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Therapeutics > End of life > Flashcards

End of life Flashcards

1
Q

dying

A
  • decline in body function -> death
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2
Q

death

A
  • final cessation of vital functions
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3
Q

brain death

A
  • irreversible cessation of brain stem
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4
Q

signs pt is actively dying

A
  • death rattle
  • jaw movement increases with breathing
  • cyanosis and skin mottling
  • no radial pulse
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5
Q

what is the death rattle

A
  • retention of fluids in pharynx and upper respiratory tract
  • causes audible breathing
  • keep bed at 45 degree angle to help
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6
Q

cheyne-stokes respirations

A
  • changes in breathing that occur right before death

- irregular breathing patterns

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7
Q

pain management treatment options

A
  • treat based on severity and type of pain
  • non-opioids: tylenol or NSAIDs
  • opioids
  • adjunct therapy- anti-convulsants, steroids, TCAs
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8
Q

what are examples of weak opioids

A
  • codeine
  • hydrocodone
  • oxycodone (oxycontin)
  • aka weak affinity for receptors
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9
Q

what are examples of strong opioids

A
  • morphine
  • hydromorphone (dilaudid)
  • fentanyl
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10
Q

how is fenatnyl absorbed as a patch

A
  • lipophilic so needs fat

- often dying pts have decreased fat so it is less likely to be absorbed and effective

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11
Q

how long is the half life of most opioids?

A
  • 3-4 hours with normal renal function
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12
Q

morphine considerations

A
  • dialyzes off

- will accumulate in renal failure -> neuroexcitation and CNS effects

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13
Q

hydromorphone considerations

A
  • inactive metabolites

- DOC in renal failure

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14
Q

methadone considerations

A
  • may cause QTc prolongation

- requires frequent EKG monitoring

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15
Q

possible causes of dyspnea

A
  • increased dead space or airway resistance
  • decreased lung compliance or hemodynamic abnormalities
  • airway obstructions
  • muscle weakness
  • cardiac issues, anemia
  • intraabdominal processes
  • psychological- anxiety
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16
Q

what should you educate pts and families about in terms of dyspnea?

A
  • changes in respiratory patterns may not equal dyspnea
  • drugs may remove perception of dyspnea but not alter breathing patterns
  • explain possible reasons for dyspnea
17
Q

treatment for dyspnea

A
  • oxygen- even if not hypoxic
  • opioids- esp morphine due to venodilation and sedation
  • BZDs/ anxiolytics
  • steroids
  • thoracentesis or paracentesis
  • palliative radiation
  • inhaled bronchodilators if bronchospasm
18
Q

non-pharm approaches for dyspnea

A
  • avoid exacerbating activities
  • reduce temp and maintain humidity
  • window/ bring pt outside
  • avoid irritants
  • elevate head of bed
  • relaxation therapies
19
Q

opioids and dyspnea

A
  • most effective if stead state blood levels
  • causes suppression of respiratory drive with peaks and valleys
  • if pt is on opioid for pain then dev dyspnea increase dose by 25-50%
20
Q

nausea

A
  • stimulation of GI lining, chemoreceptor trigger zone in 4th ventricle, vestibular apparatus, or cerebral cortex
  • cerebral cortex= learned response
21
Q

vomiting

A
  • neuromuscular reflex centered in medulla oblongata
22
Q

mediators of N/V

A
  • serotonin
  • dopamine
  • acetylcholine
  • histamine
23
Q

pharmacologic treatment for N/V

A
  • dopamine antagonists
  • histamine antagonists
  • serotonin antagonists
  • prokinetic agents
  • antacids- tums
  • steroids
  • cannabinoids
  • BZDs- for anticipatory nauesa
24
Q

examples of dopamine antagonists

A
  • pramipexole dihydrochloride

- ropinole

25
Q

examples of histamine antagonists

A
  • diphenhydramine

- meclizine

26
Q

examples of serotonin antagonists

A
  • zofran
27
Q

examples of prokinetic agents

A
  • metoclopramide

- good for paralytic ileus

28
Q

causes of constipation

A
  • drugs* esp opioids
  • metabolic
  • diet
  • decreased motility
  • SC compression
  • mechanical obstruction
  • dehydration
  • autonomic dysfunction
  • ileus
  • treating cause in advanced stages might not always be appropriate
29
Q

nonpharm treatment options for constipation

A
  • scheduled toileting
  • position to sit upright
  • fluids
  • avoid bulking agents- might precipitate obstruction
30
Q

pharm treatment options for constipation

A
  • stimulant or osmotic laxatives
  • detergent laxatives (stool softener)
  • enemas
  • opioid antagonists- methylnaltrexone
31
Q

terminal delirium

A
  • common near end of life esp in geriatrics or hospitalized pts
  • can be reversible
  • spiritual and emotional needs of pt must be addressed
32
Q

si/sx of terminal delirium

A
  • agitation/ irritability
  • impaired consciousness
  • myoclonic jerks or twitching
  • hallucinations, paranoia
  • confusion and disorientation
33
Q

causes of terminal delirium

A
  • opioid toxicity
  • pain-> agitation
  • drug interactions- esp hypnotics, antimuscarinics, and anticonvulsants
  • fever or sepsis
  • hypercalcemia-> confusion and agitation in cancer pts
  • increased ICP -> agitation
  • may be imbalance between acetylcholine and dopamine
34
Q

nonpharm treatment options of terminal delirium

A
  • create familiar environment
  • reassure pt/ family
  • give permission to let go
  • use touch/ soothing touch
  • maintain sleep- wake cycles
35
Q

pharm treatment options for terminal delirium

A
  • BZD- may make things worse
  • neuroleptics- haldol, chlorpromazine
  • treat seizures
36
Q

anorexia

A
  • inflammatory process -> loss of fat and muscle
  • common in advanced illness
  • often see with asthenia
  • increased nutrition doesnt reverse/ improve cachexia or stop disease process
37
Q

anorexia treatement

A
  • search for and treat specific causes i.e. nausea, emesis, pain
  • if no specific etiology ID then consider pt QOL and try to balance normalcy in daily living
  • educate that it is normal to not feel hunger/ thirst
  • pharm options- steroids, progesterone drugs, mirtazapine, and androgen

Therapeutics (5 decks)

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