100+ Free ABIM Palliative Care Practice Questions

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A hospitalist is called to the medical floor to see a 68-year-old man with metastatic pancreatic cancer admitted for pain crisis. He has been on morphine ER 60 mg PO BID (120 mg/day) with breakthrough morphine IR 20 mg PO Q2H PRN, using roughly 80 mg IR over the past 24 hours. What is the total daily oral morphine equivalent (MME) and an appropriate 24-hour IV morphine infusion rate after a 25% reduction for incomplete cross-tolerance when rotating to IV morphine?

MME 200 mg/day; IV morphine ~2 mg/h

MME 120 mg/day; IV morphine ~1 mg/h

MME 200 mg/day; IV morphine ~8 mg/h

MME 80 mg/day; IV morphine ~3 mg/h

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2026 Statistics

Key Facts: ABIM Palliative Care Exam

220

Max MCQ Questions

Up to 220 single-best-answer items

1 Day

Exam Length

Comprehensive computer-based, ~10 hr on-site

~$2,990

ABIM HPM Fee

ABIM application + exam (subject to change)

12 mo

Required Fellowship

ACGME-accredited HPM fellowship since 2014

Cosponsoring Boards

Shared exam, ABIM administers

LKA

5-Year MOC Option

Or 10-year recertification exam

ABIM HPM is a 1-day computer-based subspecialty exam of up to 220 single-best-answer MCQs at Pearson VUE. Candidates must continuously maintain ABIM primary Internal Medicine certification and have completed a 12-month ACGME HPM fellowship. Content covers pain management (opioid rotation, equianalgesic conversions, methadone, breakthrough dosing), non-pain symptoms (dyspnea, nausea by mechanism, delirium, OIC with PAMORAs, malignant bowel obstruction), communication/ACP (SPIKES, REMAP, NURSE, Serious Illness Conversation Guide, POLST), ethics (capacity, palliative sedation, MAID, double effect, withholding=withdrawing), psychosocial/spiritual (total pain, FICA, bereavement, prolonged grief DSM-5-TR), and prognostication (PPS, Karnofsky, FAST 7A-7D, NYHA IV, FEV1<30%, MELD-Na, Medicare Hospice Benefit, surprise question). IM-hospitalist emphasis on inpatient symptom crises, family meetings for refractory ICU/MCS scenarios, transitions to hospice, and 30-day readmission reduction. Maintained through ABIM continuous MOC (LKA or 10-year exam) plus underlying IM certification.

Sample ABIM Palliative Care Practice Questions

Try these sample questions to test your ABIM Palliative Care exam readiness. Each question includes a detailed explanation. Start the interactive quiz above for the full 100+ question experience with AI tutoring.

1A hospitalist is called to the medical floor to see a 68-year-old man with metastatic pancreatic cancer admitted for pain crisis. He has been on morphine ER 60 mg PO BID (120 mg/day) with breakthrough morphine IR 20 mg PO Q2H PRN, using roughly 80 mg IR over the past 24 hours. What is the total daily oral morphine equivalent (MME) and an appropriate 24-hour IV morphine infusion rate after a 25% reduction for incomplete cross-tolerance when rotating to IV morphine?

A.MME 200 mg/day; IV morphine ~2 mg/h

B.MME 120 mg/day; IV morphine ~1 mg/h

C.MME 200 mg/day; IV morphine ~8 mg/h

D.MME 80 mg/day; IV morphine ~3 mg/h

Explanation: Total daily PO morphine = 120 + 80 = 200 mg PO. PO:IV morphine ratio = 3:1, so 200 mg PO = ~66 mg IV/24 h. Reduce 25% for incomplete cross-tolerance when rotating routes in an uncontrolled pain scenario where tolerance may be incomplete = ~50 mg IV/24 h = ~2 mg/h basal. Exam Tip: IM hospitalists running IV opioid conversions must convert total 24-hour PO MME first, then apply route conversion (3:1 PO:IV for morphine), then apply a 25-50% reduction for cross-tolerance.

2A 71-year-old woman on the medicine service with advanced cancer is on scheduled oxycodone 15 mg PO Q4H (90 mg/day) with good pain control but intolerable nausea. You rotate to oral hydromorphone with a 25-50% reduction for incomplete cross-tolerance. Using standard equianalgesic dosing, what is the most appropriate starting daily dose of oral hydromorphone?

