ACHPN - Advanced Certified Hospice and Palliative Nurse Examination Managing Imminent Death Symptoms Questions and Answers — Questions and Answers
Question 1: A 72-year-old hospice patient with metastatic colon cancer has been comfortable on a regimen of long-acting oral morphine 60 mg every 12 hours. He is now unable to swallow and is transitioning to the actively dying phase. The ACHPN needs to convert his basal opioid to a continuous subcutaneous infusion. Using a standard oral to parenteral morphine conversion ratio of 3:1, what is the correct initial rate for the continuous subcutaneous morphine infusion?
- 5 mg/hour
- 1.7 mg/hour (Correct answer)
- 10 mg/hour
- 3.3 mg/hour
Correct answer: 1.7 mg/hour
The total daily oral dose is 120 mg (60 mg x 2). Using the specified equianalgesic conversion ratio of 3:1 for oral to parenteral morphine, the 24-hour subcutaneous dose is 40 mg (120 mg / 3). To find the hourly infusion rate, this total is divided by 24 hours (40 mg / 24 hours), which equals approximately 1.7 mg/hour.
Question 2: A patient in the last hours of life is exhibiting significant restlessness, moaning, and attempting to climb out of bed, despite not appearing to be in pain. Repositioning and a quiet environment have not been effective. The patient's family is very distressed by these behaviors. Which of the following interventions is most appropriate to manage this patient's terminal agitation?
- Applying soft restraints to ensure patient safety and prevent falls.
- Requesting a psychiatric consult to assess for an underlying mood disorder.
- Administering a bolus dose of an opioid, as this is likely a sign of undertreated pain.
- Administering a benzodiazepine such as lorazepam or midazolam. (Correct answer)
Correct answer: Administering a benzodiazepine such as lorazepam or midazolam.
Terminal restlessness or agitation is a common symptom in the dying process and is often a manifestation of delirium. While pain should be ruled out, if it is not the suspected cause, benzodiazepines are a primary treatment for managing the anxiety and agitation associated with this syndrome. Opioids can sometimes worsen delirium, restraints are a last resort that can increase agitation, and a psychiatric consult is not practical or indicated in the last hours of life.
Question 3: An 80-year-old patient with end-stage renal disease, receiving hospice care, develops prominent myoclonic jerks while on a continuous subcutaneous infusion of hydromorphone for pain. Which of the following is the most appropriate initial management strategy?
- Rotate to a different opioid, such as methadone or fentanyl, and consider adding a benzodiazepine. (Correct answer)
- Increase the rate of the hydromorphone infusion to treat the jerks as a pain equivalent.
- Add a non-steroidal anti-inflammatory drug (NSAID) to the patient's regimen.
- Administer an anticholinergic agent like glycopyrrolate to counteract the side effect.
Correct answer: Rotate to a different opioid, such as methadone or fentanyl, and consider adding a benzodiazepine.
Opioid-induced myoclonus is a form of neurotoxicity, which can be exacerbated by the accumulation of active metabolites in renal failure. The primary management strategy is to rotate to a different opioid with a different metabolic profile, such as fentanyl or methadone. A benzodiazepine like clonazepam or midazolam can be used as an adjuvant to treat the muscle spasms. Increasing the dose of the offending opioid will worsen the myoclonus.
Question 4: An unresponsive patient in the final days of life develops a fever of 38.9°C (102°F). The patient does not appear distressed. The family asks if something should be done. Which of the following statements represents the most appropriate approach to managing fever in this context?
- Aggressive treatment with antibiotics and IV fluids should be initiated immediately to treat the underlying infection.
- Fever is a normal part of the dying process and should never be treated with medication.
- The primary goal is to treat the fever only if it is causing distress to the patient, often with acetaminophen administered rectally. (Correct answer)
- An ice-water bath is the most effective non-pharmacologic method to rapidly reduce the temperature.
Correct answer: The primary goal is to treat the fever only if it is causing distress to the patient, often with acetaminophen administered rectally.
In the imminently dying patient, the goal of care shifts entirely to comfort. Fever should be treated only if it is perceived to be a source of discomfort for the patient (e.g., causing restlessness or sweating). Aggressive interventions like antibiotics are inconsistent with comfort-focused goals. Gentle non-pharmacologic measures (e.g., light clothing) are preferred over aggressive cooling methods, which can cause shivering and discomfort. Acetaminophen suppositories are a common and effective pharmacologic approach when treatment is indicated for comfort.
Question 5: The daughter of a hospice patient who is actively dying calls the ACHPN in distress, stating, "My mother's feet and hands are cold and have a purple, blotchy look to them. What is happening?"
- "Apply several heating pads to her legs and arms to warm them up and restore circulation."
- "This is a normal change called mottling. It happens as circulation slows and is a sign she is nearing the end. We can place a light blanket on her for comfort." (Correct answer)
- "This is a sign of a blood clot. I will call for an ambulance to take her to the emergency room immediately."
- "This indicates severe dehydration. We need to increase her fluid intake immediately, possibly with a subcutaneous infusion."
Correct answer: "This is a normal change called mottling. It happens as circulation slows and is a sign she is nearing the end. We can place a light blanket on her for comfort."
Mottling is a common and expected sign in the actively dying patient, caused by the shunting of blood from the extremities to core organs as the circulatory system fails. It is not typically painful. The most important intervention is to educate and reassure the family that this is a natural part of the dying process. Interventions like emergency transport or aggressive hydration are inappropriate. Applying heating pads can cause skin damage due to fragile skin and poor circulation.
Question 6: When a patient in the last days of life loses the ability to swallow safely (terminal dysphagia), what is the primary guiding principle for managing oral intake?
- Transition all essential medications to parenteral or rectal routes and focus on gentle oral care for comfort. (Correct answer)
- Initiate artificial nutrition and hydration via a feeding tube to prevent starvation.
- Encourage the family to frequently offer small sips of water to prevent the sensation of thirst.
- Use thickened liquids exclusively to ensure the patient receives some form of oral hydration safely.
Correct answer: Transition all essential medications to parenteral or rectal routes and focus on gentle oral care for comfort.
As a patient approaches death, the body's need for food and fluids diminishes, and the gag reflex weakens, making aspiration a significant risk. The priority is to prevent the distress of choking or aspiration. Therefore, essential symptom-management medications are converted to other routes (e.g., subcutaneous, rectal), and comfort is maintained through meticulous oral care with swabs to moisten the mouth. Forcing oral intake, even with thickened liquids or small sips, can still pose an aspiration risk and is generally contraindicated when the patient can no longer swallow safely. Artificial nutrition and hydration are not typically indicated as they do not improve comfort and can cause complications.
ACHPN - Advanced Certified Hospice and Palliative Nurse Examination Managing Imminent Death Symptoms Questions and Answers
A 72-year-old hospice patient with metastatic colon cancer has been comfortable on a regimen of long-acting oral morphine 60 mg every 12 hours.
He is now unable to swallow and is transitioning to the actively dying phase.
The ACHPN needs to convert his basal opioid to a continuous subcutaneous infusion.
Using a standard oral to parenteral morphine conversion ratio of 3:1, what is the correct initial rate for the continuous subcutaneous morphine infusion?