PALLIATIVE MEDICINE & END OF LIFE CARE MCQs

Q-1
A 65-year-old man on palliative treatment for metastatic oesophageal cancer is finding it increasingly
difficult to take his morphine and as such is in increasing discomfort. His current prescription is for 60 mg
BD oral.

Which of the following is the most appropriate option to manage his pain?

A. Switch to subcutaneous morphine infusion at 120 mg/24hrs

B. Switch to gabapentin
C. Switch to fentanyl ‘100’ patch (100 micrograms/hour)
D. Switch to subcutaneous morphine infusion at 60 mg/24hrs
E. Increase oral morphine solution to 90 mg BD

ANSWER:
D. Switch to subcutaneous morphine infusion at 60 mg/24hrs

EXPLANATION:
Divide by two for oral to subcutaneous morphine conversion

This patient’s daily dose of oral morphine is 120 mg in total. Based on the history provided, his increasing
pain is a result of his inability to swallow, rather than a change in his condition. As such the most
appropriate option is to switch to an equivalent dose of an opioid via a more tolerable route.

1) The ratio of oral to parenterally administered morphine is 2:1, that is to say, subcutaneous or
intravenous doses are half that of the oral dose. This dose is, therefore, double his current requirements.

2) There has been no change in his condition or nature of his pain. As such, it would not be appropriate to
switch to a different class of pain relief.

3) Transdermal patches are suitable for those with stable levels of pain who will not require regular
titration of their pain relief. This will not always be the case in a palliative cancer patient. They should also
not be given to opioid naïve patients. At this dose, a fentanyl 100 patch will deliver 2400 micrograms or
2.4 mg of fentanyl per 24 hours. The conversion of oral morphine to transdermal fentanyl is however
1:100, and as such this is equivalent to 240 mg oral morphine per 24 hours, double his current
requirements.

4) This is correct as a subcutaneous dose of 60 mg/24 hours is equivalent to 120 mg of oral morphine.

5) This option would be inappropriate as it is the patient’s difficulty in taking his pain relief that is causing
his pain, not an increase in his pain requirements.

Please see Palliative Care Prescribing: Pain

Q-2
A 76-year-old patient has recently been diagnosed with lung cancer and has been commenced on a
chemotherapy regime. He is taking 15mg of morphine sulphate twice daily with a breakthrough dose of
5mg of oramorph as needed. Unfortunately, he has developed diffuse oral pain as a consequence of
treatment and is distressed by this.

What is the single most appropriate treatment to improve his pain?

A. Add a neuropathic agent such as amitriptyline to be taken at night

B. Increase in breakthrough oramorph dose
C. Prescribe a chlorhexidine mouthwash
D. Arrange blood tests to check for B12 deficiency
E. Prescribe a benzydamine mouthwash

ANSWER:
E. Prescribe a benzydamine mouthwash

EXPLANATION:
Benzydamine hydrochloride mouthwash or spray may be useful in reducing the discomfort associated with
a painful mouth that may occur at the end of life

Mouth care is important in patients receiving cancer treatment as well as in end of life care. There can be
numerous causes of mouth pain including the effect of dentures/sharp teeth, intercurrent infection e.g.
Candida, haematinic deficiency, dry mouth from reduced oral intake and mucositis of various grades as a
result of chemotherapy and/or radiotherapy.

The Applied Knowledge Test summary reports indicated that candidates can improve upon specific
prescribing of drugs in end of life care (including mouth care).

There is specific guidance on mucositis depending on the severity. However, in the absence of significant
ulceration and severe mucositis, for diffuse oral pain, a benzydamine mouthwash is a useful starting point.

There is nothing from the clinical history to suggest a neuropathic agent will be of benefit.

Although using oral opioids for pain is useful in this case, it is not suggested that the patient's as required
or regular use has increased and therefore this is not the best option.

