Match each end-of-life clinical scenario with the most appropriate targeted pharmacological intervention.
- A 75-year-old hospice patient with end-stage renal disease (not on dialysis) who develops severe resting dyspnea.Initiate low-dose fentanyl or methadone to avoid neurotoxic metabolite accumulation.
- A 64-year-old patient with advanced ovarian cancer presenting with an inoperable complete malignant bowel obstruction, intractable nausea, and colicky pain.Administer subcutaneous octreotide to decrease gastrointestinal secretions.
- A 70-year-old patient with metastatic prostate cancer on high-dose morphine who develops new-onset diffuse allodynia, myoclonus, and delirium.Provide hydration and rotate to a different opioid analgesic class at an equianalgesic dose reduction.
- An 82-year-old actively dying patient who is unresponsive and develops loud, gurgling respirations ('death rattle') that are distressing to the family.Prescribe an antimuscarinic agent such as sublingual glycopyrrolate.
Answer
End-stage renal disease matches with fentanyl/methadone; malignant bowel obstruction matches with octreotide; opioid-induced neurotoxicity matches with opioid rotation and hydration; and terminal secretions match with glycopyrrolate.
Each match correctly pairs a complex end-of-life clinical scenario with its gold-standard palliative intervention based on pharmacokinetics and pathophysiology. Fentanyl is safe in renal failure, octreotide manages malignant bowel obstructions without stimulating motility, opioid rotation clears neurotoxic metabolites, and glycopyrrolate addresses terminal pooling of secretions.
Step-by-Step Solution
Key Concept
Targeted pharmacological symptom management at the end of life requires integrating medication pharmacokinetics (e.g., avoiding morphine in renal failure) with the pathophysiology of specific terminal complications (e.g., using octreotide to reduce secretions in bowel obstruction).