A.Hydromorphone 7.5 mg/day (1 mg Q4H)

B.Hydromorphone 17-25 mg/day (~3-4 mg Q4H)

C.Hydromorphone 45 mg/day (7.5 mg Q4H)

D.Hydromorphone 3 mg/day (0.5 mg Q4H)

Explanation: Equianalgesic: morphine 30 mg PO = oxycodone 20 mg PO = hydromorphone 7.5 mg PO. So 90 mg oxycodone/day = 135 mg morphine PO/day = ~34 mg hydromorphone PO/day. Reduce 25-50% for incomplete cross-tolerance = ~17-25 mg/day hydromorphone (roughly 3-4 mg Q4H). Exam Tip: Memorize PO morphine 30 = oxycodone 20 = hydromorphone 7.5 = IV morphine 10 = IV hydromorphone 1.5, and always reduce 25-50% when rotating to a different opioid.

3According to the WHO analgesic ladder, which medication class is appropriate for Step 1 (mild pain)?

A.Strong opioids such as morphine or hydromorphone

B.Weak opioids such as codeine or tramadol

C.Non-opioid analgesics such as acetaminophen or NSAIDs, with or without adjuvants

D.TCAs or gabapentinoids alone

Explanation: WHO ladder: Step 1 = non-opioids (acetaminophen, NSAIDs) +/- adjuvants for mild pain; Step 2 = weak opioids (codeine, tramadol, low-dose hydrocodone); Step 3 = strong opioids (morphine, oxycodone, hydromorphone, fentanyl). Adjuvants added at any step. Exam Tip: In severe cancer pain, current practice often skips Step 2 and moves directly to low-dose strong opioids.

4An internal medicine hospitalist cares for a 63-year-old woman with advanced lung cancer on morphine ER 60 mg PO Q12H (total daily dose 120 mg PO). What is the appropriate morphine immediate-release (IR) breakthrough dose?

A.Morphine IR 5 mg PO Q4H PRN

B.Morphine IR 60 mg PO Q4H PRN

C.Morphine IR 12-24 mg PO Q1H PRN

D.Morphine IR 1-2 mg PO Q1H PRN

Explanation: Breakthrough dose = 10-20% of total 24-hour opioid dose, offered Q1H PO PRN (or Q15-30 min parenteral). 120 mg × 10-20% = 12-24 mg. Oral morphine IR peaks at ~60 min, so Q1H dosing matches PK. Exam Tip: A breakthrough dose of 5 mg Q4H is under-dosed for a patient on 120 mg PO morphine/day.

5A 79-year-old woman admitted to the hospital with advanced Alzheimer dementia is nonverbal and appears restless with grimacing during repositioning. Which pain assessment tool is most appropriate?

A.PAINAD (Pain Assessment in Advanced Dementia)

B.Numeric Rating Scale

C.Brief Pain Inventory

D.McGill Pain Questionnaire

Explanation: PAINAD is a 5-item observational scale (breathing, negative vocalization, facial expression, body language, consolability), scored 0-10, validated for nonverbal patients with advanced dementia. NRS, BPI, and McGill require reliable self-report. Exam Tip: FLACC for infants/unresponsive adults; PAINAD for dementia; CPOT/BPS in ICU.

6A 55-year-old woman with metastatic pancreatic cancer develops burning, lancinating leg pain consistent with neuropathic pain. She is already on controlled-release opioids. Which adjuvant has the strongest evidence for first-line use?

A.Ibuprofen

B.Gabapentin

C.Acetaminophen

D.Methocarbamol

Explanation: First-line adjuvants for neuropathic pain: gabapentinoids (gabapentin, pregabalin), SNRIs (duloxetine), TCAs (nortriptyline, amitriptyline). NSAIDs and acetaminophen alone are ineffective. Exam Tip: Duloxetine and pregabalin have FDA approval for diabetic neuropathy; gabapentin, pregabalin, and topical lidocaine/capsaicin are first-line for postherpetic neuralgia.

7A hospitalist cares for an inpatient on long-term oral opioids with severe constipation despite senna and docusate. Work-up shows no obstruction. Which agent specifically targets the peripheral mu-opioid receptor to reverse OIC without reversing analgesia?

