Palliative and end of life care questions test symptom control and the conversations that come with it. These ten cover strong opioids and their side effects, nausea, cholestatic itch, terminal agitation, hydration in the last days of life, advance care planning and recognising dying.
Pick your answer, then open the explanation.
Question 1Palliative and end of life care
A 50-year-old man with locally advanced oesophageal cancer has pain inadequately controlled by regular co-codamol. He has mild dysphagia to solids, normal renal function, and prefers to remain on oral medication while a stable analgesic regimen is established. Which strong opioid is most appropriate to start first-line?
- AOral methadone
- BOral immediate-release plus modified-release morphine
- CSubcutaneous diamorphine via syringe driver
- DTransdermal fentanyl patch
- EOral oxycodone modified-release
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B. Oral immediate-release plus modified-release morphine
Oral morphine, in immediate-release and modified-release forms, is recommended as the first-line strong opioid when step 2 analgesia is inadequate. The combination supports flexible titration to match the patient's pain pattern and allows breakthrough dosing while a steady background dose is established.
Remember
First-line strong opioid for cancer pain in UK palliative care is oral morphine.
Question 2Pharmacology
A 70-year-old woman with advanced cancer and worsening renal function on a stable dose of oral morphine becomes increasingly drowsy with small pupils. Which metabolite of morphine is most responsible?
- ANormorphine
- BHydromorphone-3-glucuronide
- CMorphine-3-glucuronide
- DMorphine-3-sulfate
- EMorphine-6-glucuronide
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E. Morphine-6-glucuronide
Morphine is hepatically glucuronidated to morphine-6-glucuronide (M6G), a potent mu-opioid receptor agonist, and morphine-3-glucuronide (M3G); both depend on renal clearance. In renal impairment M6G accumulates and drives opioid toxicity (sedation, respiratory depression), while M3G adds myoclonus, so UK palliative-care guidance recommends fentanyl, alfentanil or buprenorphine in significant renal impairment, with oxycodone only in milder impairment and at a reduced dose, since its metabolites also accumulate.
Remember
M6G is the active morphine metabolite that accumulates in renal impairment, causing sedation and respiratory depression.
Question 3Palliative and end of life care
A 70-year-old man with chronic constipation due to long-term opioid use for cancer pain has had no benefit from a combined stimulant and osmotic laxative regimen for two weeks. He has no bowel obstruction and would prefer to avoid injections. What is the most appropriate next step?
- AOral lactulose with no other change
- BOral docusate sodium
- COral naloxegol
- DSubcutaneous methylnaltrexone
- EIncrease oral senna dose further
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C. Oral naloxegol
Oral naloxegol (a peripherally acting mu-opioid receptor antagonist, PAMORA) is recommended for opioid-induced constipation in adults with an inadequate response to laxatives. It blocks opioid effects on gut mu-receptors without crossing the blood-brain barrier or compromising analgesia.
Remember
Oral naloxegol (PAMORA) is recommended for opioid-induced constipation refractory to laxatives.
Question 4Palliative and end of life care
A 58-year-old woman with metastatic colorectal cancer has persistent nausea despite trials of haloperidol and cyclizine. There is no mechanical obstruction. The team wishes to start a broad-spectrum antiemetic. Which is most appropriate?
- AMetoclopramide
- BOndansetron
- CLevomepromazine
- DProchlorperazine
- EDexamethasone
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C. Levomepromazine
Levomepromazine is a sedating phenothiazine with antagonist activity at D2, H1, 5HT2 and muscarinic receptors, making it the broad-spectrum antiemetic of choice when cause-specific agents fail. Typical starting dose is 6.25 mg SC nocte or 6.25–12.5 mg/24h via syringe driver.
Remember
Levomepromazine is the broad-spectrum antiemetic of choice when cause-specific agents fail.
Question 5Palliative and end of life care
A 71-year-old woman with cholestatic jaundice from inoperable pancreatic cancer reports severe generalised pruritus. A biliary stent is in situ but bilirubin remains markedly elevated. What is the most appropriate first-line pharmacological treatment for the pruritus?
- AOral cetirizine
- BTopical emollients with no systemic agent
- COral naltrexone
- DOral colestyramine
- EOral rifampicin
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E. Oral rifampicin
Colestyramine is normally first-line for cholestatic pruritus where bile flow is preserved, but it is ineffective in complete or persistent biliary obstruction, as here, where the stent has not normalised bilirubin. In that setting rifampicin (typically 150 mg twice daily, increased to 300 mg twice daily) is recommended; it acts via PXR-mediated metabolism of pruritogens. LFTs need monitoring for hepatotoxicity.
