Palliative Care 🕯️

A 77 year old man with stage 4 colorectal cancer is seen by the palliative team at home for uncontrolled vomiting over the past few days. He is bed-bound and has carers coming in 4 times a day to help him with his meals and hygiene. His wife reports that he has been eating and drinking very little and that he vomits mainly clear secretions. He has not passed stools for the past 14 days and complains of abdominal cramping. On examination, he has generalised abdominal tenderness and distension. What is the SINGLE most appropriate medication to prescribe?

56 year old man whose pain was relieved by oral morphine, now presents to the outpatient clinic with progressively worsening pain. Increasing the dose of oral morphine helps to relieve his pain. However, he now complains that the increased morphine makes him drowsy and he is unable to carry out his daily activities. What is the SINGLE most appropriate next step?

A 55 year old man has suffered a massive left parietal lobe infarction 3 months ago. The stroke has left him to be non-verbal and with paresthesia on the right side of the body. Since the stroke, he has been having slight difficulty with swallowing. His swallowing deteriorated after a month and consequently started losing weight. He lacks mental capacity. Artificial feeding has been discussed with his wife as the medical team and GP believe it would be the next best management. His wife who is his next of kin would not like him to have any form of artificial feeding. He does not have any advance directive. What is the SINGLE most appropriate management?

A 59 year old man with oesophageal cancer and liver metastasis has increasing pain at his right hypochondriac region. He describes it as a dull ache with varying intensity throughout the day. He takes paracetamol and morphine sulfate regularly. Aside from increasing his dose of morphine sulphate, what other medications could be added to help with his pain?

An 87 year old man has been suffering from nausea and vomiting over the past few weeks. His medical history includes Parkinson’s disease. He feels weak and has been bed- bound for the past few days with little oral intake. Which SINGLE antiemetic given subcutaneously would benefit him?

A 65 year old man has suffered a massive left parietal lobe infarction 2 days ago. The stroke has left him to be non-verbal and with paresthesia on the right side of the body. Since the stroke, he has been having great difficulty with swallowing. He lacks mental capacity but has an advance directive which states that he does not want artificial feeding. His wife who is his next of kin would like him to have artificial feeding. What is the SINGLE most appropriate management?

An 81 year old man presents to the GP surgery with a request to end his life. He has a background of prostate cancer with bone metastasis which his oncologist has told him that he likely has a life expectancy of 6 months if not less. He takes regular oral morphine for his pain but feels it is not well controlled. He often wakes up at night with pain in his back. He feels depressed and feels he has nothing else to live for. He is mobile but walks with a frame. He is not married and has no children. When he was a teenager, he watched his father have a slow painful death with prostate cancer and he would not want to end his life in a similar manner. He would like a lethal dose of medication to end his life quickly. What is the SINGLE most appropriate action?

A 75 year old man with liver metastasis is complaining of a sharp, stabbing right upper quadrant pain. He is already on an optimised dose of morphine and paracetamol for pain. He also takes atenolol, aspirin and rivaroxaban on a daily basis. What is the most appropriate medication to add on?

A 64 year old man presents with the complaint of pain in his mid-thigh. He was diagnosed with prostate cancer a year ago and has since undergone radical prostatectomy as treatment for his cancer. A few weeks ago, he began experiencing pain in his left mid-thigh region. He describes the pain as being dull and constant and complains of an inability to sleep at night due to the pain. The pain sometimes radiates to his back. He takes regular oral morphine which brings some pain relief. Other than his prostate cancer history, he has no other significant medical history of note. A radioisotope bone scan reveals distant bony metastasis involving his left femur. What is the SINGLE best method for managing this patient’s pain?

A 56 year old man with secondary bone metastasis of his left femur had recently undergone radiotherapy for pain management 3 days ago. He complains of severe pain on his thigh which disturbs his sleep. The pain worsened a day after he had the radiotherapy. He takes regular ibuprofen and codeine for pain relief. What is the SINGLE most appropriate management for his pain?

