients with metastatic non-small cell lung cancer, patients who received early palliative care
(within three weeks after enrollment in the study) lived significantly longer than those who
received standard oncologic care only (11.6 months vs. 8.9 months) [30]. In the same study, the
quality of life and symptoms of depression were also significantly better for the cohort of patients
who received early palliative care. Similarly, a retrospective study found a slight survival
advantage to hospice care among older individuals (>65 years) with advanced lung cancer [52].
These observations prompted the American Society of Clinical Oncology (ASCO) to publish a
Provisional Clinical Opinion in which it states that concurrent palliative care and standard
oncologic care should be offered to people with metastatic non-small cell lung cancer at the time
of initial diagnosis [53]. The ASCO Opinion also notes that although the evidence of survival
benefit is not as strong for other types of cancer, the same approach should be considered for
any patient with metastatic cancer and/or high symptom burden [53]. The 2013 American
College of Chest Physicians (ACCP) guideline for the diagnosis and management of lung cancer
also recommends that "palliative care combined with standard oncology care be introduced early
in the treatment course" for patients with late-stage (i.e., stage IV) lung cancer and/or a high
symptom burden [54].
Click to Review

5 . Which of the following is NOT a barrier to the optimum use of palliative care at the end
of life?
 A) Reimbursement policies
B) Easily determined prognoses
C) Lack of well-trained healthcare professionals
D) Attitudes of patients, families, and clinicians

CONCEPT OF PALLIATIVE CARE

Among the most important barriers to the optimum use of palliative care at the end of life are the
lack of well-trained healthcare professionals; reimbursement policies; difficulty in determining
accurate prognoses; and attitudes of patients, families, and clinicians.
Click to Review

6 . Which of the following is TRUE regarding the Medicare hospice benefit?

A) The policy requires a survival prognosis of nine months or less.

B) The policy excludes curative treatment of the terminal disease.

C) A financial penalty is assessed if the patient lives beyond the criterion for life
expectancy.
D) The policy accounts for palliative treatments that serve a dual purpose of palliating
symptoms and prolonging life.

CONCEPT OF PALLIATIVE CARE

Medicare reimbursement for hospice care became available when the Medicare Hospice Benefit
was established in 1982, and reimbursement through private health insurances soon
followed [34]. Reimbursement for hospice enabled more people with life-limiting disease to
receive palliative care at home and in hospice units: the number of hospices in the United States
has increased steadily, from 158 Medicare-certified hospices in 1985 to 4,639 in 2018 [1].
Despite the positive impact of the Medicare Hospice Benefit, fewer than half of eligible Medicare
beneficiaries use hospice care and most only for a short period of time. This is because
Medicare beneficiaries are required to forgo Medicare payment for care related to their terminal
condition in order to receive access to Medicare hospice services (Table 4) [34,85]. The
eligibility requirements of the benefit explicitly state that the focus of hospice "is on caring, not on
curing," and in order to receive reimbursement for hospice services, patients must sign a
statement that they will forego curative treatment [34]. This requirement frightens some patients
or their families, who subsequently view hospice as "giving up." Furthermore, the restriction does
not account for palliative treatments that serve the dual purpose of alleviating symptoms while
prolonging life. For example, therapeutic regimens and measures designed to optimally treat
heart failure are the same as those used for palliative care of patients with heart failure [76]. At
present, there are no Medicare regulations that specify which treatments are considered
palliative, and this lack of clarity has led to variation in what treatments individual hospice
programs offer. Hospice care may be denied to patients receiving palliative chemotherapy or
radiotherapy, and this may result in many people not choosing hospice. Although oncology
experts have noted that radiotherapy is an important component of palliative care for many
people with metastatic cancer, only 3% of people receiving hospice care receive radiation
therapy; expense and the need to transport patients were the primary barriers [77,78,79]. Other
palliative interventions, such as chemotherapy, blood transfusions, total parenteral nutrition, and
intravenous medications, may not be economically feasible for small hospice units but may be
possible at larger ones [80,81,82].
Many have suggested that the hospice model should change to allow for integration of disease-
directed therapy [83,84]. The Affordable Care Act of 2010 stipulates that the Centers for
Medicare & Medicaid Services (CMS) implement a three-year demonstration project to evaluate
concurrent hospice care and disease-directed treatment [84]. This project represents a
significant change to the eligibility criteria and, while the change has the potential to improve
access to hospice care, careful assessment of the effect of concurrent treatment on use of
hospice as well as on quality of life, quality of care, survival, and costs is needed [84]. Phase 2
of the project, the Medicare Care Choices Model (MCCM), became a six-year study (2016–
2021) to assess whether offering Medicare beneficiaries the option to receive supportive,
palliative care services through hospice providers without forgoing Medicare payments for
treatment of their terminal conditions would improve beneficiaries' quality of life, increase their
satisfaction with care, and reduce Medicare expenditures. In all, 89 of141 (63%) Medicare-
certified hospices participated in MCCM; however, only 44 (31%) participated for all six
years [85].
The Medicare Hospice Benefit criterion of a life expectancy of six months or less has also
affected the timeliness of referral to hospice because of the aforementioned challenges in
predicting prognosis. Many hospices were accused of fraud and were assessed financial
penalties when government review found documentation of patients who received hospice care
for longer than six months. As a result, many clinicians delayed hospice referral because of their
lack of confidence in their ability to predict survival within six months. However, the six-month
regulation has been revised, and a penalty is no longer assessed if a patient lives beyond six
months if the disease runs its normal course [34].
Click to Review

7 . Which of the following is TRUE regarding prognostication for life-limiting illnesses?

A) Heart disease is associated with accurate prognostication.

B) Physicians' predictions for prognoses are usually optimistic.

C) Determining the prognosis for cancer has improved over the past few years.
D) There have been no guidelines developed to help physicians determine prognoses.

