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MRCP PART 1 · PALLIATIVE MEDICINE AND END OF LIFE CARE

Palliative medicine and end of life care questions
for MRCP Part 1.

Clinora has 167 palliative medicine and end of life care single best answer questions covering 161 topics. Every question explains all five options, separates the key clue from what it means and what to do next, and links to its source. Try the 5 sample questions below, then practise more for free.

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FREE SAMPLE QUESTIONS

Try 5 palliative medicine and end of life care questions

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Question 1Total pain assessmentMedium

A patient with advanced lung cancer reports worsening pain despite stable imaging. He is fearful about finances, sleeping poorly and feels abandoned. What is the best next step?

  1. AComplete a multidimensional pain assessment
  2. BIncrease the opioid dose immediately without further assessment
  3. CExplain that emotional distress cannot influence physical pain
  4. DArrange spinal imaging as the only assessment
  5. EStop analgesia until a psychological review
Show answer and explanation

Answer: A Complete a multidimensional pain assessment

Worsening pain with stable imaging, alongside financial fear, poor sleep and feeling abandoned, is the picture Cicely Saunders called 'total pain'. Physical, psychological, social and spiritual distress all add to the suffering a patient reports. The next step is a structured, multidimensional assessment. Assess the pain itself (site, character, timing, breakthrough pain, any new or neuropathic component), its effect on function and sleep, how analgesia is actually being taken, and its adverse effects. Assess mood and anxiety, financial and practical worries, and spiritual or existential concerns. Record intensity on a 0–10 scale and use a body map. Treatment then targets each part: analgesia adjusted to the pain mechanism, with a breakthrough dose of about one-tenth to one-sixth of the 24-hour opioid dose (Scottish Palliative Care Guidelines); benefits and welfare advice for the money worries; psychological support; chaplaincy if wanted; and involvement of the specialist palliative care team. Escalating opioids alone risks toxicity while the distress driving the pain goes untreated.

Key clue
Worsening pain with prominent psychosocial distress
What it means
Pain is multidimensional and the mechanism may have changed
What to do
Complete a holistic pain assessment and agree goals

Why the other options are less appropriate

  • B Increasing opioids without assessment can cause toxicity and may miss a new pain mechanism or distress that would respond to other measures.
  • C Distress makes pain worse, and saying it plays no part dismisses the patient. It should be explored alongside the physical pain.
  • D Imaging may be indicated if there are features of new bone or spinal disease, but it is not a full pain assessment on its own.
  • E Stopping analgesia leaves him in pain and is unsafe. Psychological support is added to analgesia, not offered instead of it.

Source: Scottish Palliative Care Guidelines: Pain management

Question 2Breakthrough painMedium

A patient has stable background pain on modified-release morphine but develops brief, unpredictable episodes of severe pain. What is the most appropriate prescribing principle?

  1. AUse a modified-release tablet for each episode
  2. BIncrease only the next week's maintenance dose
  3. CProvide immediate-release opioid rescue treatment
  4. DAdvise the patient to wait until the next regular dose
  5. EReplace the opioid with paracetamol alone
Show answer and explanation

Answer: C Provide immediate-release opioid rescue treatment

Breakthrough pain is a short flare of severe pain on top of background pain that is otherwise well controlled. Modified-release morphine is designed to give a steady level over 12 or 24 hours, so it is too slow to treat a sudden episode. The patient needs an immediate-release (normal-release) opioid, usually the same drug as the background opioid, available as required. In UK palliative care guidance the rescue dose is usually one-sixth of the total 24-hour regular opioid dose, with some guidance allowing one-tenth to one-sixth. Oral immediate-release morphine starts to work in about 20–30 minutes. Very brief, unpredictable episodes may peak and settle before an oral dose works, which is why specialists sometimes use transmucosal fentanyl products. Keep a record of how often rescue doses are needed. If more than two or three are needed each day, review the background dose and increase it if the pain is opioid responsive. Look for causes such as movement-related or neuropathic pain, and prescribe a laxative with all regular opioids.

