Post-test Oic In Palliative care: A Case Based Approach

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?

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

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

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