CONCEPT OF PALLIATIVE CARE

To make appropriate referrals to hospice, clinicians must be able to determine accurate
prognoses, at least within the six-month timeframe required for reimbursement. However,
prognostication is a complex issue and is a primary barrier to hospice
use [88,89,90,91,92,93,94,95]. Studies have found that physicians typically overestimate
survival, and one study found that physicians overestimate prognosis both in determining it and
in communicating it to the patient [93,96,97]. The difficulty in determining the risk of death within
a specific time period not only affects the ability of clinicians to make appropriate referrals to
hospice but also impedes the ability of patients and families to make necessary end-of-life
decisions, with many patients not fully understanding the severity and progressive nature of the
disease [98].
Several factors contribute to physicians' difficulty in prognostication, including a desire to meet
the patient's needs (for a cure or prolongation of life) and a lack of reliable prognostic
models [81,97,99]. Perhaps the most important factor contributing to prognostic difficulty is the
variations in disease trajectories, which have been characterized as a short period of evident
decline, long-term limitations with intermittent serious episodes, and a prolonged decline (Figure
5) [9,32,100].
How difficult it is to determine a prognosis depends on the disease trajectory. Determining a
prognosis in the cancer setting was once clear-cut because of the short period of evident
decline, but advances in cancer therapies have made it more difficult to estimate a prognosis.
Studies have shown rates of accurate prognosis of 20%, with survival usually overestimated, up
to a factor of five [93,96]. The unpredictable course of organ-failure diseases, with its long-term
limitations and acute exacerbations has always made prognostication difficult [62,89,101,102]. In
a survey of cardiologists, geriatricians, and internists/family practitioners, approximately 16% of
respondents said they could predict death from heart failure "most of the time" or "always" [89].
Predicting survival for people with the third type of trajectory (prolonged decline) is extremely
difficult because of the wide variation in progressive decline. The prognosis for dementia can
range from 2 to 15 years, and the end-stage may last for 2 years or more [103,104].
Click to Review

8 . Which of the following is a clinician-related factor that contributes to the low rate of
end-of-life discussions?

A) Lack of time

B) Certainty about prognosis

C) Excessive confidence in curative therapies
D) Awareness of the patients' and/or families' concerns regarding prognosis

CONCEPT OF PALLIATIVE CARE

Several patient-related and clinician-related factors contribute to the low rate of end-of-life
discussions or their untimeliness. Most patients will not raise the issue for many reasons: they
believe the physician should raise the topic without prompting, they do not want to take up
clinical time with the conversation, they prefer to focus on living rather than death, and they are
uncertain about continuity of care and fear abandonment [62,117,148,150]. Clinician-related
factors include [81,147,148,160,161]:
Lack of time for discussion and/or to address patient's emotional needs
Uncertainty about prognosis
Fear about the patient's reaction (anger, despair, fear)
Lack of awareness and inability to elicit the concerns of patients and their families regarding
prognosis
Lack of strategies to cope with own emotions and those of patient and family
Feeling of hopelessness or inadequacy about the lack of curative therapies (perceived as "giving
up")
Click to Review

9 . Which of the following is TRUE regarding the discussion of palliative treatment

options and goals?

A) Discussion of treatment options and goals should not include the patient's family.

B) Most physicians engage in discussion about treatment options near the end of life.
C) Unrealistic expectations are a major contributor to an increased use of aggressive
treatment at the end of life.
D) Patients will not choose life-extending therapy if the consequences of aggressive
treatment are discussed.

CONCEPT OF PALLIATIVE CARE

Treatment options and goals of care are other topics that are often avoided in the end-of-life
setting. A discussion of the survival benefit of palliative chemotherapy is frequently vague or
absent from discussions of treatment options for patients with cancer [176]. In another example,
approximately 60% to 95% of physicians involved with the care of patients with heart failure
have two or fewer conversations about deactivation of implantable cardioverter defibrillators, and
the discussions are usually within the last few days of life [89,177].
Deciding when curative therapy should end is difficult because of the advances made in
treatment and life-prolonging technology and the unpredictable course of disease, especially for
organ-failure diseases. These factors have led many patients, as well as some clinicians, to
have unrealistic expectations for survival [30,178]. Unrealistic expectations are a major
contributor to an increased use of aggressive treatment at the end of life. Among more than 900
patients with cancer, those who thought they would live for at least six months were more likely
to choose curative therapy than "comfort care" compared with patients who thought there was at
least a 10% chance they would not survive for six months [179].
Click to Review
10 . Which of the following is TRUE regarding advance directives?

A) Most individuals have prepared advance directives.

B) There are no cultural differences in the rates of advance directives.

C) Advance directives have been associated with a lower likelihood of in-hospital death.
D) The rate of advance directives is lower in the gay and lesbian community than the
general population.

CONCEPT OF PALLIATIVE CARE

Advance directives, designation of a healthcare proxy, do-not-resuscitate (DNR) orders, and
living wills were developed as a way to ensure that patients received care that was consistent
with their preferences and goals. Advance directives offer many benefits; they have been
associated with a lower likelihood of in-hospital deaths, an increased use of hospice, and a
significant reduction in costs [195]. Although early studies showed that advance directives did
not always translate into patients receiving their preferred level of care, later studies have
demonstrated that most patients with advance directives do receive care consistent with their
preferences, especially if they want limited care (rather than "all possible" care) [194,196].
The American College of Physicians recommends that clinicians ensure that patients with
"serious illness" engage in advance care planning, including the completion of advance
directives [47]. Clinicians must emphasize the value of advance directives because most
patients have not completed them. An estimated 20% of the population have written advance
directives, with higher rates among the older population and nursing home residents and lower
rates among minority populations and those with nonmalignant life-limiting diseases (compared
with people with cancer) [197,198,199,200,201]. Other guidelines recommend that advance care
planning be done early in the course of disease, to help avoid potential compromise of decision-
making capacity near the end of life [62,108,121,122].
In preparing for a discussion about advance directives, clinicians should ask the patient if he or
she wishes to have other family members present during the conversation. This is especially
important for patients of some cultural backgrounds, as healthcare decisions are the
responsibility of family members in many cultures [200]. Increased efforts should be aimed at
obtaining advance directives from patients of minority races/ethnicities. Although the rate of
advance directives is higher in the gay and lesbian community than in the general population,
clinicians should emphasize the importance of these documents to gay and lesbian patients to
ensure that the patient's wishes are carried out and to avoid legal consequences for the patient's
partner [202].
Click to Review

11 . Evidence-based guidelines for palliative care interventions are available from the
American College of Physicians for which of the following symptoms?