Chlorhexidine mouthwash can be useful in certain circumstances. However, due to the high alcohol
contact, it can exacerbate pain in an individual's mouth. In this instance, it is therefore not the best option.
For prevention, washing with water or sodium chloride regularly is recommended.

Although a deficiency in vitamin B12, iron, or folate can feasibly cause a painful mouth and aphthous
ulceration, in this scenario the patient's pain is likely a result of their chemotherapy treatment and
therefore checking vitamin B12 level is not a priority.

Please see Palliative Care Prescribing: Pain

Q-3
A 72-year-old man with metastatic colon cancer is reviewed. He currently takes co-codamol 30/500 2
tablets qds for pain relief. Unfortunately this is not controlling his pain. What is the most appropriate
change to his medication?

A. Switch to MST 15mg bd + paracetamol 1g qds

B. Switch to MST 35mg bd + paracetamol 1g qds
C. Add tramadol 50-100mg 1-2 qds
D. Switch to MST 25mg bd
E. Switch to MST 15mg bd

ANSWER:
A. Switch to MST 15mg bd + paracetamol 1g qds

EXPLANATION:
His total codeine dose is 30 * 2 * 4 = 240 mg/day. Converting this to oral morphine = 24 mg/day. It is
therefore reasonable to start MST 15mg bd as his pain is not currently controlled. Paracetamol should be
continued as it has been shown to give benefits even to patients on large doses of morphine

Please see Palliative Care Prescribing: Pain

Q-4
A 70-year-old man with metastatic lung cancer comes in for review. His pain is not currently controlled
with MST 100 mg bd. He also takes paracetamol 1g tds and diclofenac 50mg tds. What is the most
appropriate next step?

A. Increase MST to 140 mg bd

B. Increase MST to 120 mg bd
C. Increase MST to 110 mg bd
D. Increase MST to 160 mg bd
E. Add codeine 60mg qds

ANSWER:
A. Increase MST to 140 mg bd

EXPLANATION:
In palliative patients increase morphine doses by 30-50% if pain not controlled

Please see Palliative Care Prescribing: Pain

Q-5
A 69-year-old man with terminal lung cancer is reviewed. He currently takes MST (oral, modified-release
morphine) 60mg bd for pain. He has become unable to take oral medications and a decision is made to
set-up a syringe driver. What dose of diamorphine should be prescribed for the syringe driver, to cover a
24-hour period?
A. 60 mg
B. 40 mg
C. 120 mg
D. 30 mg
E. 20 mg

ANSWER:
B. 40 mg

EXPLANATION:
To convert from oral morphine to diamorphine the total daily morphine dose (60 * 2 = 120mg) should be
divided by 3 (120 / 3 = 40mg)

Please see Palliative Care Prescribing: Pain

Q-6
A 69-year-old man with terminal lung cancer is reviewed. He currently takes MST 60mg bd for pain. He has
become unable to take oral medications and a decision is made to set-up a syringe driver. What dose of
diamorphine should be prescribed for the syringe driver?

A. 60 mg
B. 40 mg
C. 120 mg
D. 30 mg
E. 20 mg

ANSWER:
B. 40 mg

EXPLANATION:
To convert from oral morphine to diamorphine the total daily morphine dose (60 * 2 = 120mg) should be
divided by 3 (120 / 3 = 40mg)

Please see Palliative Care Prescribing: Pain

Q-7
A 72-year-old man with metastatic small cell lung cancer is admitted to the local hospice for symptom
control. His main problem at the moment is intractable hiccups. What is the most appropriate
management?

A. Chlorpromazine
B. Codeine phosphate
C. Diazepam
D. Methadone
E. Phenytoin

ANSWER:
A. Chlorpromazine
EXPLANATION:
Hiccups in palliative care - chlorpromazine or haloperidol

Haloperidol may also be used

Please see Palliative Care Prescribing: Hiccups

Q-8
You are reviewing an elderly man with prostate cancer. Unfortunately his pain is not currently controlled
by co-codamol 30/500 2 tablets qds and diclofenac 50mg tds. You decide to switch him to oral morphine.
What is the conversion factor between oral codeine and oral morphine?

