End of Life Care Flashcards
What is MAID not the same as?
palliative care
palliative sedation
-ongoing sedation until natural death
-use of medications to reduce consciousness
withholding or withdrawing life-sustaining or life-prolonging treatment
How are MAID requests handled in Saskatchewan?
through the provincial MAID program
-prescriptions for MAID are filled by hospital pharmacies
Can a pharmacist decline to participate in MAID?
yes
-a pharmacist or tech may decline to participate in MAID for reasons of conscience or religion
-express objection to MD or NP instead of patient
-if not able to assists, must provide an effective referral
What are the limitations of the scope of the pharmacist in MAID?
no participation in MAID unless contacted by MD or NP
we can provide education about MAID but must not imply leading the process
-refer to someone who can
we do not assess a patient for eligibility
we do not collect consent for MAID
we do not prescribe or administer drugs for MAID
we do not prescribe drugs for “office use”
What is the role of a pharmacy technician in MAID?
activities performed by the pharmacy technician as part of the dispensing process must be done with a pharmacist present
-legal risk: the amendments needed to protect everyone involved are extensive and they be could be open to prosecution
Describe a good process to take with MAID prescriptions.
MAID or non-MAID? if unsure, call MAID program
-if the purpose is for MAID it must be written
-if for MAID, you cannot dispense from a community pharmacy
-if not, (i.e. ondansetron for nausea), you can dispense from a community pharmacy
Where are MAID prescriptions dispensed?
hospital pharmacy
-can only dispense to MD or NP (NOT the patient)
How does palliative care address patient needs?
addresses the patients needs in the physical, psychological, social, and spiritual domains via:
-communication around goals of care
-symptom management
-practical support for patient and family needs
What are the elements of good palliative care?
patient and family-centered
strives for the best possible QoL
an active approach to symptom management
affirms life and regards dying as part of the normal process of living
does not attempt to hasten nor postpone death
uses a team approach to address the needs of the patient and their families
offers a support system to help the family cope
is offered early in course of illness, in conjunction with therapies intended to prolong life
Who is palliative care not exclusively meant for?
is NOT meant exclusively for individuals who are imminently dying and not exclusively for cancer patients
Who is palliative care appropriate for?
any patient with a chronic, life-limiting illness who is experiencing symptoms related to their illness or treatment
-e.g. renal dialysis, oxygen therapy, cancer chemotherapy
-includes patients still receiving treatment intended to prolong life
unfortunately access to specialized palliative care teams and services may be reserved for individuals with advanced terminal illness
What are some examples of palliative conditions?
cancer
progressive/advanced organ failure (ex: HF, COPD, ESRD)
advanced neurodegenerative disease (ex: dementia, Parkinsons)
sudden onset of a serious medical condition (ex: serious infection, MI/stroke, bowel obstruction)
What do individuals recieving palliative care report?
greater satisfaction with symptom management and care received
Where would most Canadians prefer to die?
at home
What is the goal of palliative care?
limit physical and emotional suffering by adequately managing pain and other symptoms
support the ability to enjoy remaining life while avoiding inappropriate prolongation of death
What does the goal of palliative care look like from a pharmacist perspective?
stopping non-essential drugs
ensure ongoing administration of essential drugs
-management of symptoms
-appropriate route of admin
What plays a big role in symptom control at the end of life?
drug therapy
Who is palliative drug coverage an option for in SK?
individuals with a life expectancy measured in months, for whom curative or life-prolonging treatment is not an option
-form must be completed by physician and submitted to SPDP
-100% coverage for Rx and adjunctive OTC
-may also cover dietary supplements as required
What are the most commonly used drugs in the last year of life in the palliative setting?
opioids
corticosteroids
reflux drugs
propulsives
anxiolytics
What is the goal of palliative pain management?
comfort
Which types of pain are most common in the palliative setting?
nociceptive & neuropathic
How is palliative pain primarily managed?
opioids
How are opioids scheduled in the palliative pain setting?
around the clock plus breakthrough
Which route of admin is preferred for pain management in the palliative setting?
oral route when possible
What is the preferred parenteral route of administration in the palliative setting?
subcutaneous
What is the onset of subcutaneous analgesics?