A.Magnesium citrate

B.Methylnaltrexone

C.Lactulose

D.Bisacodyl

Explanation: Methylnaltrexone (and oral naldemedine, naloxegol) are PAMORAs — peripherally acting mu-opioid receptor antagonists that don't cross the blood-brain barrier, so they reverse OIC without blocking analgesia or precipitating withdrawal. Exam Tip: Constipation is universal with opioids with NO tolerance — always prescribe senna prophylactically; reserve PAMORAs for refractory OIC.

8A 72-year-old man with end-stage COPD (FEV1 20% predicted) admitted to the medicine service reports severe dyspnea at rest despite maximal bronchodilators, steroids, and supplemental O2 (SpO2 96%). Which pharmacologic intervention has the strongest evidence for refractory dyspnea?

A.High-dose IV furosemide

B.Low-dose systemic opioids

C.Sublingual nitroglycerin

D.Nebulized albuterol around-the-clock

Explanation: Low-dose systemic opioids (oral or parenteral morphine 2.5-5 mg, or equivalent) are first-line for refractory dyspnea (Level 1 evidence). They reduce perception of breathlessness without clinically significant respiratory depression at palliative doses. Benzodiazepines added only when anxiety is prominent. Nebulized opioids are NOT recommended. Exam Tip: Supplemental O2 helps dyspnea only if hypoxemic; bedside fan is a useful non-pharmacologic adjunct.

9An inpatient with advanced cancer develops hyperactive delirium with agitation, hallucinations, and combativeness on the oncology floor. After addressing reversible causes, which first-line pharmacologic agent is most appropriate?

A.Lorazepam

B.Haloperidol 0.5-2 mg PO/IV/SC Q4-6H

C.Diphenhydramine

D.Morphine

Explanation: Haloperidol is first-line for hyperactive delirium (0.5-2 mg PO/IV/SC Q4-6H). Atypicals (risperidone, olanzapine, quetiapine) are alternatives. Benzodiazepines worsen delirium (except in alcohol/benzo withdrawal or refractory terminal delirium). Diphenhydramine is strongly anticholinergic and worsens delirium. Exam Tip: Search aggressively for reversible causes (UTI, constipation, hypoxia, dehydration, medications, pain) before labeling as terminal.

10A hospitalized patient with advanced cancer reports chronic nausea attributed to chemoreceptor trigger zone (CTZ) mechanisms (opioid-induced, metabolic). Which antiemetic is best first-line?

A.Haloperidol

B.Lorazepam

C.Dexamethasone

D.Promethazine

Explanation: Haloperidol is a potent D2 antagonist at the CTZ — highly effective for opioid-induced and metabolic (uremia, hypercalcemia) nausea at low doses (0.5-2 mg). Mechanism-based antiemetic selection: CTZ (dopamine) = haloperidol; vestibular = meclizine/scopolamine; gastric stasis = metoclopramide; chemo/radiation = 5HT3 antagonists (ondansetron); raised ICP = dexamethasone; bowel obstruction = anticholinergic (glycopyrrolate) +/- octreotide; multi-mechanism = olanzapine. Exam Tip: Match antiemetic to mechanism — high-yield.

About the ABIM Palliative Care Exam

The ABIM Hospice and Palliative Medicine (HPM) subspecialty certification recognizes internists with specialized expertise in inpatient and outpatient serious-illness care, pain and symptom management, goals-of-care communication, ethics, and end-of-life care. Since 2014, eligibility requires completion of a 12-month ACGME-accredited HPM fellowship. The exam is the same single comprehensive examination used by all 10 cosponsoring ABMS boards (ABIM, ABFM, ABA, ABEM, ABPMR, ABPN, ABOG, ABP, ABR, ABS) and is administered by ABIM on behalf of the entire consortium. IM candidates register through the ABIM Physician Portal.

