1. Which one of the following statements concerning nausea while taking opioids is true?
A) Nausea to opioids is due to bowel distention and stimulation of the vagus nerve
B) Nausea to opioids is due to decreased bowel motility
C) Nausea to opioids is usually accompanied with itching
D) Nausea to opioids represents a drug allergy
E) Nausea to opioids resolves in most patients within 7 days

2. Because of delayed onset of activity after the first application of a Duragesic Patch (transdermal fentanyl), it is especially important to have breakthrough pain medicine available for the first
A) 2-6 hours
B) 7-12 hours
C) 13-24 hours
D) 24-36 hours
E) 48-72 hours

3. Which one of the following statements about treating terminal delirium is true?
A) Family members should leave the room to help decrease the agitation
B) Paradoxical worsening may occur after administration of a minor tranquilizer (e.g. Ativan or Valium)
C) Placing the patient in a dark room will help decrease sensory input and reduce the agitation
D) The drug treatment of choice is an anti-cholinergic medication
E) The drug treatment of choice is an opioid analgesic

4. Which one of the following statements about depression at end of life is true?
A) Clinical depression is a normal stage of the dying process
B) Depression associated with HIV is more difficult to treat than in cancer patients
C) Feelings of hopelessness/worthlessness are indicators of a clinical depression
D) The degree of appetite and sleep disturbance is predictive of response to anti-depressant medication
E) Tricyclic antidepressants are the first choice for drug therapy

5. A 60 y/o woman has metastatic breast cancer with bone and pleural metastases. Her husband brings her to clinic stating that over the past week she has noted fatigue, thirst and frequent need to urinate. On examination she is dehydrated and lethargic but rousable, there are no focal neurological findings. Her only medication is oral morphine. The most likely diagnosis of this new problem is
A) Brain metastases
B) Hypercalcemia
C) Hyperglycemia
D) Hypernatremia
E) Sepsis

6. The best class of drugs to treat “death rattle” is
A) anti-cholinergic/anti-muscarinic (e.g. scopolamine)
B) benzodiazepine (e.g. lorazepam, Ativan)
C) butyrophenone (e.g. haloperidol, haldol)
D) local airway anesthetic (e.g. inhaled lidocaine)
E) opioid analgesic (e.g. morphine)

7. Comfort measures during the Syndrome of Imminent Death include all the following, except:
A) anti-pyretic PRN fever
B) changing body position frequently
C) intravenous hydration
D) lip balm
E) morphine PRN respiratory distress

8. The most important supplemental therapy to consider when starting patients on opioids for pain is:
A) amphetamines to increase alertness
B) antidepressants to supplement pain relief
C) antiepileptic medication to treat neuropathic pain
D) laxatives to prevent constipation
E) non-steroidals (NSAID’s) to treat inflammation

9. Neuropathic pain is often characterized by episodes of:
A) achy pain
B) colicky pain
C) gnawing pain
D) shock-like pain
E) squeezing pain

10. Three months after a patients death her husband comes to your office. He says that he sometimes thinks that his wife is in the house talking with him, that he imagines he hears her voice, he has gained 5 kilos since her death, but otherwise feels well. He is concerned that he is “going crazy” These symptoms are most consistent with a:
A) Complicated grief reaction
B) Major depression
C) Normal grief reaction
D) Post traumatic stress disorder
E) Psychotic disorder

11. Death resulting from side effects of opioid analgesics, used with the intent to treat severe dyspnea in a dying patient, is an example of:
A) acceptable medical practice
B) assisted suicide
C) euthanasia
D) murder
E) unprofessional practice

12. All of the following are common signs of approaching death except:
A) decreasing interest in eating
B) decreasing recognition of family members
C) decreasing urine output
D) increasing confusion
E) increasing number of bowel movements

13. The single best predictive factor in determining prognosis in patients with metastatic cancer is:
A) functional ability
B) Nausea to opioids is due to decreased bowel motility
C) presence of brain metastases
D) serum albumin
E) severity of pain

14. A woman with metastatic pancreatic cancer is losing weight and spending >75% of time in bed or lying down, no further anti-neoplastic treatments are planned. The patient asks you “how much time do you think I have?” The best approach is to say:
A) I believe time is short, only a few weeks to a few months
B) I really can’t tell how much time you have left
C) Life is a mystery, you must not give up hope
D) On average patients with your condition live for about sex-nine months
E) Only God can determine how long someone has to live