15-30 minutes
What are the advantages of the subcutaneous route?
less equipment vs IV
may be administered by patient or family member
absorption is slower than IV, but complete
What are the disadvantages of the subcutaneous route?
potential discomfort
local tissue irritation
limited volume for injection (5 mL maximum)
requires one subcut line per medication
What is the role of the WHO analgesic ladder in the palliative setting?
often ignored and we start with opioids
What is often the preferred analgesic in the palliative setting?
hydromorphone
-higher potency vs morphine (5:1)
-no active metabolite
-low induction of histamine release vs morphine
Which opioid is quite high in potency?
fentanyl
What is the role of injectable fentanyl?
SC or buccally for relief of incident pain
What is the onset and duration of injectable fentanyl?
onset ~ 10 min
lasts ~ 1 hour
What is the role of the fentanyl patch?
stable, chronic pain
not suitable for patients requiring opioid titration
What are the side effects we should be ready to manage with opioids?
nausea and vomiting
constipation
sedation
delirium/confusion/hallucinations
pruritis
dry mouth
urinary retention
respiratory depression
myoclonus
hyperalgesia & allodynia
Describe how to manage sedation induced by opioids.
tolerance develops ~ 2-4 days
may occur when initiating or increasing dose
if persistent, decrease dose or switch to another opioid
palliative care: can use psychostimulant (MPH)
Describe how to manage delirium/confusion/hallucinations induced by opioids.
usually resolves within 3-4 days
management:
-avoid increasing opioid until resolved
-rule out other causes
-palliative care: haloperidol po/subcut
Describe how to manage pruritis induced by opioids.
if persistent, reduce dose, switch to another opioid or pre-treat with anithistamine
-DPH po/subcut 15-30 min before opioid
-2nd gen antihistamine if can administer orally to avoid droswiness
What causes pruritis in the context of an opioid?
secondary to histamine release (not a true allergy)
Describe how to manage dry mouth induced by opioids.
may be exacerbated by other drugs
mouth care, ice chips, frequent sips
palliative care: pilocarpine (can use eye drops orally)
Describe how to manage urinary retention induced by opioids.
usually improves within one week
catheter in the meantime if complete retention
Which serious side effect of opioids is rare in the palliative setting?
respiratory depression
Describe how to manage respiratory depression induced by opioids.
if mild ( > 8 breaths/min):
-monitor patient closely
-hold further doses of opioids, BZD until resolved - then review/reduce
if severe ( < 8 breaths/min):
-naloxone
-monitor closely (opioids have a longer duration of action than naloxone)
What is myoclonus?
spontaneous jerking movement
Describe how to manage myoclonus induced by opioids.
if pain is controlled, reduce opioid dose
switch to another opioid
add a BZD
Differentiate hyperalgesia and allodynia.
hyperalgesia: exaggerated pain response
allodynia: pain evoked by a non-painful stimulus
Describe how to manage hyperalgesia & allodynia induced by opioids.
significantly reduce dose and/or switch to another opioid
-methadone
palliative care: may add a NMDA antagonist (ketamine) if severe
What are some adjuvant agents for pain?
anticonvulsants
antidepressant
dexamethasone
What is the role of dexamethasone for pain management in the palliative setting?
e.g. metastatic bone pain, neuropathic pain
-less mineralocorticoid activity
What are the causes of nausea and vomiting in palliative care?
often multifactorial:
-constipation
-medications (e.g. opioids, NSAIDs)
-reduced GI motility
-metastatic disease/obstruction
-metabolic changes (e.g. hypercalcemia, hyponatremia, uremia)
-increased intracranial pressure
-uncontrolled pain
-anxiety
-candidiasis
Describe the approach taken to NV in palliative care.
identify and correct likely cause(s)
optimize non-pharm strategies
select an antiemetic based on cause and appropriate route, reassess q2-3 days
-if patient vomits oral dose within 30 min, repeat the dose
-titrate the dose up or down as needed
-scheduled vs prn vs scheduled + prn
if nausea persists after 48h, add another agent with different MOA
anticipate need for antinauseants
proactively assess for and manage AE
Describe the non-pharm management of NV in the palliative setting.
cold food may be associated with less nausea
separating solid and liquid foods may decrease early satiety
offer preferred foods and textures, allow eating at own pace
dont pressure a person to eat or drink against their will
peppermint oil or ginger tea if patient finds soothing
cold, lightly carbonated beverages
What are the 1st line anti-nauseants in palliative care?
haloperidol
-fast onset, mild sedation
metoclopramide
-fast onset, prokinetic, mild sedation
What are the 2nd line anti-nauseants in palliative care?
methotrimeprazine
-broad spectrum receptor activity, more sedation
olanzapine
-if concurrent anxiety/mental distress
What are some “other” anti-nauseants seen in palliative care?