A) Fatigue
 B) Depression
C) Constipation
D) Nausea and vomiting

CONCEPT OF PALLIATIVE CARE

In the wake of such studies, the American College of Physicians published a clinical practice
guideline on palliative care interventions for three symptoms with the overall strongest
evidence—pain, dyspnea, and depression—and evidence-based guidelines and
recommendations for palliative care have been developed for respiratory diseases, heart failure,
and end-stage renal disease [47,108,121,122,212,213,214]. These guidelines represent an
important step toward enhancing palliative care, but more work is needed in many disease
settings to address all aspects of palliative care. For one, definitions in palliative and supportive
care are not standardized and remain a significant barrier to improvement [215].
Click to Review

12 . Which of the following offers the best approach for the assessment of physical
symptoms?

A) Asking open-ended questions

B) Traditional systems approach

C) Asking which symptom is least troublesome
D) Systematic assessment of symptoms plus open-ended questions

PHYSICAL CARE
Although asking open-ended questions about symptoms is helpful, systematic assessment of
symptoms is also necessary. A study of patients in a palliative medicine program demonstrated
that significantly more symptoms were identified on systematic assessment than through open-
ended questioning (2,075 symptoms compared with 325) [221]. The symptoms that went
unreported were not inconsequential; of those symptoms not initially volunteered by the patient,
69% were rated as "severe" and 79% were described as "distressing" [221]. Studies have
demonstrated that patients are often reluctant to report worsening symptoms because of fear
that they indicate progressive disease. Clinicians should describe potential symptoms to help
patients and family understand which symptoms can be expected and when it is appropriate to
notify a member of the healthcare team. It is important for the healthcare team to acknowledge
the patient's symptoms as real and to take prompt actions to relieve them adequately. The
patient's comfort should take precedence over the exact cause of the symptom. Diagnostic
studies to determine the cause of symptoms should be undertaken only if the results will
substantially help in directing effective treatment. The risks, benefits, costs, and options for
treating an underlying cause should be discussed with the patient and family and considered
within the context of the patient's culture, belief system, and expectations.
Click to Review

13 . A patient's fear to take opioids might be related to a belief that

A) the side effects of opioids cannot be managed.

B) the increase of pain signifies that the disease is getting worse.

C) if he or she takes strong drugs now, no drugs will be effective in the future.
D) All of the above

PHYSICAL CARE
The inadequate management of pain is the result of several factors related to both patients and
clinicians. In a survey of oncologists, patient reluctance to take opioids or to report pain were two
of the most important barriers to effective pain relief [226]. This reluctance is related to a variety
of attitudes and beliefs [222,226]:
Fear of addiction to opioids
Worry that if pain is treated early, there will be no options for treatment of future pain
Anxiety about unpleasant side effects from pain medications
Fear that increasing pain means that the disease is getting worse
Desire to be a "good" patient
Concern about the high cost of medications
Click to Review

14 . Which of the following is FALSE regarding practitioner liability in pain management?

A) Undertreatment of pain carries a risk of malpractice liability.

B) Breach of duty is difficult to prove in cases of inadequate pain management.

C) Establishing malpractice requires evidence of breach of duty and proof of injury and
damages.
D) Careful documentation on the patient's medical record regarding the rationale for
opioid treatment is essential.
PHYSICAL CARE
Fear of license suspension for inappropriate prescribing of controlled substances is also
prevalent, and a better understanding of pain medication will enable physicians to prescribe
accurately, alleviating concern about regulatory oversight. Physicians must balance a fine line;
on one side, strict federal regulations regarding the prescription of schedule II opioids (morphine,
oxycodone, methadone, hydromorphone) raise fear of Drug Enforcement Administration
investigation, criminal charges, and civil lawsuits [222,232]. Careful documentation on the
patient's medical record regarding the rationale for opioid treatment is essential [232]. On the
other side, clinicians must adhere to the American Medical Association's Code of Ethics, which
states that failure to treat pain is unethical. The code states, in part: "Physicians have an
obligation to relieve pain and suffering and to promote the dignity and autonomy of dying
patients in their care. This includes providing effective palliative treatment even though it may
foreseeably hasten death" [233]. In addition, the American Medical Association Statement on
End-of-Life Care requires that physicians "reassure the patient and/or surrogate that all other
medically appropriate care will be provided, including aggressive palliative care and appropriate
symptom management, if that is what the patient wishes" [234].
Physicians should consider the legal ramifications of inadequate pain management and
understand the liability risks associated with both inadequate treatment and treatment in excess.
The undertreatment of pain carries a risk of malpractice liability, and this risk is set to increase
as the general population becomes better educated about the availability of effective approaches
to pain management at the end of life. Establishing malpractice requires evidence of breach of
duty and proof of injury and damages. Before the development of various guidelines for pain
management, it was difficult to establish a breach of duty, as this principle is defined by
nonadherence to the standard of care in a designated specialty. With such standards now in
existence, expert medical testimony can be used to demonstrate that a practitioner did not meet
established standards of care for pain management. Another change in the analysis of
malpractice liability involves injury and damages. Because pain management can be considered
as separate from disease treatment and because untreated pain can lead to long-term physical
and emotional damage, claims can be made for pain and suffering alone, without wrongful death
or some other harm to the patient [235].
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15 . Which of the following is TRUE regarding end-of-life care for patients with a history of
substance abuse?

