73. Palliative Care Flashcards
Describe : Principles of Palliative Care (9)
- Affirms life and regards dying as a normal process
- Neither hastens nor postpones death
- Provides relief from pain and other distressing symptoms
- Integrates the spiritual, cultural, psychosocial aspects of care
- Ask patients about meaning of symptom/burden
- Patient, family, caregivers are treated with dignity and respect
- Patient, family, caregivers are supported in bereavement
- Offers a support system to help patients live as actively as possible until death
- Offers a support system to help patients’ families cope during the patient’s illness and in their own bereavement
Describe management of Massive Hemorrhage in palliative care
- Anticipation (head and neck tumors - carotid, lung, GI, hematological)
- Prepare the entourage
- Major distress order (see below)
- Cover with dark blankets/towels
- Consider tranexamic acid
Describe management of dyspnea in palliative care (4)
- Position (turn, sit up, elevate head of bed)
- Air circulation (fan), oxygen PRN
- Manage cough, secretions, anxiety (relaxation therapy)
- Opioids (eg. morphine 1mg PO), benzodiazepines, bronchodilators
Describe management of pain in palliative care (4)
- Total Pain (physical, psychological, social, spiritual)
- Non-Pharmacological
- Opioids (eg. morphine liquid or subcutaneously)
- Adjuvant: Acetaminophen, NSAIDs, steroids, bisphophonates, cannabinoids
- Interventional techniques (nerve block)
- Frequent reassessments
Name : Risk factors for difficult pain control (6)
- Rapid titration of opioids
- Addiction or chemical coping
- Psychiatric
- Incidental
- Delirium
- Neuropathic pain (DN4)
Describe tx : Neuropathic pain
- Gabapentinoids
- TCA
- SNRI
- opioids
- cannabinoids
- methadone
- Topical lidocaine, capsaicin
Name Non-Pharmacological management for pain (6)
- Massage / Physical therapy
- Pet therapy
- Acupuncture
- Relaxation / Hypnotherapy
- Aromatherapy / Music therapy
- Heat/Cold
Name side effets : Opoids (5)
- constipation [no tolerance]
- nausea
- sedation
- urinary retention
- neurotoxicity
Describe Neurotoxicity of opioids
increased opioids, no improvement, hyperesthesia or hyperalgesia, tactile hallucinations, allodynia, myoclonus, seizures, delirium
Describe : Fentanyl patch
- (Fentanyl transdermal = 200:1 morphine PO)
- Half-dose if cover skin with tegaderm underneath (do not cut)
- 12h before onset and 12h coverage after removal
- Consider inhaled ICS sprayed on patch for irritation
Describe management of constipation in palliative care (5)
- Scheduled toileting, sitting position
- Exercise/mobility
- Hydration
- Laxatives : (1) Osmotic (PEG), (2) Stimulant (senna, bisacodyl), (3) Surfactant/Lubricating (docusate, glycerine suppository)
- Warm water enema
Describe management of diarrhea in palliative care (3)
- Rehydration, electrolyte correction
- Hold laxatives
- Consider psyllium, loperamide, opioid
Describe management of no-vo in palliative care (3)
- Treat reversible causes
- Non-pharmacological management
- Pharmacological
Name reversable causes of no-vo (5)
- Severe pain, Cough, Infection, Hypercalcemia, Tense ascites, Raised ICP, Anxiety
- Drug-induced or metabolic
- Constipation / Intestinal obstruction
- Gastritis
- Oral candidiasis
Describe tx of Drug-induced or metabolic no-vo (6)
- Opioid rotation
- Haloperidol
- Metoclopramide
- Cyclizine
- Hyoscine hydrobromide
- Ondansetron
Name Non-pharmacological management of no-vo ()
- Cut out intolerant foods
- Control malodour
- Restrict intake (sips, ice chips, then gradually fluids to solids)
- Small frequent meals
- Cool fizzy drinks
- Avoid lying flat after eating
- Acupuncture/acupressure, ginger, relaxation, hypnosis, music therapy
Name pharmacological management of no-vo (6)
- Prokinetic (metoclopramide)
- 5HT3 antagonists (ondansetron)
- Antihistamine (dimenhydramine)
- Anticholinergics (scopolamine)
- Antipsychotics (Haloperidol 0.5mg SC q6-8h PRN, chlorpromazine, olanzapine)
- Cannabinoids
Describe management of Anorexia/Cachexia in palliative care (4)
- Rule out contributing causes (N/V, anxiety, pain, stool)
- Encourage favorite foods
- Small frequent meals
- Medical management:
Describe MEDICAL management of Anorexia/Cachexia in palliative care (4)
- Steroids (eg. dexamethasone 4mg PO BID at breakfast, and lunch), rapid onset but short-lasting (weeks)
- Progesterone (megestrol acetate), slow-onset 2-3 weeks for effect
- Prokinetic (metoclopramide) if early satiety
- Mirtazapine
Describe management of Asthenia/Fatigue in palliative care (4)
- Coordinate activities/help
- Change medications
- Sleep
- Medical management: Steroids. Methamphetamines
Describe management of Noisy respiratory secretions
in palliative care (3)
- Turn head to side
- Avoid deep suctioning
- Medical management : Glycopyrrolate, Scopolamine Atropine ophtalmic drops
Describe management of Confusion/delirium
in palliative care (3)
- Haloperidol PRN
- Methotrimeprazine PRN
- Midazolam PRN
Describe management of DEPRESSION
in palliative care (3)
- Psychotherapy
- Methylphenidate in short-term
- Consider SSRI if >4w
Describe management of ANXIETY
in palliative care (2)
- Hypnosis
- Benzodiazepines (lorazepam 1mg SL/SC q6h PRN)
Describe management of SOCIAL
in palliative care (3)
- Guardianship
- Wills
- Finances
Describe management of SPIRITUAL
in palliative care (3)
- Personal values : “Are spirituality or religion important in your life?”, “Are you at peace?”
- Relationships
- Meaning of life/death : “Why me?”, “What’s after death?”
Describe : Advance Care Planning and Goals of Care (7)
- Breaking Bad News
- Prognostication PPS
- Hopes and Fears
- Mandate
- Goals of Care : Treatments, resuscitation (CPR, intubation, ICU), antibiotics, PEG/NG feeding, palliative sedation
- Home vs. hospital vs. hospice
- Medical Aid in Dying
How to Prepare family for end of life (4)
- Progressive unresponsiveness
- Purposeless movements, facial expressions
- Noisy breathing
- Possible acute events and action plan (seizure, stroke)
How to confirm and document Pronouncement of Death (7)
- Check ID bracelet
- No spontaneous respiration
- No response to tactile stimulation and pain (pressure on nailbed)
- Absent breath sounds, heart sounds
- Absent carotid pulse
- Fixed pupils, non-reactive to light
- Time of death
