Final Flashcards
Pain
Unpleasant sensory and emotional experience associated with actual or potential tissue damage
Total Pain
Physical, psychological, spiritual, and social dimensions of suffering
Cicely Saunders
Bio-psycho-social-spiritual model. Existential experience effected by gender, culture and SES
PC team members in order
RN, doc, social worker, homecare RN, spiritual, pharmacist, PT/OT, nurse practitioner, volunteers
Allodynia
Pain in response to normally non-pianful stimulus. Light pressure
Dysaesthesia
Unpleasant, abnormal sensation that is spontaneous or provoked. May have precipitating factors
Hyperalgesia
Exaggerated response to painful stimulus. Super pain
Hyperesthesia
Increased sensitivity to any stimulus
Hyperpathia
Abnormally painful reaction to a trigger. Explosive and delayed, poorly localized.
Parasthesia
Abnormal sensation, spontaneous or provoked but not unpleasant
Nociceptive Pain
Tissue damage from injury or pathology
Visceral pain
Referred pain. Colicky and episodic in the gut. Dull aching pain in parenchymal organs
Somatic pain
Well localized, aching, burning, throbbing
Neuropathic pain
Injury in CNS/PNS from development of abnormal nociceptive perception or transmission
Which type of pain has a weak response to opioids
Neuropathic
Background Pain
Baseline/basal. Constant, lasting more than 12 hours a day
Breakthrough pain
Exacerbation on a background of stable pain. Flare up or transient pain
Paroxysmal
Occurs unexepectedly
Incident pain
Precipitated and related to specific events
Volitional pain
Provoked by voluntary action like reaching
Non-volitional
Caused by involuntary action like coughing
Procedural pain
Related to intervention like wound dressing
End of Dose Failure
Pain occuring between doses of analgesics
Nociception
Activation of specialized nerve endings by mechanical, thermal or chemical stimuli
Nerve fibres
A,B and C fibres with alpha, beta, gamma and delta subcategories
A beta
6-12 myelination (thickest)
35-90 m/s conduction (fastest)
senses touch
A delta
1-5 myelination
5-40 conduction
thermal/mechanical, pricking, pinching
C
0-1.5 unmyelinated
0.2-2 conduction
mech/thermal throbbing and diffuse pain
Ascending pain pathway
Dorsal horn of spinal cord Raphe nuclei Reticular formation PeriQ Gray matter Hypothalamus Cerebrum
Descending pain pathway
Cerebrum PeriQ gray matter Midbrain Medulla Dorsal horn of spinal cord Afferent fibres Nerve endings
Gate control
Sensory afferent nerve fibres inhibit transmission of painful stimuli to thalamus and cortex
Opioid receptors
Distributed throughout body. Mostly in CNS. Antagonized by naloxone. Mu, kappa, delta, ORL-1
Mu
Analgesia
Respiratory repression
Reduced GI motility
Hypotension
Kappa
Analgesia
Respiratory Repression
Sedation
Psychometric Effects
Delta
Analgesia
Respiratory repression
Pain assesment
Documentation of observed behavior to share with team. Reassess as pain changes
Suffering
State of distress brought by real/ perceived threat to fulfill hopes and expectations for life plan
Things to record in pain
Sire, severity, raditiation Timing, frequency, variation Quality--> throbbing, burning Associated Symptoms Patient concerns
5 single pain scales
Numerical Rating scale Visual analogue scale Brief pain inventory Edmonton Symptom assessment system Leeds Assessment Neuropathic symptoms and signs
6 pain management principles
Communication Modify cause Raise pain threshold Modify environment and support AODL Modify pain perception with drugs Interrupt pain pathway--> nerve blockers
3 types of analgesics in Palliative Care Formulary
NSAID
Opiates
Adjuvant
NSAID
Non-opioids, paracetamol, aspirin, operate as local anasthetic lower down
Opioid
Exert effects on opioid receptors in CNS, antagonized by naloxon
Opiate
Naturally occuring, derived from poppy
Adjuvant
Primary purpose is not analgesia but it does have relieving effects
2 Opioid reccomendations
Give orally
Give on a clock and not as needed
3 steps in WHO analgesic ladder
NSAID + adjuvant
Moderate opioid + adjuvant +NSAID
Strong opioid + NSAID +adjuvant
% of dementia patients experiencing regular pain
50%
Rises to 80% as cognitive impairment increases
Proxy measures
Observe current behavior, compare to previous condition
2 pain assesment scales for dementia
Pain assesment in advanced dementia scale (PAINAD)
Pain assesment checklist for sensiors with limited ability to communicate (PACSLAC)
Palliative Sedation Therapy
Used to control intolerable suffering and refractory symptoms such as pain, nausea, delirium and dyspnea. Fatigue, existential suffering
Goal of PST
Alter consciousness and symptom palliation. Goal is not pain control
Most common reasons for request of PST
Non-physcial symptoms and breathlessness
4 drugs groups used in PST
Anxiolytic sedatives
Antipsychotics
Antiepileptics
General anesthesia
Proportionality
Dose adjusted based on patient distress
Sudden sedation
Deep sleep to control bretahlessness or delirium. Usually with benzodiazipiens
PST Doctrine of the double effect
Intervention is proportionate to the desired outcome and the beneficial effect is more likely than the harmful one
3 Ethical issues in PST
Linked to expedition of detah, slow euthanasia
Lack of research, cant test placebo
Shouldnt be used for non-physical symp.