A) Opioids should be avoided for pain relief.

B) The issues are the same for past and active substance abusers.
C) Recurrence of addiction is high among recovered substance abusers.
D) Long-acting pain medications are preferred for active substance abusers.
PHYSICAL CARE
The population of people with a history of substance abuse presents challenges to the effective
use of pain medication, with issues related to trust, the appropriate use of pain medications,
interactions between illicit drugs and treatment, and compliance with treatment. The issues differ
depending on whether substance abuse is a current or past behavior.
With active substance abusers, it is difficult to know if patients' self-reports of pain are valid or
are drug-seeking behaviors. It has been recommended that, as with other patients at the end of
life, self-reports of pain should be believed [67,227]. A multidisciplinary approach, involving15
psychiatric professionals, addiction specialists, and, perhaps, a pain specialist, is necessary. To
decrease the potential for the patient to seek illicit drugs for pain, an appropriate pain
management plan should be implemented, and the patient should be reassured that pain can be
managed effectively [67,227]. When planning treatment, the patient's tolerance should be
considered; higher doses may be needed initially, and doses can be reduced once acute pain is
under control. Long-acting pain medications are preferred for active substance abusers, and the
use of nonopioids and co-analgesics can help minimize the use of opioids. Setting limits as well
as realistic goals is essential and requires establishing trust and rapport with the patient and
caregivers.
Establishing trust is also essential for patients with former substance abuse behavior, who often
must be encouraged to adhere to a pain management program because of their fears of
addiction. Involving the patient's drug counselor is beneficial, and other psychological clinicians
may be helpful in assuring the patient that pain can be relieved without addiction. Recurrence of
addiction is low, especially among people with cancer, but monitoring for signs of renewed
abuse should be ongoing [227].
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16 . Which of the following is the most reliable indicator of pain?

A) Patients' self-report

B) Results of physical examination

C) Results of functional assessment
D) Results of multidimensional assessment

PHYSICAL CARE
Pain should be assessed routinely, and frequent assessment has become the standard of
care [223]. Pain is a subjective experience, and multidimensional in nature, and although
patients' self-reporting of pain does not always correlate with objective functional measures, the
patient's self-report of pain is the most reliable indicator [239,240]. Research has shown that
pain is underestimated by healthcare professionals and overestimated by family
members [223,241]. Therefore, it is essential to obtain a pain history directly from the patient,
when possible, as a first step toward determining the cause of the pain and selecting appropriate
treatment strategies. When the patient is unable to communicate verbally, other strategies
should be used to determine the characteristics of the pain, as will be discussed.
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17 . Referred pain is usually an indicator of

A) bone pain.

B) visceral pain.
C) tissue damage.
D) central nervous system damage.

PHYSICAL CARE
Questions should be asked to elicit descriptions of the pain characteristics, including its location,
distribution, quality, temporal aspect, and intensity. In addition, the patient should be asked
about aggravating or alleviating factors. Pain is often felt in more than one area, and physicians
should attempt to discern if the pain is focal, multifocal, or generalized. Focal or multifocal pain
usually indicates an underlying tissue injury or lesion, whereas generalized pain could be
associated with damage to the central nervous system. Pain can also be referred, usually an
indicator of visceral pain.
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18 . Strong evidence supports pain management approaches for people with which of the
following life-limiting diseases?

A) Cancer

B) HIV/AIDS
C) Heart failure
D) Cardiovascular disease

PHYSICAL CARE
Strong evidence supports pain management approaches for people with cancer, but the
evidence base for management of pain in people with other life-limiting diseases is
weak [47,54,108,187,212,214]. Effective pain management involves a multidimensional
approach involving pharmacologic and nonpharmacologic interventions that are individualized to
the patient's specific situation [223].
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19 . According to the World Health Organization (WHO) ladder, pain should be managed

A) with only nonopioids for Steps 1 and 2.

B) in every case, according to a stepwise progression from Step 1 to Step 3.

C) in an individualized manner according to the intensity of the pain.
D) with nonopioids given around the clock and opioids given on an as-needed basis.

PHYSICAL CARE
The WHO analgesic ladder, introduced in 1986 and disseminated worldwide, remains
recognized as a useful educational tool but not as a strict protocol for the treatment of pain. It is
intended to be used only as a general guide to pain management [245]. The three-step
analgesic ladder designates the type of analgesic agent based on the severity of pain (Figure
6) [245]. Step 1 of the WHO ladder involves the use of nonopioid analgesics, with or without an
adjuvant (co-analgesic) agent, for mild pain (pain that is rated 1 to 3 on a 10-point scale). Step 2
treatment, recommended for moderate pain (score of 4 to 6), calls for a weak opioid, which may
be used in combination with a step 1 nonopioid analgesic for unrelieved pain. Step 3 treatment is
reserved for severe pain (score of 7 to 10) or pain that persists after Step 2 treatment. Strong
opioids are the optimum choice of drug at Step 3. At any step, nonopioids and/or adjuvant drugs
may be helpful. Some consider this model to be outdated and/or simplistic, but most agree that it
remains foundational. It can be modified or revised, as needed, to apply more accurately to
different patient populations.
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20 . Which of the following is TRUE regarding pain medications?

A) Opioids have a ceiling effect.

B) Meperidine is a recommended pain reliever in Step 3 palliative care.