15. Current evidence suggests that a feeding gastrostomy in advanced dementia, will:
A) improve quality of life
B) improve resistance to infections
C) increase the need to use physical restraints
D) prevent episodes of aspiration pneumonia
E) prevent the development of bedsores

16. A 65 y/o anuric, end stage renal failure patient has been receiving hemodialyses three times per week for nine years. She is considering stopping dialysis, as it is increasingly a burden due to infections, vascular access problems and fatigue. The patient wants to know how long she would likely survive if she stops dialysis. The best response would be to say:
A) about 2-3 days
B) about 1-2 weeks
C) about 2-4 weeks
D) only God can determine how long someone has to live
E) there is no way to tell for sure

17. Which one of the following statements about treating terminal delirium is true?
A) family members should leave the room to help decrease the agitation
B) paradoxical worsening may occur after administration of a benzodiazepine
C) placing the patient in a dark room will decrease sensory input and reduce agitation
D) the drug treatment of choice is lorazepam (ativan)
E) the drug treatment of choice is an opioid analgesic

18. Which one of the following statements is closest to the definition of “physician assisted suicide”?
A) discontinuing intravenous fluid administration in a patient who can no longer take oral medication
B) discontinuing tube feedings in an end stage dementia patient
C) raising the dose of intravenous morphine with the intent of depressing respiration to the point of death
D) removing a respirator at the request of a decisional patient
E) writing a prescription for a lethal dose of a medication that the patient can use at the time of their choice

19. A patient dies an expected death in the hospital, from congestive heart failure. You are called to “pronounce the patient”; the family is at the bedside. Which of the following is not appropriate
A) ask the family to leave the room while you perform your examination
B) offer to remove medical paraphernalia (e.g. Oxygen mask, IV line)
C) stand quietly for a moment and offer consolation to the family
D) volunteer to contact a Chaplin
E) volunteer to contact family members not present

20. A long-term patient of yours comes to see you 3 months after the death of his wife. He says that he sometimes thinks that his wife is in the house talking with him, that he imagines he hears her voice; he has gained 5kilos since her death, but otherwise feels well. He is concerned that he is “going crazy”. These symptoms are most consistent with a:
A) Complicated grief reaction
B) Major depression
C) Minor depression
D) Normal grief reaction
E) Psychotic disorder

21. Which one of the following statements is true about medical futility?
A) a physician is ethically bound to comply with a patient or family’s wish for treatment, even when the physician believes that the treatment requested by the patient has no likelihood of medical benefit
B) decisions about futility should be made on the basis of the financial resources of the patient
C) futility refers to a specific medical intervention applied to a specific patient at a particular time
D) futility refers to any treatment with less than a 5% chance of positive outcome
E) the term, “futility” should be used with patients and family when discussing medical treatment that the physician believes will not help the patient

22. When discussing bad news over the telephone the first thing you should do is:
A) ask the person to describe their understanding of the medical issue22
B) clarify who it is you are talking to – their relationship to the patient
C) explain that you are calling with some bad news
D) give a fair “warning shot” that you have bad news
E) offer to contact another family member or friend

23. Mr. Phillips is in a home hospice program with end stage COPD. He has lost 25 pounds in the last two months. His wife calls you and expresses concern that he is lethargic and appears dehydrated. She wonders whether an intravenous line should be started at home so that he can receive fluids. Your response should be to:
A) admit the patient to an inpatient hospice program for terminal care
B) begin home intravenous therapy
C) place a nasogastric tube and give plain water through the tube
D) reassure the wife that dehydration is an expected aspect of dying
E) recommend inpatient hospital care to manage terminal symptoms

24. Withdrawal of artificial feeding through a feeding tube, from a patient dying of end stage heart disease, who is comatose with death expected within a few days, is an example of:
A) acceptable medical practice
B) assisted suicide
C) euthanasia
D) murder
E) unprofessional practice

25. Spirituality is best defined as a persons understanding of:
A) heaven and hell in the context of imminent death
B) how a higher being values life accomplishments
C) the origins of life and the universe
D) their relationship between one’s self, others and the universe
E) their religious traditions and rituals