Key clue
Controlled background pain with short severe flares
What it means
Breakthrough pain rather than continuous undertreatment
What to do
Use immediate-release rescue analgesia and review

Why the other options are less appropriate

  • A Modified-release tablets take hours to reach peak effect, so they cannot treat a sudden episode of pain.
  • B Increasing the background dose may be needed later, but it does not treat the current episodes and waiting a week leaves him in pain.
  • D Making him wait leaves severe pain untreated. Rescue doses are meant to be taken when the pain occurs.
  • E Paracetamol alone will not control severe breakthrough pain in someone already needing regular morphine.

Source: Scottish Palliative Care Guidelines: Pain management

Question 3Opioid toxicityHard

A patient taking escalating morphine becomes persistently drowsy, confused and develops visual hallucinations and myoclonus. Pain is controlled. Which interpretation is most likely?

  1. AOpioid toxicity
  2. BNormal progression of pain
  3. CAn opioid allergy
  4. DUncomplicated grief
  5. ETherapeutic failure requiring an immediate dose increase
Show answer and explanation

Answer: A Opioid toxicity

Drowsiness, confusion, hallucinations and myoclonus with pain well controlled is the typical picture of opioid toxicity. The cause is often not the dose increase alone. Renal impairment is common: dehydration, infection or progressive disease can reduce kidney function so that active morphine metabolites (morphine-3- and morphine-6-glucuronide) build up. Other features of toxicity include pinpoint pupils, nausea and, when severe, slowed breathing. Management is to review the dose and reduce it, check renal function, hydration, calcium and infection, and stop other sedating drugs where possible. Specialist palliative care advice may help, for example switching to an opioid less dependent on the kidneys, such as oxycodone, or alfentanil in severe renal impairment. Naloxone is only for significant respiratory depression. It is given in small titrated doses, because a full reversing dose can cause severe pain and withdrawal.

Key clue
Sedation, hallucinations and myoclonus after escalation
What it means
Neurotoxic opioid accumulation is likely
What to do
Recognise toxicity and urgently review the regimen

Why the other options are less appropriate

  • B His pain is controlled, so this is not progression of pain. Progression would not explain the neurotoxic features.
  • C Opioid allergy is rare and would cause rash, angioedema or bronchospasm, not neurotoxicity. Itching from histamine release is common and is not an allergy.
  • D Grief does not cause myoclonus or persistent sedation.
  • E Increasing the dose would worsen the toxicity. The dose should be reviewed and usually reduced.

Source: Scottish Palliative Care Guidelines: Pain management

Question 4Incident painMedium

A 70-year-old woman receiving palliative care takes modified-release morphine, which controls her pain at rest, but she has severe brief pain during each daily dressing of a fungating wound. Which approach is most appropriate?

  1. AUse sedation as the primary aim
  2. BIncrease the long-acting opioid substantially regardless of rest pain
  3. CGive an NSAID alone once the dressing is finished
  4. DGive short-acting analgesia before the procedure
  5. EGive oral immediate-release morphine as the dressing begins
Show answer and explanation

Answer: D Give short-acting analgesia before the procedure

Incident pain is a type of breakthrough pain with a known trigger, such as a dressing change, moving or washing. Because it can be predicted, it can be prevented. Increasing the background opioid enough to cover a brief, intense episode would leave the patient over-sedated the rest of the time, since their pain at rest is already controlled. Scottish Palliative Care Guidelines advise a pre-emptive breakthrough dose instead. For oral immediate-release morphine, that dose is usually one-tenth to one-sixth of the total 24-hour opioid dose, given about 20 to 30 minutes before the procedure so that it is working when the dressing starts. For short procedures, faster-acting options can be used with specialist advice. These include transmucosal fentanyl, or Entonox during the dressing change itself. Also look at the wound care itself. Non-adherent dressings, soaking dressings off, and topical local anaesthetic can all reduce pain. Afterwards, review how well the dose worked and any side effects, and adjust the timing or dose for the next dressing.

Key clue
Brief pain linked to dressing with comfort at rest
What it means
Predictable incident pain
What to do
Use pre-emptive short-acting analgesia

Why the other options are less appropriate

  • A The aim is pain relief that keeps the patient alert. Sedation does not relieve pain and should not be the goal.
  • B Rest pain is controlled, so a large rise in background opioid would cause drowsiness between dressings without reliably covering the peak.
  • C Analgesia given afterwards does not cover the pain, and an NSAID alone is unlikely to control severe incident pain.
  • E Oral immediate-release morphine takes 20–30 minutes to work, so a dose given as the dressing starts misses the worst of the pain.