Remember
Rifampicin is the first-line pharmacological treatment for cholestatic pruritus when bile drainage cannot be restored.
Question 6Palliative and end of life care
A 71-year-old man with metastatic lung cancer develops a large symptomatic right-sided pleural effusion. He has been admitted three times in two months for drainage, and the lung does not fully re-expand after each drain. He has a life expectancy of months. Which is the most appropriate definitive management?
- AIndwelling pleural catheter
- BLong-term oral diuretics
- CTalc pleurodesis via VATS
- DPleurectomy
- ERepeat therapeutic thoracocentesis as needed
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A. Indwelling pleural catheter
An indwelling pleural catheter is the preferred option for recurrent malignant pleural effusion when the lung does not re-expand, because pleurodesis needs pleural apposition to succeed, and it also suits a short prognosis by enabling outpatient drainage and reducing readmissions. With an expandable lung, an indwelling catheter and talc pleurodesis are offered as co-equal first-line options according to patient preference.
Remember
Indwelling pleural catheter is preferred over talc pleurodesis for recurrent malignant pleural effusion with non-expandable lung; with an expandable lung, IPC and pleurodesis are co-equal first-line options chosen by patient preference.
Question 7Palliative and end of life care
An 82-year-old woman in the last hours of life with metastatic colorectal cancer is restless, anxious and trying to climb out of bed. She has no urinary retention or faecal impaction on examination. What is the most appropriate first-line pharmacological management?
- ASubcutaneous haloperidol
- BOral lorazepam
- CSubcutaneous morphine
- DSubcutaneous midazolam
- ESubcutaneous levomepromazine
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D. Subcutaneous midazolam
Midazolam is first-line for terminal agitation/restlessness once reversible causes (pain, urinary retention, constipation, opioid toxicity) are excluded. Typical starting doses are 2.5–5 mg SC PRN or 10–20 mg/24h by syringe driver, titrated to effect.
Remember
Midazolam (SC 2.5–5 mg PRN) is first-line for terminal restlessness once reversible causes are excluded.
Question 8Palliative and end of life care
A 73-year-old man with metastatic lung cancer in the last days of life is dying in hospital. His daughter asks whether intravenous fluids should be continued. He is not thirsty and has dry mucous membranes but is comfortable. Which is the most appropriate response according to NICE guidance?
- ADiscuss benefits and burdens; review hydration daily with the patient and family
- BStop all fluids immediately as they prolong dying
- CDefer decision until the consultant ward round next day
- DInsist on subcutaneous fluids regardless of preference
- ERoutinely commence intravenous fluids at 100 mL/h
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A. Discuss benefits and burdens; review hydration daily with the patient and family
Individualised review of clinically assisted hydration in dying adults is advised, discussing benefits (e.g. relief of thirst, delirium) and harms (e.g. respiratory secretions, oedema), and involving the patient (where possible) and family in the decision, with daily review.
Remember
Review clinically assisted hydration daily; weigh benefits vs harms with the patient and family.
Question 9Palliative and end of life care
A 67-year-old man has advanced motor neurone disease with a forced vital capacity of 45% predicted and orthopnoea. He has been offered non-invasive ventilation but declines. He asks about future treatment limits. Which is the most appropriate next step?
- AInsist on a trial of non-invasive ventilation first
- BDefer planning until he becomes acutely unwell
- CRefer for invasive ventilation via tracheostomy
- DRefer urgently for psychiatric assessment of capacity
- EDiscuss and document an advance care plan including a ReSPECT recommendation
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E. Discuss and document an advance care plan including a ReSPECT recommendation
Timely advance care planning is recommended for patients with progressive life-limiting illness, ideally before crisis. A ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) document records preferences and treatment ceilings and travels with the patient between settings.
Remember
Advance care planning and ReSPECT should be undertaken proactively in progressive life-limiting illness.
Question 10Palliative and end of life care
A 78-year-old woman with advanced cancer has been deteriorating over the past 48 hours and is thought to be entering the dying phase. Which finding is most predictive of dying within 72 hours?
- ACold peripheries
- BIncreasing daytime drowsiness
- CCheyne-Stokes respiration with peripheral mottling
- DBedbound status
- EReduced oral intake over the preceding week
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C. Cheyne-Stokes respiration with peripheral mottling
The cluster includes Cheyne-Stokes respiration, peripheral mottling, cool extremities, profound weakness, increasing somnolence and reduced intake. Among these, Cheyne-Stokes breathing combined with mottling is the most specific cluster for imminent dying (next hours to a few days).
Remember
Cheyne-Stokes respiration plus peripheral mottling is the most specific cluster for imminent dying.
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