dexamethasone
-broad-spectrum anti-nauseant, unknown MOA
PPI
-lansoprazole or pantoprazole, add-on therapy may help provide relief regardless of cause
octreotide
-nausea associated with malignant bowel obstruction
What is dyspnea?
subjective experience of difficulty breathing or unsatisfactory breath
-may or may not be related to underlying pathology
-one of the most feared aspects of dying
What is the non-pharm management for dyspnea in palliative care?
provide ‘fresh air’ - open a window or direct a fan to face
oxygen if hypoxic
nebulized saline
reduce room temperature
use a humidifier if air is dry
plan rests around activities
What are the pharmacologic options for dyspnea in palliative care?
opioids - treatment of choice
if respiratory panic attacks - BZDs
if history of asthma or COPD - bronchodilators, steroids
What is the 1st line therapy for dyspnea in palliative care?
opioids
What is the MOA of opioids for dyspnea?
act on respiratory centre, reducing respiratory effort
central sedative effect, attenuating the ventilatory response
lower sensitivity to hypercapnia and hypoxemia
reduce oxygen consumption
diminish perception of dyspnea and anxiety
How are opioids dosed for dyspnea?
same principles as for palliative pain control
-i.e. scheduled and rescue doses, dosage increases, manage side effects
Which route is preferred for opioids when used for dyspnea?
oral or SC most common
What is seen with regards to severity and occurrence of dyspnea in the last hours of life?
occurrence & severity increases in last 48 h of life
actively dying patients can have altered breathing patterns
-unresponsive does not equal dyspnea
-reassure family that altered breathing is not distressing to the patient
What is a cognitive disturbance that is common at the end of life?
delirium
Which drug classes are used to treat delirium in palliative care?
antipsychotics and/or sedatives only as needed to calm agitation and relieve distress
-do not speed recovery from delirium
How is delirium managed in the palliative care setting?
look for and address underlying cause(s)
drug therapy if needed
-haloperidol 1st line
-if more sedation needed: methotrimeprazine, olanzapine, BZD
Which drugs warrant reassessment at the end of life?
hypoglycemics, diuretics, antihypertensives
-advanced illness: malnourished, hypotensive, dizzy, dehydrated
cardio-protective agents, vitamins/minerals, HRT, etc
Which drugs are considered essential at the end of life?
analgesics
antiemetics
anxiolytics
antipsychotics
sedatives
What is commonly seen in the last few days of life?
sleeping for longer and difficult to arouse
eat and drink less
difficulty swallowing
become restless or confused –> terminal restlessness
What is the rally?
close to ‘normal’ functioning within hours –> days of end
-1/3 patients
seeing loved ones or pets who have passed, speaking childhood languages, talk of ‘going home’
-respect their reality
What is commonly seen in the last hours of life?
unresponsive to touch/voices
develop wet or rattley-sounding breathing
irregular pulse or heartbeat
lose control of bladder or bowels
cool limbs
irregular or shallow breathing
Describe management of decreased appetite and fluid intake at the end of life.
key: natural part of dying process
most people do not experience hunger or thirst as death approaches
offer but do not force food or fluids
providing nutrition or fluids artificially may actually increase some distressing symptoms, such as respiratory congestion or NV
artificial hydration does not prevent thirst or relieve a dry mouth (mouth care more helpful)
What is respiratory congestion?
rattling, gurgling sound caused by accumulation of secretions in the airway
may be due to increased secretion production, decreased swallowing, decreased mucociliary clearance or ineffective cough reflex
What is often a signal that death is near?
respiratory congestion
-distressing to family; provide reassurance
Describe management of respiratory congestion at the end of life.
non-pharm:
-reposition head or lie patient on their side
-avoid/dc IV fluids
pharm:
-anticholinergics to dry up secretions
-must be started at first sign of resp cong, will not dry up secretions already present
-conscious: glycopyrrolate
-unconscious: atropine, scopolamine
How is terminal restlessness managed?
assess for other causes/contributors
meds may be necessary to relieve distress
-haloperidol 1st line
-if ineffective or more sedation needed, use BZD
What is palliative sedation?
use of sedating meds to relieve symptoms or reduce awareness when symptoms intractable to other measures and causing intolerable suffering
-when all possible treatment has failed
-may be appropriate in the final stage of illness
How does palliative sedation differ from MAID?
context very different from MAID
-MAID: patient must be alert and competent to access
-palliative sedation is usually implemented gradually and consent of substitute decision maker is sufficient