Source: Scottish Palliative Care Guidelines: Pain management

Question 5Non-pharmacological measuresEasy

A stable patient with advanced COPD remains breathless despite optimal disease treatment and is not hypoxaemic. Which measure should be tried?

  1. ARecommend avoiding activity to prevent further breathlessness
  2. BStart ambulatory oxygen as primary treatment despite normal saturation
  3. CBegin a benzodiazepine before trying non-drug measures
  4. DUse a handheld fan plus breathing and positioning strategies
  5. EUse nebulised saline routinely despite absent airway secretions
Show answer and explanation

Answer: D Use a handheld fan plus breathing and positioning strategies

Disease treatment is already optimised and the patient is not hypoxaemic, so the aim is symptom control rather than correcting oxygen levels. The Scottish Palliative Care Guidelines recommend non-drug measures first and alongside any medication. A handheld fan directed at the face cools the area supplied by the trigeminal nerve and reduces the sensation of breathlessness. Breathing control, pursed-lip breathing, leaning forward with the arms supported, and pacing and planning activity reduce effort and panic, and pulmonary rehabilitation helps in COPD. Oxygen gives no extra benefit over air for breathlessness in people who are not hypoxaemic. In COPD, NICE NG115 offers long-term oxygen only to people with a PaO2 below 7.3 kPa when stable, or 7.3–8 kPa with secondary polycythaemia, peripheral oedema or pulmonary hypertension. If breathlessness remains distressing, low-dose oral morphine can be considered. Benzodiazepines such as sublingual lorazepam are reserved for marked anxiety or panic and are not first line.

Key clue
Persistent breathlessness without hypoxaemia
What it means
Perception and breathing pattern can be modified
What to do
Use airflow and self-management strategies

Why the other options are less appropriate

  • A Avoiding activity leads to deconditioning, which worsens breathlessness over time; pacing and graded activity are recommended instead.
  • B Oxygen offers no benefit over air for breathlessness without hypoxaemia, and adds burden, cost and fire risk.
  • C Benzodiazepines are reserved for breathlessness with marked anxiety after non-drug measures, and can cause sedation and respiratory depression.
  • E Nebulised saline helps only with thick retained secretions and has no role in breathlessness without them.

Source: Scottish Palliative Care Guidelines: Breathlessness

That is 5 of 167. Carry on with palliative medicine and end of life care in the practice bank, with progress tracking, flashcards and timed sessions.