A. Divide by 4
B. Divide by 15
C. Divide by 6
D. Divide by 20
E. Divide by 10

ANSWER:
E. Divide by 10

EXPLANATION:
Codeine to morphine - divide by 10

Please see Palliative Care Prescribing: Pain

Q-9
A 69-year-old man with metastatic prostate cancer presents with worsening pain. He currently takes oral
modified-release morphine sulphate 60mg bd but it is decided to convert this to subcutaneous
administration as he is frequently vomiting. What is the most appropriate dose of morphine to give over a
24 hour period using a continuous subcutaneous infusion?

A. 20mg
B. 30mg
C. 40mg
D. 60mg
E. 120mg

ANSWER:
D. 60mg

EXPLANATION:
The BNF recommend half the oral dose of morphine in this situation:

The equivalent parenteral dose of morphine (subcutaneous, intramuscular, or intravenous) is about half of
the oral dose. If the patient becomes unable to swallow, generally morphine is administered as a
continuous subcutaneous infusion
This patient is on 60mg bd = 120mg. Divided by 2 = 60mg of subcutaneous morphine.

Please see Palliative Care Prescribing: Pain

Q-10
Jean is an 85-year-old lady who is currently suffering from metastatic ovarian cancer. She is currently
being treated with palliative intent. She has deteriorated further and her husband calls you for a home
visit. She is currently taking 60 mg BD of MST (morphine slow release tablet) but is no longer able to
tolerate oral medications. What dose of subcutaneous morphine over 24 hours would you prescribe?

A. 60 mg
B. 30 mg
C. 120 mg
D. 20 mg
E. 90 mg

ANSWER:
A. 60 mg

EXPLANATION:
Jean is having a total of 120 mg of morphine over 24 hours currently via an oral route.

Given that we are converting her from an oral to subcutaneous morphine we must divide by 2.

Therefore the correct dose of subcutaneous morphine over 24 hours is 60 mg.

The following website (see below) by North Yorkshire and York NHS Trust is an excellent reference for how
to convert between opioids and route of administration.
Please see Palliative Care Prescribing: Pain
Q-11
You review a 72-year-old man with metastatic bowel cancer who is in the terminal phase and has a
syringe driver. Unfortunately he has developed intestinal obstruction and is suffering with bowel colic.
What is the most appropriate drug to add to the syringe driver?

A. Metoclopramide
B. Hyoscine hydrobromide
C. Levomepromazine
D. Haloperidol
E. Hyoscine butylbromide

ANSWER:
E. Hyoscine butylbromide

EXPLANATION:
Syringe drivers
 respiratory secretions: hyoscine hydrobromide
 bowel colic: hyoscine butylbromide
Please see Syringe Drivers

Q-12
A 71-year-old woman with metastatic breast cancer comes to surgery with her husband. She is known to
have bone metastases in her pelvis and ribs but her pain is not controlled with a combination of
paracetamol, diclofenac and MST 30mg bd. Her husband reports she is using 10mg of oral morphine
solution around 6-7 times a day for breakthrough pain. The palliative care team at the hospice tried using
a bisphosphonate but this unfortunately resulted in persistent myalgia and arthralgia. What is the most
appropriate next step?

A. Switch to oxycodone
B. Increase MST
C. Increase MST + add dexamethasone
D. Increase MST + suggest course of complimentary therapies
E. Increase MST + refer for radiotherapy

ANSWER:
E. Increase MST + refer for radiotherapy

EXPLANATION:
Metastatic bone pain may respond to analgesia, bisphosphonates or radiotherapy

Dexamethasone should be considered if the metastatic spinal cord compression, but this is not a feature
given the location of the lesions.

