Post-Test OIC in Palliative Care: A Case Based Approach

1. Walter is a 36-year old cancer patient, treated successfully with chemotherapy but developed peripheral neuropathy · Walter's pain was so severe that he was unable to work or even stand. · He consulted a physician at a pain clinic, and he was started on an opioid regimen. · The treatment was very effective. Walter was able to move without pain and return to work. · However, he developed constipation, and wanted to cut his dose of opioids. · An evaluation revealed that Walter had not been taking his bowel regimen because of the pill burden (8 senna and 2 docusate). · On restarting the constipation regimen, Walter found that it did not work as before. · In discussion with his provider, it was decided to rotate the opioids to see if Walter's pain and constipation could be controlled on fewer pills. · A switch to methadone and lactulose successfully controlled pain and constipation on fewer pills.

With respect to opioid rotation, which of the following is associated with less constipation?

Oxycodone

Methadone

Hydromorphone

Fentanyl

B and D

Methadone and Fentanyl are associated with less constipation compared to Oxycodone and Hydromorphone. This is because Methadone and Fentanyl have a lower incidence of constipation as side effects compared to Oxycodone and Hydromorphone. By switching to Methadone, Walter was able to control his pain and constipation on fewer pills.

Explanation

Methadone and Fentanyl are associated with less constipation compared to Oxycodone and Hydromorphone. This is because Methadone and Fentanyl have a lower incidence of constipation as side effects compared to Oxycodone and Hydromorphone. By switching to Methadone, Walter was able to control his pain and constipation on fewer pills.

2. Isabel is a 57-year old woman with chronic progressive multiple sclerosis, receiving care at home · During a recent pain crisis, Isabel requested morphine, which had worked in another pain crisis. · On the previous regimen of opioids, Isabel had difficult-to-manage constipation which had resulted in hospitalization for fecal impaction. The patient and her family were concerned that this would happen again and thus requested guidance. · When oral laxatives were recommended, the physician was told that Isabel had difficulty swallowing at times, but that she refused to have a standing regimen of enemas since she did not want her family to have to perform this task. · The physician prescribed long-acting morphine ER 15 mg every 12 hrs, with immediate-release morphine 5 mg every 2 hrs for breakthrough pain. · At the same time, the physician initiated a standing dose of docusate sodium 200 mg bid and sennoside 8.6 mg bid, ensuring the family that if constipation occurred for more than 3 days on this regimen, a subcutaneous injection of methylnaltrexone would be prescribed. · This satisfied the patient and family, knowing that Isabel would be able to obtain adequate pain relief and maintain bowel function at home

The pathophysiology of constipation in patients with multiple schlerosis is due to inherent:

Metabolic alterations

Electrolyte imbalance

Neurogenic bowel

Pain modulation mechanisms

Lack of mobility

The correct answer is neurogenic bowel. In patients with multiple sclerosis, the pathophysiology of constipation is often due to neurogenic bowel dysfunction. This means that there is a disruption in the normal functioning of the nerves that control bowel movements. This can result in difficulties with stool evacuation and can be exacerbated by factors such as immobility and certain medications, like opioids. In this case, the patient had previously experienced difficult-to-manage constipation while on opioids, which led to hospitalization. The physician prescribed a combination of medications and interventions to help manage constipation and maintain bowel function at home.

Explanation

The correct answer is neurogenic bowel. In patients with multiple sclerosis, the pathophysiology of constipation is often due to neurogenic bowel dysfunction. This means that there is a disruption in the normal functioning of the nerves that control bowel movements. This can result in difficulties with stool evacuation and can be exacerbated by factors such as immobility and certain medications, like opioids. In this case, the patient had previously experienced difficult-to-manage constipation while on opioids, which led to hospitalization. The physician prescribed a combination of medications and interventions to help manage constipation and maintain bowel function at home.

3. Multifactorial issues leading to constipation in palliative care patients include all of the following EXCEPT:

Immobility

Reduced intake of food

Inadequate fluid intake

Pain

Care giver support

The correct answer is "Care giver support." In palliative care patients, constipation can be caused by various factors such as immobility, reduced intake of food, inadequate fluid intake, and pain. However, caregiver support does not directly contribute to constipation in these patients. It is important for caregivers to provide adequate support and assistance to palliative care patients, but it is not a factor that directly affects constipation.

Explanation

The correct answer is "Care giver support." In palliative care patients, constipation can be caused by various factors such as immobility, reduced intake of food, inadequate fluid intake, and pain. However, caregiver support does not directly contribute to constipation in these patients. It is important for caregivers to provide adequate support and assistance to palliative care patients, but it is not a factor that directly affects constipation.

4. Please check if you agree with the following statements:

The way I practice in this clinical area is acceptable to me

I may need to examine one or more of my clinical practices in this area

I plan to change the way I practice in this area in the near future

The answer suggests that the individual finds their current practice acceptable but also acknowledges the need to evaluate and potentially change certain practices in the near future. This indicates a willingness to reflect on their clinical practices and make improvements as necessary.

Explanation

The answer suggests that the individual finds their current practice acceptable but also acknowledges the need to evaluate and potentially change certain practices in the near future. This indicates a willingness to reflect on their clinical practices and make improvements as necessary.

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5. May we contact you in the future regarding other CME activities and to determine the impact of this activity on your practice?

Yes

No

The given correct answer is "Yes, No". This means that the individual is open to being contacted in the future for other CME activities and to assess the impact of this activity on their practice. It indicates a willingness to engage in further professional development and contribute to the evaluation of educational initiatives.

Explanation

The given correct answer is "Yes, No". This means that the individual is open to being contacted in the future for other CME activities and to assess the impact of this activity on their practice. It indicates a willingness to engage in further professional development and contribute to the evaluation of educational initiatives.

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6. Do you anticipate making any changes in practice as a result of participating in this program?

Yes

This program confirms my current practice

No

The correct answer is "Yes, This program confirms my current practice, No." This response suggests that the individual anticipates making changes in their practice as a result of participating in the program. They acknowledge that the program aligns with their current practice, indicating that they may continue or reinforce their current approach. However, they also state "No," indicating that they do not anticipate making any changes. This response may be seen as contradictory, but it could imply that while they recognize the program's alignment with their practice, they do not foresee any significant changes or adjustments being made.

Explanation

The correct answer is "Yes, This program confirms my current practice, No." This response suggests that the individual anticipates making changes in their practice as a result of participating in the program. They acknowledge that the program aligns with their current practice, indicating that they may continue or reinforce their current approach. However, they also state "No," indicating that they do not anticipate making any changes. This response may be seen as contradictory, but it could imply that while they recognize the program's alignment with their practice, they do not foresee any significant changes or adjustments being made.

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