C) Methadone is an option for first-line treatment of severe pain.
D) Intravenous administration of opioids is preferred over oral delivery.
PHYSICAL CARE
Strong opioids are used for severe pain (Step 3). Guidelines suggest that the most appropriate
opioid dose is the dose required to relieve the patient's pain throughout the dosing interval
without causing unmanageable side effects [187,206,246]. Morphine, buprenorphine,
oxycodone, hydromorphone, fentanyl, and methadone are the most widely used Step 3 opioids
in the United States. Unlike nonopioids, opioids do not have a ceiling effect, and the dose can be
titrated until pain is relieved or side effects become unmanageable. For an opioid-naïve patient
or a patient who has been receiving low doses of a weak opioid, the initial dose of a Step 3
opioid should be low, and, if pain persists, the dose may be titrated up daily until pain is
controlled. Opioid-naïve patients are those who are not receiving opioid analgesic daily and
therefore have not developed significant tolerance. Opioid-tolerant patients are those who have
been taking an opioid analgesic daily for at least one week. The FDA identifies tolerance as
receiving at least 60 mg of morphine daily, 30 mg of oral oxycodone daily, 8 mg of oral
hydromorphone daily, or an equianalgesic dose of another opioid for one week or longer [187].
Typical starting doses for patients who are opioid-naïve have been noted, but these doses
should be used only as a guide, and the initial dose, as well as titrated dosing, should be done
on an individual basis (Table 8).
More than one route of opioid administration will be needed by many patients during end-of-life
care, but in general, opioids should be given orally, as this route is the most convenient and
least expensive. The transdermal route is preferred to the parenteral route, although dosing with
a transdermal patch is less flexible and so may not be appropriate for patients with unstable
pain [223]. Intramuscular injections should be avoided because injections are painful, drug
absorption is unreliable, and the time to peak concentration is long [223].
The use of methadone to relieve pain has increased substantially over the past few years,
moving from a second-line or third-line drug to a first-line medication for severe pain in people
with life-limiting diseases [254]. A systematic review showed that methadone had efficacy similar
to that of morphine. However, the authors' conclusions were based on low-quality evidence.
Other opioids (e.g., morphine, fentanyl) are easier to manage but may be more expensive than
methadone in many economies [255]. Physicians must be well educated about the
pharmacologic properties of methadone, as the risk for serious adverse events, including death,
is high when the drug is not administered appropriately [255,256]. If the dose of methadone is
increased too rapidly or administered too frequently, toxic accumulation of the drug can cause
respiratory depression and death. Because of the unique nature of methadone, and its long and
variable half-life, extreme care must be taken when titrating the drug, and frequent and careful
evaluation of the patient is required. Practitioners are advised to consult with a pain or palliative
care specialist if they are unfamiliar with methadone prescribing or if individual patient
considerations necessitate rapid switching to or from methadone [187].
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21 . Which of the following is considered the first-line opioid for Step 3?

A) Fentanyl

B) Morphine
C) Methadone
 D) Oxycodone

PHYSICAL CARE
Morphine is considered to be the first-line treatment for a Step 3 opioid [206]. Morphine is
available in both immediate-release and sustained-release forms, and the latter form can
enhance patient compliance. The sustained-release tablets should not be cut, crushed, or
chewed, as this counteracts the sustained-release properties. Morphine should be avoided in
patients with severe renal failure [214].
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22 . Which of the following is TRUE regarding the management of fatigue?

A) Aerobic exercise has been shown to relieve fatigue.

B) Additional rest/sleep is an effective strategy for alleviating fatigue.

C) Fatigue should be aggressively treated in the last days or hours of life.
D) Causal treatment should be provided rather than symptomatic treatment.

PHYSICAL CARE
Little evidence is available to support guidelines for the management of fatigue during the end of
life. Most of the research on nonpharmacologic and pharmacologic treatment options has been
conducted with subjects receiving active cancer treatment or long-term follow-up care after
cancer treatment. Fatigue in the palliative care setting is addressed specifically by the European
Association for Palliative Care (EAPC) (all settings) and the NCCN (cancer setting) and is noted
in guidelines for palliative care for advanced heart failure [108,187,279]. In addition, the Agency
for Healthcare Research and Quality has addressed fatigue in the cancer setting, and systematic
reviews have been done to help determine effective pharmacologic and nonpharmacologic
interventions [281,290,291,292,293]. Management of fatigue should include treatment of an
underlying cause, if one can be identified, but symptomatic relief should also be provided
(Figure 10) [108,187,279].
When medications are the underlying cause of the fatigue, nonessential medications should be
discontinued, and changing medications or the time of dosing may reduce tiredness during the
day. Appropriate management of infection, cachexia, depression, and insomnia may also help
reduce fatigue [279,287]. The patient's life expectancy and preferences should be considered
before carrying out treatment of an underlying cause [279]. Fatigue may provide a protective
effect for patients in the last days or hours of life [279]. As such, the patient may be more
comfortable without aggressive treatment of fatigue during that period [279].
Most patients will try to manage fatigue by resting and/or sleeping more often, and many
healthcare professionals will also recommend this strategy. However, additional rest and/or
sleep usually does not restore energy in patients who have fatigue related to a life-limiting
disease; continued lack of exercise may even promote fatigue [279]. Regular aerobic exercise
and strength training has been found to alleviate fatigue, although much of the research in this
area has been conducted with cancer survivors [284]. For example, a meta-analysis (28 studies,
2,083 subjects) demonstrated a significant effect of exercise in the treatment of fatigue during
and after cancer treatment [293]. An update to this review and meta-analysis supported the
benefit of aerobic exercise for individuals with cancer-related fatigue and recommended further
research to determine the optimal type, intensity, and timing of an exercise intervention [300].
Some small studies of fatigue have been done in the palliative care setting, and exercise was
found to be beneficial [301,302,303].
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23 . When managing dyspnea in patients with terminal illness,

A) nonpharmacologic interventions are generally ineffective.