Please see Palliative Care Prescribing: Pain

Q-13
You review a 65-year-old woman in oncology clinic. She has known metastatic breast cancer, and has
received a mastectomy, chemotherapy and radiotherapy.

She has complained of headaches and nausea for the last 7 days, which are worse in the mornings. A CT
head showed multiple brain metastases, with compression of the ventricles and sulci.

Your patient declines further chemotherapy or radiotherapy. She is currently taking opioid painkillers.

Which of the following medications can be used as an adjunct to further relieve her symptoms?

A. Ondansetron
B. Cyclizine
C. Dexamethasone
D. Haloperidol
E. Sumatriptan

ANSWER:
C. Dexamethasone
EXPLANATION:
Headache caused by raised intracranial pressure due to brain cancer (or metastases) can be palliated with
dexamethasone

Dexamethasone is used to reduce oedema around brain metastases, to palliate symptoms of raised
intracranial pressure.

Ondansetron, cyclizine and haloperidol are all effective agents for nausea, but would not treat the root
cause.

Sumatriptan is a treatment for migraines and has no role here.

Please see Palliative Care Prescribing: Pain

Q-14
You are asked to review an 85-year-old man who was admitted 5 days ago with community acquired
pneumonia. He has a past medical history of type 2 diabetes mellitus, angina, chronic obstructive
pulmonary disease (COPD) and spinal stenosis.

Unfortunately, despite optimal ward-based treatment including IV co-amoxiclav, the patient has
continued to deteriorate. He current scores 11 on the Glasgow coma scale. His pupils are 3mm bilaterally
and reactive to light. He has been unable to take his morning medications which include morphine
sulphate modified release (Zomorph) 30mg twice daily, oramorph 10mg as required, and metoclopramide
10mg three times a day. In the past 24 hours, he has used 4 doses of PRN oramorph.

He is reviewed on the consultant ward round and the decision is made that he should be for end of life
care. He is currently comfortable, with no evidence of hallucinations, pruritis or myoclonus. The nurse
asks you to convert his medications to a syringe driver.

What will you prescribe?

A. Metoclopramide 30mg s/c + morphine 50mg s/c

B. Metoclopramide 30mg s/c + morphine 100mg s/c
C. Metoclopramide 30mg s/c + morphine 80mg s/c
D. Metoclopramide 30mg s/c + oxycodone 100mg s/c
E. Metoclopramide 30mg s/c + oxycodone 50mg s/c

ANSWER:
A. Metoclopramide 30mg s/c + morphine 50mg s/c

EXPLANATION:
Divide by two for oral to subcutaneous morphine conversion

This question is asking you to convert oral morphine to subcutaneous morphine for use in a syringe driver -
also known as a continuous subcutaneous infusion (CSCI).

The first step to calculate doses for use in a CSCI is to calculate the total 24-hour usage of the drug. We are
told this patient is taking both zomorph (modified release morphine), and oramorph (immediate release) -
we need to include both of these medications in our calculation.
The patient is taking 30mg zomorph twice daily = 60mg/24 hours.
He has also taken 4 doses of 10mg oramorph = 40mg/24 hours.

This gives us a total of 60mg + 40mg = 100mg/24 hours of oral morphine. In order to convert this to
subcutaneous morphine, we must divide by two. Therefore the amount of morphine needed in the CSCI is
100mg/2 = 50mg/24 hours.

The patient is comfortable, with no evidence of opioid toxicity, and so there is no indication to change to
oxycodone at the moment.

Please see Palliative Care Prescribing: Pain

Q-15
A 76-year-old female with multiple myeloma is experiencing acute back pain. Her oral regular analgesic
medications include 7.5mg morphine QDS and 1g paracetamol QDS.

What breakthrough dose of morphine should be given?