A 77 year old woman who has widespread metastatic breast carcinoma is in her home under the palliative team. She is bed-bound and has been complaining of difficulty swallowing over the past few days. She takes 60 mg of prolonged-release morphine sulphate capsules twice a day for her pain. She also experiences nausea which the palliative team have started her on haloperidol subcutaneously. What is the mast appropriate dose and administration route of morphine to switch her to?

A 80 year old woman with multiple myeloma has her back pain usually relieved with oral morphine 30 mg sustained released capsules twice a day which she is prescribed. For the past week, she has required to use additional morphine sulphate orally three to four times a day for breakthrough pain. The palliative team has reviewed her medications and has decided to increase her morphine dose by. What would be the appropriate regimen to prescribe?

A 78 year old man is seen by his GP at home. He has Hodgkin’s lymphoma which was diagnosed 3 years ago. He has been discharged by the oncology team and referred to the palliative community team as he is not fit for further active treatments. He is bed- bound and has regular carers that attend his care needs. He lives with his wife. He has a DNACPR in place. Which of the following are appropriate for the GP to prescribe as anticipatory medications?

A 72 year old woman with metastatic hepatocellular carcinoma is treated in the hospice as an inpatient for symptomatic management for nausea and pain. She has developed a persistent hiccup which has not resolved over the past 3 days. Attempts with valsalva maneuver and breath holding has been unsuccessful. What is the SINGLE mast appropriate medication to be administered to resolve the hiccups?

A 91 year old man with terminal prostate cancer is brought to the Emergency Department by ambulance as he is more confused than usual. His carer reports that he fell and hit his head 3 days ago when trying to get out of bed. He is usually wheelchair bound and has carers come in four times a day to attend his cleaning needs. He has been having end of life care and requires full support with his activities of daily living. He looks cachexic. He has a Glasgow Coma Scale of 8/15. He is agitated and moaning in pain. A CT scan shows a crescent-shaped homogeneously hyperdense extra-axial collection over the left hemisphere with a midline shift to the right. He does not have any relatives or an advance directive. What is the SINGLE most appropriate management?

A 56 year old palliative patient with a background of colorectal cancer has increasing pain at his right upper abdomen. He describes it as a dull ache with varying intensity throughout the day. He takes paracetamol, immediate relief and modified-release oxycodone. He lives in a care home and is usually mobile. His blood results show the following:

Haemoglobin 120 g/L (130-180 g/L)

eGFR >75

Bilirubin 39 μmol/L (3-17 μmol/L)

Alanine transferase (ALT) 350 U/L (5-35 U/L)

Aspartate transaminase (AST) 190 U/L (5-35 U/L)

Alkaline phosphatase (ALP) 220 U/L (30-150 U/L)

Albumin 23 g/L (35-50 g/L)

What is the most appropriate medication to prescribe?

An 86 year old woman who is a resident in a nursing home is admitted to a hospital with a 4 day history of abdominal pain and nausea. She has colorectal cancer which was diagnosed 3 years ago and is on the palliative care register. She has not opened her bowels for the past 10 days and has not passed flatus. She started vomiting yesterday. Her temperature is 37.1°C and her heart rate is 80 beats/minute. A digital rectal examination reveals an empty rectum. An X-ray of her abdomen shows a large bowel obstruction. She is in obvious discomfort. What is the SINGLE most appropriate symptomatic treatment?

A 58 year old woman with ovarian cancer and peritoneal metastasis has been complaining of constipation for the past 3 weeks. She is weak and immobile. She passes flatus. She last passed stool 3 days ago. She would normally open her bowels every day. She feels nauseous and over the past 2 days, she has been vomiting her food. Her abdomen is soft and non-tender. On auscultation, bowel sounds are sluggish. She has laxatives prescribed. Which is the SINGLE most appropriate medication to prescribe for her nausea and vomiting?

