End of Life Care (Exam 3 Cut Off) Flashcards
1
Q
Palliative Care
A
- Specialized medical care for people with serious illness that focuses on relief form pain, symptoms, and distress due to illness
- Can be provided at the same time as curative care
- Any age or stage of illness
2
Q
Hospice
A
- Type of care and a philosophy or care that focuses on palliation of a terminally ill patient’s symptoms
- All is palliative care but not vice versa
3
Q
Terminal Illness
A
Estimate survival of 6 months or less
4
Q
Supportive Care
A
- Extra layer of support
- Focuses on intensive family meetings and patient/family counseling
- Resolves questions and conflicts between family/patients and physicians on achievable goals of care
- Expertise in pain and symptom management
5
Q
Medicare Hospice Benefit
A
- Passed by Congress in 1982
- 4 criteria patients must meet to enroll
- Certification periods: eligible for two 90-day periods initially, re-certification every 60 days thereafter with terminally ill certification from physician
6
Q
Hospice Benefit Criteria
A
- Eligible for Medicare Part A
- Medicare approved hospice program
- Signed statement by patient choosing hospice care instead of “regular” Medicare
- Certification by physicians and hospice medical director of terminal illness
7
Q
Symptom Management Principles
A
- Frequent, standard assessment
- Oral meds when possible and altering routes when needed
- Assess for SE and anticipate/treat them as needed
- D/C meds no longer contributing to symptom control
- Address possible reversible contributing causes
8
Q
Approach to Symptom Management
A
- Identify potential causes of symptom
- May require history, physical exam, labs, etc.
- Treat underlying cause and symptom if possible
- Re-evaluate frequently
9
Q
N/V Assessment/Approach
A
- Self-report is gold standard for nausea
- Documentation of vomiting/retching and associated symptoms, triggers, durations, severity
- Monitor food intake, hydration status, and bowel movements
- Documentation of relief from medications
10
Q
Opioid-Induced Constipation
A
First Line Options
- Stimulant laxatives (Senna or Bisacodyl)
- Osmotic laxatives (Polyethylene glycol or Lactulose)
Additional PRN Agents
- Bisacodyl suppository
- Magnesium
- Evaluation for ileus
- Low/high impaction
NOT DOCUSATE - no proven benefit
11
Q
Malignant Bowel Obstruction
A
- Common with abdominal cancers
- Symptoms: N/V, pain, distention, constipation or liquid stools
12
Q
Malignant Bowel Obstruction Treatment
A
Treatment Goal: eliminate need for NG tube/IV hydration
-Palliative surgery
Medications
- Opioids and antiemetics for pain and N/V
- Anticholinergics/antimuscarinics for colic pain (glycopyrrolate or hyoscyamine)
- Octreotide
- Corticosteroids (dexamethasone)
13
Q
Dyspnea
A
- Discomfort in breathing - common symptom in advanced cancer or illnesses
- Evaluated by subjective responses
- Could be physical, chemical, or neurological in causation
14
Q
Dyspnea Non-Pharm Treatment
A
- Re-positioning
- Maintaining cool room temperatures
- Relaxation exercises
- Acupuncture
- Minimal exertion
15
Q
Dyspnea Pharm Treatment
A
- Oxygen for documented hypoxia
- Opioids - first line, morphine is most commonly used and nebulized route not shown to be superior, no optimal agent
- Anxiolytics: Benzos reserved for breakthrough or refractory dyspnea affected by anxiety or unable to titrate opioids
16
Q
Anorexia/Cachexia
A
- Anorexia: loss of appetite or inability to eat
- Cachexia: wasting regardless of calories intake
- Could be due to inflammation, constipation, late illnesses (cancer/HIV), or other causes
- Assess for possible contributing factors like pain, infection, nausea, depression, GI conditions, meds, etc
17
Q
Anorexia/Cachexia Non-Pharm
A
- Reassurance that syndrome is normal at end-of-life
- Diet modification for easier to swallow food and for frequent/smaller meals
- Artificial nutrition doesn’t prolong life and increases costs/morbidities (N/V, aspiration, congestion)
18
Q
Anorexia/Cachexia Pharm Treatment
A
Unlikely to prolong life but could improve QoL
- Megesterol - improves appetite (better in advanced cancer) but can cause VTEs and suppress the HPA axis
- Corticosteroids: increase appetite/food intake but can effect GI and adrenal systems
- Dronabinol (sativa): used for AIDS anorexia but can cause CNS effects
19
Q
CBD
A
- Can improve appetite/food intake
- Also has receptors that effect emotion, movement, mood, and pain perception
- Approved use for several disease states in NM
20
Q
Delirium
A
- Most common neuropsychiatric complication in advanced cancer patients
- Disturbances in attention and awareness that aren’t explain by preexisting conditions
- Can be medication induced, infections, impaction/retention/dehydration, metabolic disorders, brain tumors or disorders
21
Q
Delirium Symptoms
A
- Agitation
- Restlessness
- Altered perception
- Difficulty forming thoughts and incoherent speech
- Disorientation to time, place, person
- Sleep disturbances and nightmares
- Sundowning
- Changes in consciousness level
22
Q
Delirium Non-Pharm Treatment
A
- Calm environment, music, aromatherapy, spiritual counselor
- Identify reversible causes (meds, constipation, etc.)