A. 3mg
B. 5mg
C. 7.5mg
D. 10mg
E. 15mg

ANSWER:
B. 5mg

EXPLANATION:
Breakthrough dose = 1/6th of daily morphine dose

The total daily dose of morphine is equal to 30mg (7.5*4). The breakthrough dose is 1/6 of the total daily
dose of morphine which is 5mg (30/6).

Please see Palliative Care Prescribing: Pain

Q-16
You review a palliative care patient at home. They are currently on 30mg MST bd. This is controlling the
pain but the patient is no longer able to swallow. After discussion with all concerned you agree to switch
to morphine through a syringe driver. What would be the most appropriate dose to start on?

A. 60mg over 24 hours

B. 30mg over 24 hours
C. 40mg over 24 hours
D. 10mg over 24 hours
E. 6mg over 24 hours
ANSWER:
B. 30mg over 24 hours

EXPLANATION:
Source: Clinical Knowledge Summary - Palliative cancer care (last reviewed April 2015)

When changing the route of administration of one strong opioid to another, the most common switch is
from oral morphine sulphate to subcutaneous diamorphine or morphine.

Diamorphine is much more soluble than morphine and therefore easier to administer in higher doses. It is
also compatible with most other drugs which may need to be administered by a subcutaneous infusion.
However, morphine is preferred in most cases as most people do not require doses large enough to cause
solubility issues:
 Parenteral diamorphine is approximately three times as potent as oral morphine, so the total daily
dosage of oral morphine should be divided by three to obtain the 24-hour subcutaneous dose of
diamorphine.
 The oral to subcutaneous potency ratio of morphine is between 1:2 and 1:3 (that is, the subcutaneous
dose is one third to one half of the oral dose). In practice, most centres divide the oral dose by two and
re-titrate as necessary.

See also the British National Formulary section: Prescribing in palliative care - continuous subcutaneous
infusions for further information and a table showing equivalent does of morphine sulphate and
diamorphine hydrochloride given over 24 hours.
Please see Palliative Care Prescribing: Pain
Q-17
Timothy is a 68-year-old male who has been referred to the palliative care team for ongoing management
after his recent diagnosis of advanced and progressive metastatic lung cancer. Timothy is no longer
interested in further treatment and would prefer to be palliated from now on. Timothy's past medical
history includes hypertension, chronic kidney disease secondary to type 2 diabetes (eGFR
15mL/min/1.73m²) and cataract surgery. Timothy is in severe pain and he complains this is limiting him
from activities which he would like to enjoy in his last days of life. Timothy is already taking paracetamol
1g 4-hourly, and ibuprofen 400mg 3 times daily.

Which of the following options is the safest choice of medication for pain relief in Timothy's case?

A. Fentanyl
B. Morphine
C. Methadone
D. Tramadol
E. Oxycodone

ANSWER:
A. Fentanyl

EXPLANATION:
Buprenorphine or fentanyl are the opioids of choice for pain relief in palliative care patients with severe
renal impairment, as they are not renally excreted and therefore are less likely to cause toxicity than
morphine
Treatment of pain in palliative care patients with end stage renal disease can be difficult because many
opiates are excreted renally, and therefore can lead to opioid neurotoxicity. Fentanyl would be the safest
choice of these options due to this patient's severe renal impairment. This is because fentanyl is not renally
excreted and therefore is less likely to cause toxicity. Another option in this case would be buprenorphine.
Both fentanyl and buprenorphine undergo hepatic metabolism and therefore are safer in these patients.

Of the options, morphine in particular should not be used and are contraindicated in renal failure as it can
lead to opioid toxicity.

Oxycodone and methadone are options, but are not as safe as either fentanyl or buprenorphine.

Tramadol can be considered however should be used in caution in end stage renal failure, and controlled
release preparations should be avoided as the drug can accumulate.

Note: Timothy is also taking ibuprofen, and NSAIDs should be avoided in renal failure as they may cause
sodium retention, hypertension and gastrointestinal toxicity.