A 78 year old woman with widespread metastatic breast cancer was admitted into the hospital with abdominal pain 5 days ago. She last opened her bowels more than a week ago. She has stop eating and drinking over the past few days. She has been bed-bound for the past few months. She has deteriorated over the past few months and is now unable to take her oral medication as she finds it difficult to swallow. She has a syringe driver for morphine sulphate and midazolam. She lacks capacity and is intermittently awake for short periods during the day. Her daughter, who is her main carer, is concerned about her oral intake. What is the most appropriate action?

A 66 year old man with a background of bronchogenic carcinoma is seen at home by the palliative team. He has had a recent onset of bad breath which he is very embarrassed about. He has been feeling more fatigued over the past few months with a new-onset low-grade fever. His last CT scan 2 weeks ago shows a large right upper lobe cavitary lesion. There are no lesions seen in the oral cavity. His family are also concerned about his bad breath. What is the SINGLE most appropriate management?

A 59 year old man has increasing breathlessness. He is managed by the palliative care team in the hospital for bronchogenic cancer with bone metastasis. His symptoms have been worsening over the past few weeks. A chest X-ray done recently shows a right- sided pleural effusion. Which SINGLE option would provide the best relief to this patient?

A 76 year old man is on treatment for prostate cancer and bone metastasis. He complains of only passing stool once every four to five days. He drinks adequate fluids and describes his stool as being saft. What is the SINGLE most appropriate management for his constipation?

A 91 year old man with advanced Alzheimer’s disease and metastatic prostate cancer is seen by his GP in a nursing home. He has been bed-bound for the past 2 years. He has stopped eating over the past few weeks. He is awake only for short periods of time during the day. He is non-verbal but opens his eyes in response to speech. His family is concerned as he has developed noisy breathing and gurgling over the past 12 hours. He has a medical history of severe COPD. Which is the most appropriate medication to prescribe?

A 63 year old woman with metastatic ovarian carcinoma diagnosed 4 years ago is admitted to the hospital following severe abdominal colicky pain for the past week. She is constantly bloated and has not passed stools in the past 6 days. She normally empties her bowels every 2 days over the past year. She is usually mobile but has been in the bed for the past few days because of nausea and pain. She takes regular morphine for the pain. On examination, her abdomen is distended with high-pitched bowel sounds. A CT scan demonstrates multiple dilated loops of small bowels likely caused by single level obstruction. What is the most definitive management?

A 65 year old man with prostate cancer with bone metastasis diagnosed 2 years ago has been an inpatient in the hospice for the past 6 weeks. He is mostly bed-bound and requires full support with his activities of daily living. He is asleep more than he is awake and has stopped eating solids. Over the past week, he has become gradually more confused. His blood results show the following:

Haemoglobin 81 g/L (115-160 g/L)

White cell count (WCC) (total) 10 x 10^9/L (4-11 x 10^9/L)

CRP 66 mg/L (< 10 mg/L)

Urea 6mmol/L (2.0-7 mmol/L)

Sodium 133 mmol/L (135-145 mmol/L)

Potassium 4.5 mmol/L (3.5-5.0 mmol/L)

Creatinine 135 μmol/L (70-150 μmol/L)

eGFR 48 (>90)

Alanine transferase (ALT) 32 U/L (5-35 U/L)

Alkaline phosphatase (ALP) 144 U/L (30-150 U/L)

Calcium (Total) 3.6 mmol/L (2.1-2.6 mmol/L)

Subcutaneous fluids were started. What is the most appropriate next management?

A 74 year old woman with breast cancer and bone metastasis has her pain relieved with oral morphine 60 mg twice a day. For the past 2 weeks, she has needed to use an additional 20mg of oral morphine every 4 hours. Her pain is not well controlled. She describes the pain as continuous pain throughout the day and not just on movement. What is the SINGLE most appropriate regimen of analgesia to prescribe?