B) the first step is treatment of symptoms rather than underlying cause.

C) evidence supports the use of opioids for patients with advanced lung disease.
D) providing supplemental oxygen should be the primary approach, even in patients
without hypoxemia.

PHYSICAL CARE
The American College of Physicians, the American Thoracic Society, the Canadian Thoracic
Society (endorsed by the ACCP), and the NCCN have developed evidence-based guidelines for
the management of dyspnea [47,54,122,213,309,310]. In addition, evidence-based
recommendations for managing dyspnea in people with advanced heart failure are
available [108]. A stepwise approach to managing dyspnea should be taken, with the first step
being treatment of the underlying cause, if one can be identified [54]. Nonpharmacologic
interventions should be used first; if the response is inadequate, pharmacologic interventions
may be added.
Supplemental oxygen is commonly used to treat dyspnea. Strong evidence supports the use of
oxygen and pulmonary rehabilitation for dyspnea, and supplemental oxygen may provide relief
of dyspnea for people with advanced lung or heart disease who have hypoxemia at rest or with
minimal activity [47,54,212,213,309,310]. However, data suggest that oxygen offers no benefit to
patients who do not have hypoxemia [108].
A variety of nonpharmacologic interventions have been suggested in several practice guidelines,
although the evidence base varies (Table 13) [122,213,309,310]. In a systematic review of
nonpharmacologic interventions and an update of that review for dyspnea in people with
advanced malignant and nonmalignant diseases, there was strong evidence for chest wall
vibration and neuroelectrical muscle stimulation and moderate evidence for walking aids and
breathing training [311,312]. The updated review found low strength of evidence for
acupuncture/acupressure, no evidence for the use of music, and insufficient evidence to
recommend the use of a fan, music, relaxation, counseling and support, and
psychotherapy [311,312]. A subsequent small randomized controlled trial demonstrated that a
handheld fan directed at the face reduced breathlessness [313].
Opioids represent the primary recommended pharmacologic intervention for intractable dyspnea
in people with advanced cancer and lung disease [47,213,309]. A systematic review and meta-
analysis (18 randomized controlled trials) demonstrated a significant positive effect of opioids on
breathlessness [315]. Guidelines recommend that oral or parenteral opioids be considered for all
patients with severe and unrelieved dyspnea; nebulized opioids have not had an effect when
compared with placebo [47,212,213,309]. Oral morphine is the most commonly prescribed
opioid, but other opioids, such as diamorphine, dihydrocodeine, fentanyl, hydromorphone, and
oxycodone, may be used [213]. The dose should be selected and titrated according to such
factors as renal, hepatic, and pulmonary function and past use of opioids [213]. An oral dose of
morphine of 2.5–10 mg every four hours as needed (1–5 mg intravenously) has been
recommended for opioid-naïve patients [122]. Although respiratory depression is a side effect
associated with opioids, especially morphine, this effect has not been found with doses used to
relieve dyspnea [122,316]. Evidence-based recommendations for palliative care for people with
heart failure note that diuretics represent the cornerstone of treatment of dyspnea [108]. Nitrates
may also provide relief, and inotropes may be appropriate in select patients [108]. The
recommendations also include the use of low-dose opioids [108].
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24 . Which of the following is TRUE regarding constipation in the end of life?

A) Constipation should be reassessed at least every three days.

B) Polyethylene glycol and lactulose improve stool frequency.

C) Assessment includes determining what herbal remedies the patient may be taking.
D) All of the above

PHYSICAL CARE
Issues of personal privacy often lead to a reluctance of patients to discuss constipation, so
clinicians and other healthcare professionals must initiate the discussion and talk honestly about
what to expect and measures to prevent and manage the symptom. The assessment tools used
most often are the Bristol Stool Form Scale and the Constipation Assessment Scale [319,320].
Assessment should include a review of the list of medications, a history of bowel habits, and
abdominal and rectal examination. In addition to checking the list of prescribed medications to
determine if constipation is a side effect, the physician should ask the patient about over-the-
counter drugs and herbal remedies, as constipation can be a consequence of aluminum-
containing antacids, ibuprofen, iron supplements, antidiarrhea drugs, antihistamines, mulberry,
and flax. A detailed history of bowel habits helps to establish what is considered normal for the
individual patient. The patient should be asked about frequency of stool, the appearance and
consistency of stools, use of bowel medications, and previous occurrence of constipation. In
general, physical examination of the abdomen for tenderness, distention, and bowel sounds can
rule out intestinal obstruction as the cause of constipation. A rectal examination can identify the
presence of stool, fecal impaction, or tumor. Imaging of the abdomen (by plain x-ray or
computerized tomography) may be appropriate to confirm the presence of obstruction.
Consideration of the patient's prognosis and preferences for care should be factored into a
decision to carry out diagnostic testing. As with assessment of all symptoms, constipation should
be reassessed frequently; assessment at least every three days is recommended [320].
Many laxatives are FDA approved for occasional constipation, and much of the evidence on their
efficacy has come from studies of chronic constipation, not patients with life-limiting disease. In
its guidelines for the management of chronic constipation, the American College of
Gastroenterology notes the following [323]:
Polyethylene glycol (PEG) and lactulose (both osmotic) improve stool frequency and stool
consistency.
Data are insufficient to make a recommendation about the efficacy of stool softeners (docusate
[Colace or Surfak]); stimulant laxatives (senna [Senokot, Ex-Lax] or bisacodyl [Dulcolax,
Correctol]); milk of magnesia; herbal supplements (aloe); lubricants (mineral oil); or combination
laxatives (psyllium plus senna).
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25 . Which of the following antiemetic agents is recommended for uremia-induced nausea

in people with end-stage chronic kidney disease?