Questions

220 scored questions

Time Limit

1-day computer-based exam (approximately 10 hours on-site)

Passing Score

Criterion-referenced scaled score (pass/fail)

Exam Fee

~$2,990 ABIM application + exam fee (American Board of Internal Medicine (ABIM) — administers on behalf of 10 cosponsoring ABMS boards)

ABIM Palliative Care Exam Content Outline

25%

Pain Assessment and Management

WHO analgesic ladder, opioid pharmacology and rotation, equianalgesic dosing (morphine 30 PO = oxycodone 20 = hydromorphone 7.5 = IV morphine 10 = fentanyl patch 25 mcg/h ~60 MME/day), breakthrough pain (10-20% TDD), neuropathic adjuvants (gabapentin, pregabalin, duloxetine, TCAs), methadone (non-linear, NMDA antagonism, QTc), PAMORAs for OIC, intrathecal therapy for refractory pain

25%

Non-Pain Symptom Management

Dyspnea (low-dose opioids first-line, fan, O2 if hypoxemic), nausea by mechanism (haloperidol CTZ, 5HT3 chemo, metoclopramide gastric stasis, dexamethasone ICP/MBO, scopolamine secretions, olanzapine multi-mechanism), delirium (haloperidol, avoid benzos), anorexia-cachexia, terminal secretions, pruritus

15%

Psychosocial, Spiritual, Cultural

Total pain (Cicely Saunders), depression vs demoralization, anticipatory grief, FICA/HOPE, bereavement (13-month Medicare benefit), prolonged grief DSM-5-TR, pediatric HPM, cultural humility

15%

Communication and Advance Care Planning

SPIKES, REMAP, NURSE statements, Ask-Tell-Ask, goals-of-care family meetings, POLST/MOLST, Five Wishes, DNR, surrogate decision-making hierarchy, Serious Illness Conversation Guide (Bernacki/Ariadne)

10%

Ethical and Legal Issues

Capacity (Appelbaum & Grisso 4 elements — understand/appreciate/reason/express), withholding = withdrawing, artificial nutrition in dementia, palliative sedation vs euthanasia, double effect, PAD/MAID (state-law dependent), terminal weaning, AICD deactivation, time-limited trials

10%

Prognostication and Hospice Eligibility

PPS, Karnofsky, FAST 7A-7D, NYHA IV + EF <20% for CHF, FEV1 <30% for COPD, MELD-Na for ESLD, PaP/PPI scores, Medicare Hospice Benefit (≤6-mo prognosis, routine/respite/continuous/GIP levels), pediatric concurrent care (ACA §2302), Medicare Advantage VBID hospice carve-in

How to Pass the ABIM Palliative Care Exam

What You Need to Know

Passing score: Criterion-referenced scaled score (pass/fail)
Exam length: 220 questions
Time limit: 1-day computer-based exam (approximately 10 hours on-site)
Exam fee: ~$2,990 ABIM application + exam fee

Keys to Passing

Complete 500+ practice questions
Score 80%+ consistently before scheduling
Focus on highest-weighted sections
Use our AI tutor for tough concepts

ABIM Palliative Care Study Tips from Top Performers

1Memorize equianalgesic conversions cold: morphine 30 mg PO = oxycodone 20 mg PO = hydromorphone 7.5 mg PO = IV morphine 10 mg = IV hydromorphone 1.5 mg, and fentanyl 25 mcg/h transdermal patch approximates 60 MME/day oral morphine. Reduce by 25-50% for incomplete cross-tolerance when rotating; methadone conversion is NON-linear and requires larger reductions with specialist guidance (typical start 2.5 mg TID)

2Breakthrough pain dose = 10-20% of total 24-hour opioid dose offered Q1H PO PRN (or Q15-30 min parenteral). Know how to calculate quickly from any baseline regimen, including transdermal fentanyl and PCA regimens — critical for hospitalist IV-to-PO transitions

3For opioid-induced constipation, prescribe a stimulant laxative (senna) prophylactically with every opioid; escalate to methylnaltrexone, naldemedine, or naloxegol (PAMORAs) for refractory OIC — these don't cross the BBB and don't reverse analgesia

4Advanced dementia and feeding tubes: PEG feeding does NOT prolong life, prevent aspiration, or improve pressure ulcers. Hand (comfort) feeding is preferred and aligns with goals of care — this is an AGS Choosing Wisely high-yield fact

5Know the Medicare Hospice Benefit cold: ≤6-month prognosis if disease runs usual course, initial certification by 2 physicians (attending + hospice medical director), 4 levels of care (routine home, respite up to 5 days, continuous home care, general inpatient/GIP), election waives curative coverage for the terminal dx, 13-month bereavement for family, pediatric concurrent care under ACA §2302, and Medicare Advantage VBID hospice carve-in expansion

Frequently Asked Questions

What is the ABIM Hospice and Palliative Medicine certification?