Please see Palliative Care Prescribing: Pain

Q-18
A 65-year-old man with metastatic prostate cancer is admitted electively to the oncology ward for
radiotherapy to bone metastases at T7, T9 and L1.

His usual medications include: paracetamol 1g four times a day, tamsulosin 400 micrograms once daily,
atorvastatin 80mg once nocte, morphine sulphate modified release (Zomorph) 30mg twice daily, and
ramipril 5mg once daily.

During your afternoon review, he tells you that he is still suffering with pain in his back, despite taking his
regular medications this morning. He thinks he usually takes another analgesic as needed, but is unsure of
the name or the dose.

What will you prescribe?

A. Oramorph 5mg PO
B. Oramorph 10mg PO
C. Oramorph 10mg S/C
D. Oxycodone 10mg PO
E. Oxycodone 15mg S/C

ANSWER:
B. Oramorph 10mg PO

EXPLANATION:
Breakthrough dose = 1/6th of daily morphine dose

This question is asking you to calculate an appropriate dose of breakthrough analgesia for a patient on
long-acting opioids.
This man is taking morphine sulphate modified release (Zomorph) 30mg twice a day = 60mg/day.

The correct dose for breakthrough analgesia is 1/6th of the total daily dose = 60/6 = 10mg.

There is no reason to switch to oxycodone for breakthrough analgesia.

We are not told that the patient is unable to swallow (and he has taken all of his other medications as
usual), therefore the oral route is most appropriate.

Please see Palliative Care Prescribing: Pain

Q-19
Jonathon is a 72-year-old male who has advanced and progressive metastatic oesophageal carcinoma. He
has recently been referred to the palliative care team for ongoing care. At this time, Jonathon is being fed
via enteral tube due to progressive odynophagia and dysphagia. While Jonathon is still active and mobile,
he complains of severe pain and wishes to get some pain relief so that he can continue to play bowls with
his friends for as long as possible.

What would be the most appropriate first-line medication for pain relief in Jonathon's case?

A. Oral sustained release morphine 10-15mg twice daily

B. Subcutaneous morphine syringe driver
C. Oral paracetamol 1g 4-hourly
D. Transdermal fentanyl patch 12 microgram/hour
E. Oral immediate release morphine 5mg as needed

ANSWER:
D. Transdermal fentanyl patch 12 microgram/hour

EXPLANATION:
Transdermal opioid patch formulations are first-line choice in palliative care patients whom oral treatment
is not suitable

In palliative care patients in whom oral treatment is not suitable, NICE guidelines recommend transdermal
opioid patch formulations as a first-line choice. This should always be supported by specialist advice when
needed.

Oral sustained and immediate release morphine are generally the first-line choice for palliative pain relief,
however these are not suitable in patients who are unable to swallow.

While regular panadol is also recommended as background pain relief, this would not be strong enough in
these patients.

Subcutaneous delivery of opioids is another alternative when oral opioids are not tolerated, however this
would not be suitable for a patient who is still active and mobile.

Please see Palliative Care Prescribing: Pain

Q-20
A 60-year-old veteran with a background of metastatic lung cancer and CKD stage 4 is deteriorating and
complains of a chronic generalised pain in his chest. Which regular pain relief would be the most
appropriate option for him?

A. Morphine sulphate liquid

B. Morphine sulphate tablets
C. Diamorphine
D. Naproxen
E. Oxycodone

ANSWER:
E. Oxycodone

EXPLANATION:
Oxycodone is preferred to morphine in palliative patients with mild-moderate renal impairment

Morphine sulphate liquid - This is the wrong answer for two reasons: 1. It is short-acting so would be
better for PRN use 2. It is not recommended in patients with renal failure as its active metabolites are
renally excreted. Immediate release Oxycodone liquid would be the preferred choice for PRN use.

Morphine sulphate tablets - Active metabolites are renally cleared so not recommended in patients with
renal failure.

