2 Palliative care, part 2 (Tintinalli)

Question 1

Functional decline is defined as

Answer 1

the loss oft the ability to care for oneself
the loss of activities of daily living is the cardinal feature of decline, especially if accompanied by unintentional weight loss, and it indicates the need for increased care assistance and suggests a short life expectancy

Question 2

Elements of the Palliative Prognostic Score include

Answer 2

Ability to
1. Ambulate
2. Provide self-care
3. Maintain oral intake
4. and level of consciousness
A bed-bound patient completely dependent for all care with reduced oral intake and a diminished level of consciousness has a Palliative PRognostic Score of 10% and a 1-week median expected survival

Question 3

If no one is available to speak for the patient, then…

Answer 3

the treating physician should act in the patient’s best interest.
This may include an order to “do not resuscitate” the patient if it is clear that aggressive therapy would not be beneficial

Question 4

The emergency physician should be adept in communicating these to the patient/surrogate

Answer 4

1. Determining patient decisionmaking capacity
2. Quality of life
3. Prognosis
4. Talking with surrogate decision makers
5. Discussing palliative care or hospice referral
6. Breaking bad news - death pronouncement

Question 5

Remarks on opioid dosing

Answer 5

1. Opioid dosing is an essential skill in the practice of emergency medicine
2. The safety of patient-controlled analgesic devices is predicated on the concept of progression of respiratory depression from sedation.
3. IV opiates reach maximum therapeutic levels and have peak effects or side effects at 6 to 10 minutes.
4. Therefore, IV pain mediacations can be safely redosed every 15 minutes until relief as long as level of consciousness is monitored

Question 6

A commonly seen side effect of opiates

Answer 6

Constipation
Patients prescribed with opiates need a concurrent bowel regimen such as an osmotic agent (i.e., polyethylene glycol) or stimulant laxatives

Question 7

Referrals to hospice care also can be made for patients with clearly expresssed prior wishes for comfort care should they sustain a catastrophic acute illness, such as:

Answer 7

intracranial bleed
infarcted bowel
devastating neurotrauma
renal failure in the presence of advanced heart failure, leading to multiorgan failure

Question 8

Remarks on delirium therapy in imminent death

Answer 8

Delirium therapy can be directed to underlying cause (pain, fever), or
If known or reversible, treated with 0.5- to 5-mg doses ofIV haloperidol.
A total dose of 5 mg can produce a calming effect on a patient and, by extension, his or her family

Question 9

Remarks on the goal of opiate therapy

Answer 9

The goal of opiate therapy is not intended to artifically hasten death but to ensure comfort.
There is firm ethical support for providing medicaiotn expresssly with a goal of comfort even if there is potential for unintentional double effect.

Question 10

the 3 most common scenarios where hospice patients may be directed to the ED

Answer 10

1. Acute symptom crisis
2. A health concern unrelated to the hospice diagnosis
3. Revoked and signed out of hospice

Question 11

Burn patient that may benefit from palliative care

Answer 11

When age plus percent burn exceeds or nears 140