Continuous PST Canada
Should only be used in the last 2 weeks of life and only if symptoms are refractory. Used as alternative to euthanasia. Lack of laws
Bill 52 Terminal Palliative sedation
Patient/SDM must know prognosis, irreversible nature of sedation and anticipated duration. Must be in writing
3 clarifications needed in CPST
Target symptoms
Target population
Drugs to be used
Ordinary sedation
Control non-physical symptoms like anxiety at any point
Proportional sedation
Use benzos to proportionally conttol sufferring by reducing conciousness
Palliative sedation to unconciousness
Given rapidly, remain under until death
8 inconsistencies in sedation guidelines
Definition Indication Timing/prognosis Level/pattern of sedation Drugs used To consider mental suffering To continue life sustaining therapies
Medical Assiastance In Dying
Euthanaisa or PAS
Sue Rodriguez 1993
Application for MAID dismissed by supreme court
Carter vs Carter 2015
Supreme court changed criminal code to comply with the Charter of Rights and Freedom
% of Canadians in favor of MAID
75% in 1994
67% in 2010
4 federal conditions for MAID
Eligible for government funded health services
18, competent and with a grevous, irremediable medical condition
Natural death is reasonably forseeable
Make the request without external pressure
Grevous medical condition
Advanced state of irreversible decline in capacity
Enduring suffering that is intolerable and not relieved by any acceptable condition
3 steps to MAID
Patient signs form to make request
Request signed by 2 witnesses and approved by a second doctor
Wait 10 days before service performed
5 differences in Quebec Bill 52 from federal
Allows voluntary euthanasia but not PAS
Must be at end of life, not forseeable death
Emphasis on suffering verified by clinician
Not required to have a serious medical con.
No required time frame before death
3 federal MAID issues
Mature minors
MAID just for mental illness
Advanced requests for MAID
7 places PAS is legal
Netherlands, Belgium, Switzerland, Luxembourg, Montana, Oregon, Washington
Death with dignity act 1998
Oregon. Must have palliative care assesment before PAS. Resulted in increased PC provisions
4 factors leading to MAID request
Suffering
Gain control
No burden to family
Depression
CHPCA
Does not view MAID as a part of EOLC. Respect patient right to choose but they choose not to participate
7 CHPCA MAID reccomendations
Policy makers be more informed Increased public debate Access to palliative care Knowledge and skills of HCPs Patients and families are informed Safeguards to protect the vulnerable CHPCA to promote well-being
Drugs used for euthanasia
Barbiturates induce coma
Muscle relaxants stop breathing
Integral Palliative care
Views MAID as a valid option at the end
3 things to avoid with legal PAS
Widening of criteria to other groups
Pressure on vulnerable pops
Allow killing to be accepted in society
Bill C-277
Framework for high quality palliative care. MAID is not voluntary without access to high quality PC
6 MOH duties under C-277
Define palliative care Identify PC training/education for HCP Measures to support care givers Collect research and data Facilitate consistent access to PC Include home PC in Canada Health Act
Euthanasia
Intentionally killing by administering drugs at competent request
Physician Assisted Suicide
Intentionally helping to terminate life by prescribing drugs. Authority of action lies with patient
NTD
Allow imminent death from underlying condition. Withdraw treatment
Palliative sedation
Monitored use of drugs to alter awareness and reduce suffering
% of EOLC complaints due to poor communication
50%
Effects of good communication
Improved emotional health reduce symptoms and pain, reduce need for drugs
Calgary Cambridge Model
Structure a consultation to make effective use of time and build rapport. Initiate session Gather info Physical exam Explanation/Planning Close session
Bad news
Gap between patient expectations and medical reality
SPIKES strategy for breaking bad news
Setting Perception Invitation Knowledge Empathy Strategy/Summary
How to deal with strong emtotion
Recognize and legitimize
Gain perspective, gather info and convey empathy
PREPARED strategy for end of life discussions
Prepare Relate Elicit Provide Realistic Encourage Document
Collusion
Illegal conspiracy to deceive others. May occur when family requests to withhold info
Deal with collusion
Clarify reasons, identify costs, propose a little info and negotiate a plan
Denial
Unconscious mechanism to negate threat of integrity to personhood. Can reduce distress but may impede access to care
People likely to be in denial
Low IQ
Sensory impairment
Incorrect information
Spirituality
Assess
Listen
Respond
Teamwork
Canadian institute for health research
Doubled the Pc publications between 2004-9, 8% world share of health reserach publications
% of patients who discussed prognosis with doctor
18%
$ funding by CIHR
4 million/year in PC reserach
4 reasons why PC doesnt fit the EBM framework
Need a large sample for adequate power
Barriers in recruitment
Low attrition rate
Same treatment for wide variety of symptoms–> poor validity
3 reasons to participate in study
Utility
Validation
Assurance
Belmont Report 1979
Rules on research ethics
Respect for persons–> autonomy, safeguards
Beneficience–> study risks/benefits
Justice–> fair distribution of risk and benefit, participant selection
4 alternatives to RCT
Good quality observational study
Collaborative research networks
Standardized data collection
Mixed methods and creativity