Diamorphine - As above however if a patient is imminently dying, it may be used in a syringe driver
preferably after discussion of the risk/benefits with the palliative care team.

Naproxen - Not recommended as it would be nephrotoxic in this case and also unlikely to provide
adequate pain relief for this gentleman.

Oxycodone - A relatively safer opioid to use as it is mostly cleared by the liver. Other options options
include fentanyl, buprenorphine, alfentanil and methadone although it is best to discuss with palliative
care team first.

Please see Palliative Care Prescribing: Pain

Q-21
A 67-year-old man with lung cancer is currently taking MST 30mg bd for pain relief. What dose of oral
morphine solution should he be prescribed for breakthrough pain?

A. 5 mg
B. 10 mg
C. 15 mg
D. 20 mg
E. 30 mg

ANSWER:
B. 10 mg
EXPLANATION:
Breakthrough dose = 1/6th of daily morphine dose

The total daily morphine dose is 30 * 2 = 60 mg, therefore the breakthrough dose should be one-sixth of
this, 10 mg

Please see Palliative Care Prescribing: Pain

Q-22
A 55-year-old male with sickle cell anaemia enters the emergency department. He is suffering another
episode of extreme pain, particularly in his hands. He has a past medical history of type 2 diabetes,
chronic kidney disease stage 4 and previous a DVT.

Which of the following analgesia would be most appropriate for the patient?

A. Co-codamol
B. Codeine
C. Diamorphine
D. Morphine
E. Oxycodone

ANSWER:
E. Oxycodone

EXPLANATION:
Oxycodone is preferred to morphine in palliative patients with mild-moderate renal impairment

Clinicians should take care in prescribing opioids in the elderly and those with renal failure. Morphine,
diamorphine, codeine and other renally excreted drugs will accumulate in patients with poor kidney
function. These should be avoided unless in certain circumstances.

Oxycodone and alfentanil are two examples of analgesics which are mainly metabolised in the liver and
thus can safely be used in patients with kidney failure.

Sickle cell patients can experience many acute and chronic complications. Sickle cell crisis (where severe
anaemia occurs) can be extremely painful and solely codeine or co-codamol will likely not control the pain.

Longer-term patients may develop sickle cell nephropathy where hemolysis and vascular occlusion leads to
loss of tubular function. Patients can further develop chronic kidney disease and later end-stage renal
disease.

Please see Palliative Care Prescribing: Pain

Q-23
A 67-year-old with chronic kidney disease stage 4 and metastatic prostate cancer presents as his pain is
not controlled with co-codamol. Which one of the following opioids is it most appropriate to use given his
impaired renal function?
A. Buprenorphine
B. Morphine
C. Hydromorphone
D. Diamorphine
E. Tramadol

ANSWER:
A. Buprenorphine

EXPLANATION:
Alfentanil, buprenorphine and fentanyl are the preferred opioids in patients with chronic kidney disease.

Please see Palliative Care Prescribing: Pain

Q-24
A 72-year-old male with metastatic lung cancer is referred to the palliative care team for end of life care.
Currently, he takes 10mg oral morphine daily which effectively controls his pain. Anticipatory medications
are prescribed in a syringe driver.

How much daily subcutaneous morphine needs to be given?

A. 3.3mg
B. 5mg
C. 6.7mg
D. 10mg
E. 15mg

ANSWER:
B. 5mg

EXPLANATION:
Divide by two for oral to subcutaneous morphine conversion

Switching the route and choice of opioid requires dose adjustment. Oral morphine is half as strong as
subcutaneous/intravenous morphine mainly due to first-pass metabolism.

Fentanyl, buprenorphine and other opioids have varying conversion ratios for different routes.