A) Haloperidol

B) Ondansetron
C) Metoclopramide
D) Hyoscine hydrobromide

PHYSICAL CARE
The prokinetic agent metoclopramide (Reglan) has been recommended as a first-line treatment
because of its central and peripheral actions and its effectiveness for many chemical and
undetermined causes of nausea [206,246,328,331]. The drug should be used with caution in
patients with heart failure, diabetes, and kidney or liver disease; the dose should be reduced by
50% for older patients and those with moderate-to-severe renal impairment [329,331]. Chronic
use of prokinetic agents and dopamine receptor antagonists may be associated with the
development of tardive dyskinesia, especially in frail, elderly patients [187]. Octreotide
(Sandostatin), dexamethasone, and hyoscine hydrobromide (Scopolamine) are recommended
for bowel obstruction [92,328,329,331,332]. Ondansetron (Zofran) has been suggested for
chronic nausea, but in September 2011, the FDA issued a safety announcement about the drug,
noting that it may increase the risk of QT prolongation on electrocardiogram. [329,335]. In 2012,
the FDA updated the safety information specifically for the 32-mg IV dose of the drug, and the
manufacturer subsequently announced changes to the drug label removing this dose [336].
Haloperidol (Haldol) is recommended for uremia-induced nausea in people with end-stage
chronic kidney disease [214]. Dexamethasone is used for nausea and vomiting related to
increased intracranial pressure and, although the evidence is limited, it is also used as second-
line treatment for intractable nausea and vomiting and as an adjuvant antiemetic [246,328,329].
Olanzapine (Zyprexa), an atypical antipsychotic, has also been effective for nausea that has
been resistant to other traditional antiemetics, as well as for opioid-induced nausea [337]. A
benzodiazepine (such as lorazepam [Ativan]) may be of benefit if anxiety is thought to be
contributing to nausea or vomiting [329].
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26 . The most widely used appetite enhancer for patients with life-limiting disease is

A) ondansetron.

B) dexamethasone.
C) megestrol acetate.
D) None of the above

PHYSICAL CARE
Two drugs are FDA approved as appetite stimulants for anorexia associated with life-limiting
disease (Table 17). Megestrol acetate is FDA approved for the treatment of anorexia, cachexia,
or unexplained weight loss in patients with AIDS [351]. It has become the most widely used drug
for these indications for people with other life-limiting diseases, and a meta-analysis of data from
studies (involving people with a variety of life-limiting illnesses) demonstrated that megestrol
acetate was beneficial, especially with respect to improving appetite and weight gain in people
with cancer [351]. Meta-analysis showed a benefit of megestrol acetate compared with placebo,
particularly with regard to appetite improvement and weight gain in cancer, AIDS, and other
underlying conditions. There was insufficient information to define the optimal dose, but higher
doses were more related to weight improvement than lower doses. Side effects (e.g., edema,
thromboembolic phenomena) and deaths were more frequent in patients treated with megestrol
acetate compared with placebo [351]. Today, use of megestrol is limited due to the increased
risk for thromboembolism. Dronabinol (Marinol), an oral cannabinoid, is FDA approved for
anorexia associated with weight loss in people with AIDS [326]. Because of its effects,
dronabinol should be used with caution for people with cardiac disorders, depression, or a
history of substance abuse; people taking concomitant sedatives or hypnotics; and older
individuals [326].
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27 . Among terminally ill patients, the highest rates of diarrhea have been associated with

A) cancer.

B) HIV/AIDS.
 C) heart failure.
D) end-stage renal disease.

PHYSICAL CARE
The prevalence of diarrhea among adults with life-limiting disease varies widely, ranging from
3% to 90%, with the highest rates reported among people with HIV infection or AIDS [211].
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28 . The most common contributor to sleep disturbances in patients at the end of life is

A) dyspnea.

B) hot flashes.
C) uncontrolled pain.
D) nocturnal hypoxia.

PHYSICAL CARE
The primary difference between insomnia in the general population and in people with life-
limiting diseases is that insomnia in the latter group is usually secondary to the life-limiting
disease or its symptoms [366]. Overall, uncontrolled pain is the most common contributor to the
inability to sleep well [366,367]. Other common physical symptoms such as dyspnea, nocturnal
hypoxia, nausea and vomiting, pruritus, and hot flashes are also causes of insomnia. Restless
legs syndrome may be a substantial contributor to the disruption of sleep among persons with
end-stage renal disease [210,310,368,369].
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29 . Which of the following is NOT a precipitating factor of delirium at the end of life?

A) Overhydration

B) Decreased sensory input

C) Psychotropic medications
D) A change in environment
PHYSICAL CARE
Because of the substantial influence of unrelieved pain, adequate pain management can help
prevent delirium. Prevention strategies are directed at minimizing precipitating factors, which
include a high number of medications (more than six), dehydration, decreased sensory input,
psychotropic medications, and a change in environment.
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30 . Of the following, which has been shown to be bothersome to the greatest proportion
of individuals receiving palliative care?

A) Relationships

B) Loss of function and normalcy

C) Concerns about the dying process and death
D) Emotional, spiritual, existential, or non- specific distress

PSYCHOSOCIAL CARE
The term "distress" has become standard to describe the psychological suffering experienced by
patients with life-limiting disease. The NCCN notes that the word "distress" is more acceptable
and is associated with less stigma than words such as "psychosocial" or "emotional" [396]. In its
guidelines on distress management, the NCCN defines distress as existing "along a continuum,
ranging from common normal feelings of vulnerability, sadness, and fears to problems that can
become disabling, such as depression, anxiety, panic, social isolation, and existential and
spiritual crisis" [396]. According to a study of patients in a palliative care program, the answers to
the question "What bothers you most?" included [216]:
Emotional, spiritual, existential, or nonspecific distress (16%)
Relationships (15%)
Concerns about the dying process and death (15%)
Loss of function and normalcy (12%)
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31 . Which of the following is TRUE regarding anxiety at the end of life?