A 58 year old woman with a diagnosis of malignant neoplasm of the mandible with bone metastasis is admitted into the hospital following worsening nausea, vomiting, confusion and feeling drowsy. She is still mobile and is able to tolerate food and drink. Her blood results show the following:

Haemoglobin 93 (115-160 g/L)

White cell count (WCC) (total) 12 x 10^9/L (4-11 x 10^9/L)

Urea 8 mmol/L (2.0-7 mmol/L)

Sadium 134 mmol/L (135-145 mmol/L)

Potassium 4.8 mmol/L (3.5-5.0 mmol/L)

Creatinine 145 μmol/L (70-150 μmol/L)

eGFR >60

Alanine transferase (ALT) 34 U/L (5-35 U/L)

Alkaline phosphatase (ALP) 298 U/L (30-150 U/L)

Calcium (Total) 3.5 mmol/L (2.1-2.6 mmol/L)

She was commenced on intravenous crystalloids immediately. In her notes, there is completed do not resuscitate form. What is the SINGLE most appropriate next step in management?

A 72 year old man with metastatic bladder cancer is seen at home by his palliative care team. He has been increasingly weak and nauseous for the past 2 weeks. He has been on a maximum dose of codeine phosphate which he takes regularly for his lower abdominal pain for several months. His pain is well controlled on his current pain relief although he finds taking oral medications increasingly difficult because he is too weak to swallow. What is the most appropriate action?

A 59 year old man is visited at home by the palliative care team. He takes regular codeine for pain associated with his colorectal cancer. He finds it increasingly difficult to take his oral medications as he feels too weak to swallow the tablets. He has not taken his tablets over the past 2 days which has resulted in increasing abdominal pain. A blood test done 2 weeks ago shows the following results:

Bilirubin 16 μmol/L (3-17 μmol/L)

Alanine transferase (ALT) 310 U/L (5-35 U/L)

Aspartate transaminase (AST) 294 U/L (5-35 U/L)

Alkaline phosphatase (ALP) 220 U/L (30-150 U/L)

Albumin 15 g/L (35-50 g/L)

Urea 6 mmol/L (20-7 mmol/L)

Creatinine 180 (70-150 μmol/L)

eGFR 70 (>90)

What is the most appropriate medication to switch his codeine tablets to?

An 85 year old woman suffering from metastatic colon cancer presents to the GP surgery requesting for some medications. After examining and reviewing the patient, she was given a handwritten FP10 for palliative medication and was advised to collect her medication from the pharmacy next door. After several minutes, the pharmacist called to reject the prescription as the prescription does not meet the legal requirements. Which of the following is the SINGLE most likely legal requirement missing from the prescription?

A 46 year old man with a background of widespread bone metastasis with a primary prostate cancer has severe pain throughout his body. The pain is present throughout the day and he describes it as a dull ache. He is currently on paracetamol, immediate-release oxycodone and prolonged-release oxycodone. What is the most appropriate medication to add to his medication list to help with pain?

A 98 year old man is visited at home by his GP. He has worsening cough over the past 2 weeks. He lives with his wife. He uses a frame to mobilise but for the past 2 weeks, he has been bed-bound because he has been feeling lethargic. He has carers that come in twice a day. His medical history includes a myocardial infarction 5 years ago. A quick assessment reveals that he has mental capacity. On auscultation, right basal crepitations are heard. His other observations were performed. What is the most appropriate next action?

A 63 year old woman with lymphoma is managed in her house by the palliative team for her end of life care. She is bed-bound and has been deteriorating over several months. She has required full support with her activities of daily living for the past 6 months. She has not been able to tolerate food for the past week. Over the past 24 hours, she has developed a rattling noise from her throat and noisy breathing which concerns the family as she looks distressed with it. What is the SINGLE most appropriate management?

A 72 year old man with colorectal cancer and liver metastasis has increasing pain at his upper abdomen. He describes it as a dull ache with varying intensity throughout the day. He takes paracetamol which does not provide him with much relief. He is still mobile and independent in his house. He refuses to take any morphine sulfate regularly because he previously suffered from severe constipation. His blood results show the following:

Haemoglobin 110 g/L (130-180 g/L)

eGFR >75

Bilirubin 39 μmol/L (3-17 μmol/L)

Alanine transferase (ALT) 215 U/L (S-35 U/L)

Aspartate transaminase (AST) 130 U/L (5-35 U/L)

Alkaline phosphatase (ALP) 190 U/L (30-150 U/L)

Albumin 25 g/L (35-50 g/L)

What is the most appropriate medication to prescribe?