Please see Palliative Care Prescribing: Pain

Q-25
An 87-year-old man with metastatic non-squamous cell lung carcinoma was asked to be reviewed for
symptom control by nurses due to concerns about his breathing. He had been struggling to breathe over
the last couple of hours with harsh breath sounds being heard on inspiration. On auscultation, it is likely
this upper airway sounds are being caused by his respiratory secretions. He denied any chest pain and
currently reported not feeling nauseous.
What would be the most suitable medication to help with his symptoms?

A. Hyoscine hydrobromide
B. Midazolam
C. Morphine sulphate
D. Normal saline nebulisers
E. Oxycodone

ANSWER:
A. Hyoscine hydrobromide

EXPLANATION:
Harsh inspiratory breath sounds in the last hours of life are caused by respiratory secretions, and can be
treated with hyoscine hydrobromide

Hyoscine butylbromide is the most appropriate first-line medication which can be administered to help
reduce respiratory secretions with glycopyrronium bromide a suitable second-line agent.

Midazolam is commonly used for anxiety/agitation/breathlessness.

Morphine sulphate is commonly used for pain relief and/or breathlessness and oxycodone used in patients
with renal impairment.

Normal saline nebulisers can be used to assist sputum expectoration in patients.

Please see Palliative Care Prescribing: Secretions

Q-26
You are asked to review a 62-year-old man with castrate-resistant prostate cancer. He is known to have
widespread bony metastases in multiple lumbar vertebrae, his left ilium and left proximal femur. He is
complaining of increased hip pain on his current dose of modified release morphine sulphate tablets (MST
Continus). He is currently taking 50mg twice daily. He has taken an extra 40mg of PRN oramorph for
breakthrough pain in the last 24 hours.

What is the best course of action to manage his pain?

A. Ensure that he is taking regular paracetamol

B. Increase MST to 60mg twice daily
C. Add in ibuprofen three times daily with a proton pump inhibitor
D. Increase MST to 70mg twice daily
E. Increase MST to 80mg twice daily

ANSWER:
D. Increase MST to 70mg twice daily

EXPLANATION:
In palliative patients increase morphine doses by 30-50% if pain not controlled
The correct answer is to increase MST to 70mg twice daily. In palliative patients, the total daily dose of
morphine should be increased by 30-50% if pain is not controlled. This dose change increases the dose by
40%, and is therefore correct. The appropriate dose can also be worked out by calculating the total daily
dose of required morphine:

50 + 50 + 40 = 140mg daily total

140 / 2 = 70mg twice daily

If the dose increase using this calculation gave a value over 50% greater than the previous day's dose, the
dose should ideally be increased only be 50%. For example:

If the patient had taken 70mg PRN morphine, this would give a daily total of 170mg (50+50+70). However,
the modified release morphine should only be increased to a daily total of 150mg to prevent adverse
effects.

Whilst paracetamol is an appropriate adjunct to improve pain control in patients taking opiate
medications, this is unlikely to be a significant enough intervention to manage this patient's pain.

Increasing MST to 60mg daily would be unlikely to get the pain under control considering 140mg total was
needed in the previous day. This also only constitutes an increase of 20%.

As below, the assertion that NSAIDs are particularly effective for metastatic bone pain is not supported by
studies.

Increasing MST to 80mg twice daily would be an increase of over 50% of total daily dose and would
therefore be inappropriate and likely increase risk of adverse effects.

Please see Palliative Care Prescribing: Pain

Q-27
A 79-year-old female with a history of COPD and metastatic lung cancer is admitted with increasing
shortness of breath. Following discussion with family it is decided to withdraw active treatment, including
fluids and antibiotics, as the admission likely represents a terminal event. Two days after admission she
becomes agitated and restless. What is the most appropriate management?

A. Subcutaneous midazolam
B. Intramuscular haloperidol
C. Oral lormetazepam
D. Oral haloperidol
E. Recommence fluids and antibiotics

ANSWER:
A. Subcutaneous midazolam

EXPLANATION:

Please see Palliative Care Prescribing: Agitation and Confusion