A) Anxiety is rarely a side effect of a medication.

 B) Pharmacologic approaches are essential for managing anxiety.
C) Anxiety manifests itself through only psychological and cognitive signs.
D) None of the above

PSYCHOSOCIAL CARE
One of the primary causes of anxiety is inadequate pain relief. Anxiety may also be the result of
a patient's overwhelming concern about his or her illness, the burden of the illness on the family,
and the prospect of death. In addition, anxiety is a potential side effect of many medications,
including corticosteroids, metoclopramide, theophylline, albuterol, antihypertensives,
neuroleptics, psychostimulants, antiparkinsonian medications, and anticholinergics. Lastly,
withdrawal from opiates, alcohol, caffeine, cannabis, and sedatives can result in anxiety,
particularly in the first few days of admission [404].
Anxiety manifests itself through physical as well as psychological and cognitive signs and
symptoms. These signs and symptoms include dyspnea, paresthesia, tachycardia, chest pain,
urinary frequency, pallor, restlessness, agitation, hyperventilation, insomnia, tremors, excessive
worrying, and difficulty concentrating.
Nonpharmacologic approaches are essential for managing anxiety, and the addition of
pharmacologic treatment depends on the severity of the anxiety [67,407]. Effective management
of pain and other distressing symptoms, such as constipation, dyspnea, and nausea, will also
help to relieve anxiety. If the anxiety is thought to be caused by medications, they should be
replaced by alternate drugs. Other strategies include psychological support that allows the
patient to explore fears and concerns and to discuss practical issues with appropriate healthcare
team members. Relaxation and guided imagery may also be of benefit [408]. A consult for
psychological therapy may be needed for patients with severe anxiety.
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32 . Which of the following is FALSE regarding depression at the end of life?

A) Polypharmacy can increase the risk of depression.

B) Cognitive therapy alone is recommended as treatment.

C) Distraction therapy has been effective for mild-to-moderate depression.
D) A diagnosis requires at least five depression- related symptoms within a two-week
period.

PSYCHOSOCIAL CARE
Unrelieved pain is one of the primary risk factors for depression. Other causes within the
physical domain include metabolic disorders (hyponatremia or hypercalcemia), lesions in the
brain, insomnia, or side effects of medications (corticosteroids or opioids). Many patients with
heart failure have comorbidities and polypharmacy, both of which can increase the risk of
depression [412,413]. Psychosocial causes include despair about progressive physical
impairment and loss of independence, financial stress, family concerns, lack of social support,
and spiritual distress.
A diagnosis of depression requires the presence of at least five depression-related symptoms
within the same two-week period, and the symptoms must represent a change from a previous
level of functioning [378]. A simple screening tool that has been found to be effective is to ask
the patient, "Are you depressed?" or, "Do you feel depressed most of the time?" [227,414,415].
The physician should also discuss the patient's mood and behavior with other members of the
healthcare team and family to help determine a diagnosis. Patients who have thoughts of suicide
must be assessed carefully. The physician should differentiate between depression and a desire
to hasten death because of uncontrolled symptoms [67]. Psychological counseling should be
sought, as well as measures to enhance the management of symptoms.
The effective management of depression requires a multimodal approach, incorporating
supportive psychotherapy, cognitive strategies, behavioral techniques, and antidepressant
medications [47]. Patients with depression should be referred to mental health services for
evaluation, and resultant approaches may include formal therapy sessions with psychiatrists or
psychologists or counseling from social workers or pastoral advisors. In addition, physicians can
help by having discussions with the patient to enhance his or her understanding of the disease,
treatments, and outcomes, and to explore expectations, fears, and goals. Behavioral
interventions, such as relaxation techniques, distraction therapy, and pleasant imagery have
been effective for patients with mild-to-moderate depression [47].
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33 . Which of the following is FALSE regarding spiritual needs of patients at the end of
life?

A) Spiritual care is well-defined.

B) Spirituality is considered to be separate from religious faith.

C) Spirituality has a strong protective effect against end-of-life distress.
D) Greater spiritual well-being has been associated with decreased anxiety and depression
among people with advanced disease.
34 . Which of the following measures are appropriate for managing the so-called "death
rattle?"

A) Oropharyngeal suction
B) Laying the patient supine
C) Anticholinergic medications
D) All of the above
35 . Palliative sedation should

A) never be carried out.

B) be initiated as soon as a patient requests it.
 C) be considered when the family asks to relieve the patient's suffering.
D) be considered after consultation with a psychiatrist and pastoral services, if appropriate
36 . Which of the following is considered to be physician-assisted death?

A) Using high-dose opioids to relieve pain

B) Administration of a lethal agent with a merciful intent
C) Deactivation of an implantable cardioverter-defibrillator
D) All of the above
37 . Which of the following is TRUE regarding grief, mourning, and bereavement?

A) Grief counseling should begin when the patient is alive.

B) Mourning is composed of sequential stages that occur in order.
C) The physician's attendance at the patient's funeral would be inappropriate.
D) The healthcare team should extend bereavement services for no more than one month
after the death of the patient.
38 . The issue of perhaps greatest importance regarding palliative care for older
individuals is improving care for patients

A) with dementia.
B) with polypharmacy.
C) who are unconscious.
D) with multiple comorbidities.
39 . Which of the following is TRUE regarding end-of-life care for children?

A) The WHO ladder is not effective for pain management.

B) Psychosocial issues are uncommon for family members and the child.
C) The most common symptoms among children are similar to those among adults.
D) The child should not be allowed to participate in discussions about the direction of
care.
40 . In end-of-life care for critically ill patients,

A) the illness trajectory is usually similar to that for other populations.

B) surrogate decision making has correlated well with patient preferences.
C) a comprehensive palliative care assessment does not need to be a priority.
D) the psychosocial needs of the family peak earlier than in other palliative care settings.