A 79 year old woman with stage 3 osteosarcoma has been having increasing difficulty breathing at home. She is on the palliative register. On examination, she looks breathless. She has a respiratory rate of 26 breaths/minute and feels distressed by her breathing. She is able to mobilise to her chair and back to her bed unaided. She has been eating and drinking. She takes regular paracetamol and codeine. What is the SINGLE mast appropriate medication to prescribe?

A 70 year old woman complains of having bad breath for two weeks. She has squamous cell carcinoma in her lungs and has been a resident in a hospice centre for two months. She is on the palliative register. There has been a history of heavy smoking for 35 years. Oral and dental examination shows no abnormalities. Her temperature is 37.3°C, pulse rate is 76 beats/minute, blood pressure is124/82 mmHg, and respiratory rate is 20 breaths per minute. Her chest X-Ray shows multiple cavitary lesions in the lungs. What is the appropriate management for her?

John who is an elderly man with metastatic pancreatic cancer has increasing abdominal pain. He has been prescribed morphine sulphate by the pain team of which his prescription is shown below.

Unfortunately, his prescription was rejected by the pharmacist as there was an error on the prescription. Which SINGLE error would prevent the pharmacist from providing morphine sulphate?

A 66 year old woman has been having worsening back pain for the past 3 days. She has a history of metastatic breast cancer and has completed a course of radiotherapy 5 days ago for her vertebral metastasis. She takes regular paracetamol, codeine and ibuprofen. She describes the pain as a dull ache which is worse in the morning. What is the SINGLE most appropriate management?

A 90 year old man is seen by the palliative care team with complaints of pain at the left thigh that has been worsening over periods of months. He describes the pain as a dull ache that can wake him up at night. He has a background of prostate cancer with bone metastasis. He has finished a course of radiotherapy to treat bone pain a few days ago. His neurological examination of the lower limbs is unremarkable. What is the SINGLE most appropriate treatment for his pain?

A 61 year old lady is seen by the palliative team with ongoing lower back pain. She has a background of squamous cell lung carcinoma with metastatic spread to her lower vertebrae. She describes the pain as being dull and constant and complains that the pain wakes her up at night. Her current medications include fentanyl patch, paracetamol, and macrogol. She has tried taking ibuprofen before but developed an unpleasant itchy rash with shortness of breath. Despite taking her medications as prescribed, she still complains of moderate pain in her back. A CT scan shows metastatic deposits at her first lumbar vertebra. What is the SINGLE most appropriate management?

A 90 year old man with terminal Hodgkin’s lymphoma is having sleepless nights. He often wakes up with anxiety about dying. He is seen to be eating less and drinking less over the past few days. He is bed-bound due to weakness. He appears cachexic. What is the SINGLE most likely medication to be offered regularly?

A 52 year old man has a history of prostate cancer and bone metastasis. He has been taking regular codeine and naproxen orally for his back pain for the past year. For the past three months, he finds the back pain worsening. He often wakes up in the middle of the night due to the back pain. What is the SINGLE most appropriate management?

A 77 year old man with a background of terminal testicular cancer and lung metastasis is becoming increasingly more agitated. He lives in the care home and has been reported by the carers as being confused over the past few days. Over the past few days, he is seen shouting at the wall in the middle of the night. He wakes up in the middle of the night with the fear that he is going to die in pain. What is the SINGLE most appropriate medication to administer?

A 68 year old man with small cell carcinoma of the right lung, who has been under the care of the palliative team in the hospice, slowly deteriorates due to his disease progression and dies. He was not eating or drinking for the last days of his life and was gradually less responsive. He had a history of heavy smoking for 20 years and hypertension. The doctor on the ward was asked to fill in his medical certificate of cause of death. What should be filled as the disease or condition that is directly leading to his death?

