How to use these practice questions
These ten single-best-answer cases cover common decisions in palliative care. They are for clinical learning, not a substitute for local guidance: drug availability, prescribing rules and clinical pathways vary by country. For a real patient, use local protocols and seek specialist advice when the situation calls for it.
Choose an answer in each question before reading the explanation beneath it. Pay attention to why the strongest alternative is less suitable: in practice, the distinction often depends on one detail, such as renal function, a possible obstruction or whether the patient is hypoxaemic.
1. Starting an opioid for cancer pain
This question tests a safe first step when an adult with cancer pain can take oral medicines and has no known renal impairment. A MySummaries practice question might look like this:
A 68-year-old with advanced cancer has persistent severe pain despite paracetamol. They are opioid-naive, can swallow tablets and have normal renal function. What is the most appropriate plan?
Immediate-release oral morphine can be titrated against pain and adverse effects, with review and a laxative plan from the outset. A long-acting preparation alone is harder to titrate when initiating treatment; waiting until pain is unbearable and omitting constipation prevention are poor plans. A fentanyl patch is not a routine first opioid for an opioid-naive patient.
The key is to make a titratable plan and anticipate constipation, not simply select a drug. Starting doses and review intervals should follow local prescribing guidance and the person’s clinical circumstances.
2. Opioids and severe renal impairment
This case tests recognition that some opioid metabolites can accumulate when kidney function is poor.
A patient with advanced illness has an eGFR of 18 mL/min/1.73 m² and needs ongoing opioid analgesia. They have become drowsy while taking morphine. What is the best next step?
Drowsiness in severe renal impairment warrants assessment for opioid toxicity and other causes. Morphine metabolites can accumulate; a carefully calculated rotation to an opioid such as fentanyl may be considered with experienced prescribing support. Increasing morphine is the strongest distractor, but could worsen accumulation and toxicity. Conversion is not a simple milligram-for-milligram substitution.
Renal impairment changes the risk of accumulation; it does not mean the person should be left in pain. Check the whole medication history and make any opioid change cautiously.
3. Preventing opioid-induced constipation
This question tests prevention and treatment of a common opioid adverse effect.
A patient starting regular oral morphine has no current constipation. What is the most appropriate approach to bowel care?
Opioids commonly slow gut motility, so bowel function should be discussed and a regular laxative plan offered at opioid initiation, then adjusted to effect. A stimulant laxative, with an osmotic agent if needed, is a common approach. A stool softener alone may not adequately address opioid-related slow transit; waiting for severe symptoms delays care.
Ask about the person’s usual bowel pattern and monitor whether the plan works. If constipation persists, reassess contributing medicines and possible causes rather than assuming the first laxative choice is sufficient.
4. Pain with a neuropathic component
This case tests when escalating an opioid alone is unlikely to address all the pain.
A patient with a painful tumour describes burning pain and brief electric-shock sensations radiating along the affected area. Their opioid dose has increased but these symptoms persist. What is the best next step?
Burning and electric-shock sensations suggest neuropathic pain, which may respond incompletely to opioid escalation alone. Assess the pain and consider an adjuvant medicine, selected for the patient’s circumstances and local guidance. Simply increasing the opioid is the strongest distractor, but may add adverse effects without adequately treating the neuropathic component.
Describe the pain before changing treatment: its character, location, pattern and effect on function can guide the next step. Review the response to any adjuvant rather than assuming it will help.
5. Nausea with features of gastric stasis
This question tests matching an antiemetic choice to the likely mechanism while checking for obstruction.
A patient receiving palliative care reports nausea and early satiety. There is no abdominal distension, colicky pain or other clinical concern for bowel obstruction. Which option is most appropriate to consider?
With nausea and early satiety, and no indication of obstruction, a prokinetic such as metoclopramide may be appropriate after checking contraindications and local guidance. It should not be used when complete mechanical obstruction is suspected because increasing gut motility may be harmful. The scenario’s lack of obstruction features is the key distinction.
