End Of Life Care

Question 1

What percent of people know their life is ending? (as opposed to sudden death)

Answer 1

90%

Question 2

what is the preferred route of delivery of medications for people with end-stage diseases?

Answer 2

oral for as long as possible

Question 3

Describe the WHO 3-step pain ladder

Answer 3

step 1: mild pain - aspirin, NSAIDs, with adjuvants (like PPIs and H2 blockers to prevent peptic ulcers)

step 2: moderate pain - codeine, hydrocodone, oxycodone

step 3: severe pain - pure opioids with no ceiling effect - morphine, hydromorphone, methadone, fentanyl

Question 4

how do you treat breakthrough pain?

Answer 4

~10% of 24 hour dose of drug they’re already taking - every hour for oral, 30 min for SC/IM, and every 10-15 min for IV

Question 5

Most important side effect of opioids that occurs in almost all patients?

Answer 5

Constipation

Question 6

How are most opioids cleared?

Answer 6

liver conjugates codeine, morphine, and oxycodone into analgesic metabolites and 95% of opioids are excreted renally

Question 7

Which two opioids should NOT be given for chronic end of life care?

Answer 7

Meperidine - due to build up of non-analgesic metabolites that cause sig side effects

Mixed-opioid antagonists like butorphanol, nalbuphine - want pure ones!

Question 8

define tolerance. How is it different from physiological dependence?

Answer 8

tolerance is a normal physiological response where increasing doses are required to produce the same effect. Physiological dependence is defined by a withdrawal syndrome after an opioid is abruptly discontinued.

Question 9

A known drug addict with terminal cancer in pain shows drug seeking behaviors. Should you withhold medication to help them with their addiction problem?

Answer 9

NEVER withhold necessary dose to treat pain adequately. Even with drug-seekers, at end of life, if they want the drugs, give them the drugs.

Question 10

What drug can be used to treat opioid-induced vomiting?

Answer 10

metoclopramide (dopamine antagonist)

Question 11

Burning/tingling neuropathic pain is commonly treated with what?

Answer 11

TCAs (amitriptyline and imipramine) or Gabapentin

Question 12

Shooting/stabbing neuropathic pain is commonly treated with what? (3)

Answer 12

gabapentin, carbamazepine, valproate

Question 13

For complex neuropathic pain where opioids don’t help, name two alternative treatments.

Answer 13

Clonidine patch
corticosteroids - opioids cant treat inflammation (almost always used at end of life because almost everyone has some sort of inflammatory process)

Question 14

first line treatment for bone pain?

Answer 14

opioids

Question 15

Name 3 ways anorexia/cachexia can be dealt with in the terminally ill. Which one is best?

Answer 15

1. non-pharmacological - give them alllllll the tasty foods (best)
2. corticosteroids (dex)
3. cannabinoids (dronabinol - not as good as cannabis itself)

Question 16

What is the drug of choice for treating dyspnea associated with end of life care?

Answer 16

Morphine - weird, don’t know why it works since opioids are respiratory depressants

Question 17

What is the first way to treat fatigue/weakness for end of life care?

Answer 17

remove all drugs that dont matter like antihypertensives and diuretics

Question 18

Most patients at end of life experience hypotension and tachycardia. How is this managed?

Answer 18

No amount of IV fluids/salt can return intravascular volume to normal, so in last HOURS of life, remove fluids