A 66 year old man with multiple myeloma has been increasingly confused and agitated over the past 4 days. He is not able to remember his grand daughter’s name and has forgotten where he lives. His blood tests show:

Haemoglobin 141 g/L (130-180)

White cell count 8 x 10^9/L (4-11)

Platelets 360 x 10^9/L (150-400)

Sodium 139 mmol/L (135-145)

Potassium 3.8 mmol/L (3.5-5)

Serum corrected calcium 3.2 mmol/L (2.1-2.6)

eGFR > 60

He was started on intravenous fluids. His repeated serum calcium levels are 3.3 mmol/L What is the SINGLE most appropriate next step?

A 65 year old man with a background of renal sarcoma with abdominal wall metastasis has been experiencing increasing pain in his abdomen and back. He is currently in a hospice being treated by the palliative team. He is currently an 200 mg of slow-release morphine twice a day and taking immediate-release morphine every 4 hours. His pain is throughout the day and even at night. What is the SINGLE most appropriate action?

A 77 year old man with a background of squamous cell carcinoma of the lung has been having worsening chest pains over the past month. His GP had prescribed him morphine sulphate oral solution (Oramorph 10mg/5ml) to be used as required for pain relief. Over time, the patient has increased the frequency of morphine sulphate oral solution usage and now takes 10 mg every 4 hours. His GP has decided to offer him the same dase of morphine sulphate as a modified release tablet. What is the SINGLE most appropriate dose of modified release and frequency to prescribe?

A 45 year old man with non-Hodgkin’s lymphoma with bone metastasis is admitted to the hospice because of uncontrolled pain. He has been vomiting over the past 2 weeks and is increasingly nauseous. He has been on a maximum dose of codeine phosphate. His pain which is in his abdomen and lumbar spine is not well controlled. He has not opened his bowels in a week. He would usually open his bowels every day. What is the SINGLE most appropriate action?

A 71 year old man with stage 4 colorectal cancer is seen by the palliative team at home for uncontrolled vomiting over the past few days. He complains of nausea most of the day. He is able to eat small amounts. He is able to defecate but with small amounts. He has abdominal distention and cramping. He was started on cyclizine via continuous subcutaneous infusions for his nausea but it did not improve his symptoms. He has a background of Parkinson’s disease. On examination, he has generalised abdominal tenderness and distension. His bowel sounds are hypoactive. A partial bowel obstruction is suspected. What is the SINGLE most appropriate medication to prescribe for his nausea?

A 78 year old man with hepatic metastasis has been an inpatient in the hospice for end of life care for the past 2 weeks. He has been slowly deteriorating and has been more confused for the past few days. He starts having severe haematemesis over the past hour. What is the most appropriate management?

A 66 year old woman with a background of COPD and bronchogenic cancer is seen in her house by a GP because she has increasing breathlessness and left chest pain. She has been told by the oncology team that she is for palliative management as the cancer has spread to her bones and liver. She has an oxygen saturation of 89% and a respiratory rate of 24 breaths/minute. Her breathing looks laboured. A chest X-ray was organised by the GP which is seen below.

What is the SINGLE most appropriate management?

A 75 year old man has had a percutaneous endoscopic gastrostomy (PEG) inserted a day ago following a stroke that occurred 1 week ago. There was a one-off leak of minimal gastric fluid around the PEG tube. His observations are within normal limits. He does not complain of pain or abdominal bloating. There is no irritation around the skin of the stoma. There is no discharge at the site. What is the SINGLE most appropriate management?

A 79 year old man with metastatic lung adenocarcinoma starts to vomit large amount of blood in the hospital. He is agitated and anxious about dying. His last CT shows liver metastases. He is on the palliative care register. He requires full support with his activities of daily living. He has been bed-bound for the past month. What is the SINGLE mast appropriate management?

A 65 year old woman with breast cancer and liver metastasis is in the hospice as an inpatient for symptomatic management for pain. Over the past 2 days, she has been suffering from persistent hiccups. Self-helped remedies such as breath holding and Valsalva manoeuvre have been attempted but have been unsuccessful. She is very distressed with the hiccups. What is the SINGLE most appropriate medication to be administered?