23
Q
Delirium Pharm Treatment
A
- Antipsychotics are first line, most evidence for haloperidol and chlorpromazine (low doses PRN) - possible anticholinergic SE
- Benzos are helpful for sedation when agitation is prominent and antipsychotics aren’t sufficient
24
Q
Anticholinergic Causing Drugs
A
- Oxybutynin
- Benztropine
- Scopolamine
- Diphenoxylate
- Hyoscyamine
- Atropine
- Ipratropium
- Diphenhydramine
- TCA
- Chlorpromazine
- Prochlorperazine
- Promethazine
- Cyclobenzaprine
25
Q
Anticholinergic Management
A
- Assess risk vs benefit before adding agent
- Choose alternative med when possible
- Consider non-drug therapy when possible
- Use lowest, effective dose for the shortest duration
26
Q
Dysphagia
A
- Can be associated with odynophagia or aspiration
- Oral route fails in ~7-% of patients at end-of-life
- Consider most appropriate non-oral route since IV isn’t practical for home hospice patients
27
Q
Secretions
A
- Respiratory secretions common in last days of life esp with pulmonary malignancies and brain tumors
- Repositioning could help with things like “death rattle”
- Possible Contributors: IV hydration, tube feedings, diminished cough reflex or dysphagia, prolonged dying phase
28
Q
Secretion Types
A
- Type I: mainly salivary secretions
- Type II: bronchial secretions as part of normal mucous production or respiratory infections
- Accumulates over days as cough reflex lessens
- May be resistant to medication therapy
29
Q
Secretion Treatment
A
Not Near Death
- Optimizing hydration
- Nebulized NS +/- guaifenesin
- Thinner secretions can use gentle suctioning and anticholinergics
Near Death
-Anticholinergics: Atropine eye drops, scopolamine, hyoscyamine, glycopyrrolate
30
Q
Terminal Restlessness
A
- Could be included with delirium
- Assess for contributing factors like med, kidney/liver failure, impaction/retention, pain
Signs/Symptoms
- Skin mottling and cool extremities
- Mouth breathing and hyperextended neck
- Calling to dead family members/friends
- Talking about going on a trip or packing bag
- Deepening somnolence
- Agitation
31
Q
Terminal Restlessness Treatment
A
- Treat underlying cause
- Non-pharm interventions as appropriate
- Pharm: Benzos, preferably Lorazepam and can consider adding an antipsychotic, preferably haloperidol, if agitation is a contributor
32
Q
Palliative Sedation
A
- Used to make patient unaware/unconscious due to extreme suffering causes by disease that will lead to death
- Usually refractory option to conventional symptom treatment
- Midazolam is most commonly used but propofol and phenobarbital can also be used
33
Q
End-Of-Life Expected Changes
A
Warn family/patient of expected changes ahead of time to lessen distress:
- Progressive unresponsiveness
- Purposeless movements and facial expressions
- Noisy breathing
- Unlikely periods of awareness right before death
- Acute events and action plans