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Topics covered

Show all 161 palliative medicine and end of life care topics
  • Advance care planning
  • Advance decision applicability
  • Advance decisions
  • Agitation at the end of life
  • Anorexia in advanced illness
  • Anticipatory medicine storage
  • Anticipatory prescribing
  • Anxiety and panic
  • Bereavement complicated grief risk
  • Bereavement risk
  • Breaking bad news warning shot
  • Breakthrough opioid dosing
  • Breakthrough pain
  • Breakthrough pain with regular opioid
  • Breathlessness
  • Cancer anorexia communication
  • Cancer pain incident pain
  • Cancer-associated colicky obstruction
  • Cancer-related fatigue
  • Cancer-related lymphoedema
  • Capacity and refusal
  • Capacity fluctuation delirium
  • Care planning
  • Carer emergency planning
  • Carer strain assessment
  • Catastrophic bleeding planning
  • Chemoreceptor-trigger-zone nausea
  • Cholestatic pruritus with biliary obstruction
  • Clinical futility and requests
  • Clinically assisted hydration
  • Communication
  • Communication about opioids
  • Communication about prognosis
  • Complete mechanical bowel obstruction
  • Constipation on strong opioids
  • Constipation-related delirium
  • Converting oral morphine to a subcutaneous infusion
  • Corticosteroid safety in MSCC
  • CPR decisions
  • Death-rattle communication
  • Decision-specific capacity
  • Delirium assessment
  • Delirium communication family
  • Delirium medication review
  • Deprescribing near end of life
  • Dexamethasone in neurological MSCC
  • Dexamethasone in partial bowel obstruction
  • Distressing thirst near death
  • Dry mouth
  • Dry mouth in dying phase
  • Energy conservation in palliative fatigue
  • Ethics and law
  • Existing fentanyl patch when swallowing fails near death
  • Failure to balance analgesia and toxicity
  • Family support
  • Fan therapy for breathlessness
  • Gastric-stasis hiccups
  • Gastric-stasis nausea
  • Holistic assessment
  • Hydration trial with new harm
  • Hypercalcaemia
  • Immediate immobilisation in suspected unstable MSCC
  • Incident pain
  • Independent mental capacity advocacy
  • Individualised care plan
  • Last-days-of-life agitation
  • Last-days-of-life hydration review
  • Laxatives in obstruction
  • Low-dose morphine for refractory dry cough
  • Malignant ascites symptom relief
  • Malignant bowel obstruction
  • Malignant bowel obstruction vomiting
  • Malignant hypercalcaemia initial fluid
  • Malignant spinal cord compression
  • Malignant spinal cord compression: initial management
  • Malignant spinal pain escalation
  • Medication review
  • Medicine rationalisation
  • Megestrol for cancer cachexia
  • MSCC imaging when MRI is contraindicated
  • Mucositis during anticancer therapy
  • Multifactorial refractory nausea
  • Naloxone for opioid respiratory depression
  • Nausea in advanced cancer
  • Nausea in Parkinson's disease
  • Neuropathic cancer pain
  • Neuropathic pain adjuvant
  • Noisy respiratory secretions
  • Non-drug delirium care
  • Non-oral opioid route with stable requirements
  • Non-oral opioid route with unstable requirements
  • Non-pharmacological measures
  • Nutrition and drinking
  • Octreotide for obstructive vomiting
  • Opioid adverse effects
  • Opioid constipation
  • Opioid conversion
  • Opioid initiation
  • Opioid review
  • Opioid rotation in renal failure
  • Opioid selection in severe renal impairment
  • Opioid toxicity
  • Opioid-induced hyperalgesia
  • Opioid-induced nausea
  • Opioids for refractory breathlessness
  • Opposing antiemetic mechanisms
  • Oral route lost, opioid need stable
  • Oxygen therapy
  • Pain assessment in cognitive impairment
  • Pain mechanism
  • Palliative care referral timing
  • Palliative constipation obstruction warning
  • Palliative delirium non-drug care
  • Palliative haemoptysis
  • Palliative pleural effusion
  • Palliative radiotherapy indication
  • Palliative sedation governance
  • Pathological fracture risk
  • Peristaltic failure in partial obstruction
  • Pharmacological treatment of fatigue
  • Preventing medication burden
  • Prognostic uncertainty
  • Purpose of advance care planning
  • Purpose of anticipatory medicines
  • Radiotherapy fractionation for MSCC
  • Recognising dying
  • Refractory opioid-induced constipation
  • Refractory symptoms
  • Renal impairment
  • Renal impairment and opioids
  • Renal impairment and the default dose
  • Repeated injections in the last days
  • Review frequency
  • Route conversion
  • Route selection at end of life
  • Secretions and positioning
  • Seizure route
  • Short corticosteroid trial for anorexia
  • Spinal cord compression
  • Strong opioids in organ impairment
  • Subcutaneous medicines
  • Superior vena cava obstruction
  • Superior vena cava obstruction signs
  • Suspected haematological malignancy and steroids
  • Symptom control
  • Symptomatic hypercalcaemia of malignancy
  • Syringe driver site reaction
  • Syringe-pump safety
  • Terminal agitation
  • Terminal haemorrhage preparation
  • Terminal secretions family reassurance
  • Total pain assessment
  • Transdermal opioids
  • Transient opioid effects
  • Treatment proportionality
  • Tumour-related persistent hiccups
  • Uncertain prognosis is not certainty of dying
  • Uraemic pruritus
  • Urgent radiotherapy for non-surgical MSCC
  • Venous thromboembolism goals of care
  • Weak productive cough with retained secretions

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