Nausea has many possible causes, including medicines, metabolic problems and bowel obstruction. Reassess if symptoms change or treatment does not help; do not keep treating a presumed mechanism without reviewing the patient.
6. Breathlessness in advanced illness
This case tests immediate supportive measures and the limits of oxygen therapy.
A person with advanced cancer is distressed by breathlessness. Their oxygen saturation is normal at rest. What is the best initial approach?
Assess the person and possible reversible causes, then offer simple measures such as comfortable positioning and airflow from a handheld fan. A symptom-directed medicine may be considered if distress persists, according to clinical context and local guidance. Routine oxygen is the strongest distractor, but normal saturation alone does not support oxygen solely to treat breathlessness.
A fan and positioning can be used while assessment continues; they do not replace investigation or treatment of a reversible cause. Oxygen is generally considered when there is a clinical indication such as hypoxaemia, not simply because the patient feels short of breath.
7. New confusion near the end of life
This question tests a structured response to delirium rather than assuming it is an inevitable part of dying.
A patient receiving palliative care develops new fluctuating confusion and agitation. What is the best next step?
New fluctuating confusion should prompt assessment for delirium and potentially reversible contributors, including infection, retention, constipation, dehydration and medicine effects. An antipsychotic may be considered in selected situations, but is not an automatic answer for every confused patient. Increasing an opioid without assessing the cause may worsen some contributors to confusion.
Consider the person’s comfort, safety and goals while assessing. Review medicines and look for physical problems that can be treated; the appropriate extent of investigation depends on the clinical context and the person’s wishes.
8. Noisy respiratory secretions in the last days
This case tests how to respond to secretions while supporting the patient and those close to them.
A dying patient has noisy respiratory secretions but does not appear distressed. Their family is frightened by the sound. What is the best response?
Assess the patient’s comfort, explain the likely nature of the sound to the family, and offer mouth care and repositioning where appropriate. Deep suction can be distressing and is not a routine response. An anticholinergic may be considered if secretions are troublesome, but should not be automatic when the patient is comfortable.
The sound may trouble relatives more than the patient. Keep checking comfort and explain what you are doing; treatment should be guided by the patient’s symptoms and local practice.
9. Opening a conversation about priorities
This question tests an approach that invites the patient’s perspective rather than imposing a decision.
A patient with progressive illness has not discussed future care. You want to understand what matters most to them. What is the best opening?
Ask permission, explore the patient’s understanding and find out what matters to them. This makes space for an individual conversation and helps guide future care. Giving a detailed prognosis before asking what the person wants to know is the strongest distractor: information should be paced to the patient’s needs and preferences.
Listen for concerns and goals before moving to options. A useful discussion is not a script: check what the person wants to know, respond honestly, and agree what should happen next.
10. Myoclonus and drowsiness during opioid treatment
This final case tests recognition of possible opioid toxicity and the need to review contributing factors.
A patient on a recently increased opioid dose develops new drowsiness and myoclonic jerks. They have also been drinking very little. What is the best next step?
New drowsiness and myoclonus after an opioid increase require assessment for opioid toxicity and contributing factors such as dehydration or impaired renal function. Review the pain and opioid plan and seek appropriate clinical advice. Increasing the opioid is the strongest distractor, but could aggravate toxicity rather than address the cause.
After reviewing the answers, note which clinical distinction you missed: for example, hypoxaemia versus breathlessness, or nausea with versus without suspected obstruction. Revisit those areas using your course materials and local guidance.
A sample review of areas where marks were lost could look like this:
If the same fact causes you to lose a mark twice, turn it into a precise retrieval question: ask for the decision and the detail that changes it, not a vague prompt to “review opioids”. A remediation prompt might read:
You lost this mark twice: a patient with eGFR 18 mL/min/1.73 m² becomes drowsy on morphine. What must you assess, and why should you avoid simply increasing the dose?
How MySummaries helps
MySummaries can build a revision board from your own palliative care notes, then use that material to generate practice questions and mark written answers against your notes. Turn missed distinctions into flashcards for spaced review. Start at portal.mysummaries.app.