A 78 year old woman with terminal non-Hodgkin’s lymphoma is admitted to a hospice for end of life care. She has pains on her lower abdomen and chest which has been progressively worsening over several weeks. She uses fentanyl patches for pain relief but she feels that the pain is no longer controlled with the fentanyl patch. She has difficulty swallowing due to pain. She remains bed-bound with a poor appetite for the past 2 weeks. Her last fentanyl patch was placed 24 hours ago. What is the most appropriate action?

A 65 year old woman suffering from metastatic squamous cell carcinoma of the lung is being discharged by the palliative team in the hospice. She has been given a handwritten prescription for Oramorph (oral morphine sulphate 10mg/5ml) which was sent to the pharmacist. Several minutes later, the pharmacist called to reject the prescription as the prescription does not meet the legal requirements. Which of the following is the SINGLE most likely legal requirement missing from the prescription?

A 55 year old man has been diagnosed with glioblastoma multiforme 3 years ago. He has worsening nausea over the past few weeks. He has been vomiting once or twice a day for the past few days. His oncology team believe that nausea is the result of an increase in intracranial pressure. He is not taking any medications for nausea at the moment. What is the SINGLE most appropriate antiemetic to prescribe?

A 56 year old man with terminal lung cancer with bone metastasis presents with shortness of breath, cough and pleuritic chest pain. His symptoms have been worsening over the past few weeks. The following chest X-ray was taken:

Which SINGLE option would provide the best relief to this patient?

A 75 year old woman with adenocarcinoma of the lung has been having increasing difficulty breathing in the hospice. She is on the palliative register. On examination, she looks breathless. She is active and able to mobilise around the hospice. She eats and drinks. She continues to have a good appetite. On examination, there is wheezing on bath her lung fields. She has a temperature of 36.2°C, heart rate of 70 beats/minute, blood pressure of 130/80 mmHg, and respiratory rate of 22 breaths/minute. What is the SINGLE most appropriate medication to prescribe?

A 78 year old man with known colorectal carcinoma on palliative management was previously on a total dose of 120 mg slow release oral morphine per day. His pain was not well controlled therefore his dose was increased to 200 mg slow release oral morphine. He is still in moderate pain but complains of terrible drowsiness and nausea since the increase of oral morphine dose. He vomited once more than 24 hours ago. What is the SINGLE most appropriate step in the management?

A 79 year old man who is an inpatient in the hospice has difficulty with pain management. His medical history includes renal cell carcinoma and is under the palliative team. He takes regular prolonged-release morphine. He finds it increasingly difficult to take his oral medications as he feels too weak to swallow the tablets. He has not taken his tablets over the past 4 days which has resulted in increasing back pain. A blood test done 3 days ago shows the following results:

Albumin 15 g/L (35-50 g/L)

Urea 7 mmol/L (20-7 mmol/L)

Creatinine 260 (70-150 μmol/L)

eGFR 15 (>90)

A syringe driver with pain relief is thought to be beneficial. What is the most appropriate medication to switch his morphine tablets to?

A 65 year old man has suffered a massive left parietal lobe infarction 2 days ago. The stroke has left him to be non-verbal and with paresthesia on the right side of the body. Since the stroke, he has been having great difficulty with swallowing. He lacks mental capacity. Artificial feeding has been discussed with his wife as the medical team and GP believe it would be the next best management. His wife who is his next of kin would not like him to have any form of artificial feeding. He does not have any advance directive. What is the SINGLE most appropriate management?

A 60 year old man with lung metastasis from a melanoma presents to your clinic with a persistent dry cough. He has already tried the over-the-counter remedy simple linctus which provided no relief. Subsequently, his GP prescribed him codeine linctus which he took as prescribed (4 times per day) which he states helped somewhat but the cough is still severe enough that he is having problems with sleep. What is the next most appropriate management?