ABIM HPM is one of the internal medicine subspecialty certifications. It is offered through ABIM as one of 10 cosponsoring ABMS boards (ABIM, ABFM, ABA, ABEM, ABPMR, ABPN, ABOG, ABP, ABR, ABS). A single shared comprehensive examination is written by representatives from all 10 boards and is administered by ABIM on behalf of the entire consortium. It tests expert-level knowledge in pain and non-pain symptom management, communication, ethics, psychosocial and spiritual care, and prognostication. Internal medicine candidates register through the ABIM Physician Portal under the internal medicine subspecialty pathway.

Who is eligible to take the ABIM HPM exam?

Candidates must continuously maintain ABIM primary certification in Internal Medicine (or an IM subspecialty), hold a valid unrestricted US medical license, and — since 2014 — have completed a 12-month ACGME-accredited Hospice and Palliative Medicine fellowship. The fellowship program director must attest to clinical competence. Diplomates from the other 9 cosponsoring boards (ABFM, ABA, ABEM, ABPMR, ABPN, ABOG, ABP, ABR, ABS) sit for the same examination but register with their primary board.

What is the format of the ABIM HPM exam?

The ABIM HPM subspecialty exam is a comprehensive 1-day computer-based examination delivered at Pearson VUE test centers. It consists of up to 220 single-best-answer multiple-choice questions organized into timed modules with scheduled breaks (approximately 10 hours on-site including tutorial and breaks). A criterion-referenced (absolute) passing standard is applied — performance does not depend on other candidates.

How much does the ABIM HPM exam cost?

The ABIM application plus exam fee for the HPM subspecialty is approximately $2,990 (subject to change — check current ABIM fee schedule). Candidates must also continuously maintain their primary ABIM Internal Medicine certification (with its own MOC fees). Late registration fees apply after the regular deadline. Consortium boards set their own application fees for their diplomates.

What topics are on the ABIM HPM exam?

Content follows the shared ABMS/ABIM HPM blueprint: pain assessment and management (~25%), non-pain symptom management (~25%), psychosocial/spiritual/cultural care (~15%), communication and advance care planning (~15%), ethical and legal issues (~10%), and disease-specific palliative care and prognostication (~10%). IM candidates should emphasize inpatient symptom crises, family meetings, hospital-to-home transitions, ICU/MCS end-of-life scenarios, and 30-day readmission reduction.

How should I prepare for the ABIM HPM exam?

Start with a structured board-review course or textbook (Oxford Textbook of Palliative Medicine, UNIPAC from AAHPM, HPM PASS). Master equianalgesic conversions and opioid rotation cold — these appear heavily. Practice communication frameworks (SPIKES, REMAP, NURSE, Ask-Tell-Ask, Serious Illness Conversation Guide). Memorize hospice eligibility criteria, PPS, FAST 7A-7D, NYHA IV for CHF, FEV1 <30% for COPD, and the Medicare Hospice Benefit. Finish with a high-volume practice-question bank covering all 6 content domains with IM-hospitalist vignettes.

How is ABIM HPM certification maintained?

Diplomates maintain certification through ABIM continuous MOC — the Longitudinal Knowledge Assessment (LKA, ~30 open-book questions per quarter over 5-year cycles) or a traditional 10-year recertification exam. Underlying Internal Medicine certification must also remain active and in good standing. Letting IM certification lapse can invalidate the HPM subspecialty credential.

Is the ABIM HPM exam the same as the ABFM or ABA palliative exam?

Yes — a single, shared comprehensive examination is used by all 10 cosponsoring ABMS boards (ABIM, ABFM, ABA, ABEM, ABPMR, ABPN, ABOG, ABP, ABR, ABS). The exam is developed by representatives from all 10 boards and is administered by ABIM on behalf of the entire consortium. Candidates register through their primary board but sit for the same examination content regardless of primary specialty. This is why the ABIM HPM blueprint applies to all cosponsoring boards' candidates.