General palliative care Flashcards
Prognosis and predicting factors in glioblastoma multiforme
Median survival 10-12mo
Survival <6mo:
- Karnofsky performance status <90
- Age >55
- tumor volume >50 cubic cm before resection
- recurrent dz
- mass in critical hemispheric brain region
- Hgb<12
- Plt >ULN
Prognosis in ARDS
40-50% mortality
Prognosis in sepsis with AKI
35% mortality
Signs of poor prognosis in colon cancer
Location- right sided
Signet rind, poorly differentiated and undiff
KRAS gene mutation
High preop CEA levels
30 day mortality after STEMI
2.5-10%
(NSTEMI has worse longer term outcomes)
Scale to assess performance status in adults
Palliative performance scale
OR
Karnofsky performance status scale
Scale to assess functional status in childern
Lansky score
Score to assess symptom intensity
Edmonton symptom assessment (ESAS)
OR
Memorial symptom assessment scale (MSAS)
Timing for diagnosis of complicated grief
requires 12mo since death of someone close to them
Characteristics of complicated grief
maladaptive thoughts, dysfunctional behaviors, dysregulated emotions, serious psychosocial problems that impede adaptation to loss.
Contraindications to organ donation
active heme malignancy
active melanoma
hx of creutzfeldt-jakob dz
HIV + can only go to HIV+ pts
Sx tx in ESRD: Agitation
Haldol 1mg q12h
Sx tx in ESRD: Anorexia
Tx: gastroparesis, depression, dry mouth. Appetite stimulants do not increase QoL
Dronabinol
megestrol
Prednisone 10mg daily
Sx tx in ESRD: Dyspnea
Hydromorphone 1mg PO q4h
Morphine (only if actively dying)
Fentanyl (acute care setting and short duration of action)
Sx tx in ESRD: Fatigue
Causes: Anemia, depression, malnutrition, meds, dialysis associated
Epo for anemia
fluoxetine 20mg daily
sertraline
NO TCA
Sx tx in ESRD: n/v
Causes: uremia, gastroparesis
Zofran 4mg q8h
metoclopramide
haldol for refractory n/v
Sx tx in ESRD: pruritis
Cause: ?? uremia, 2dary hyperPTH, hyper phos, IDA
Nonpharm: emollients, UVB phototherapy
pharm: Hydroxyzine 25mg q6h
Zofran
Naltrexone
adjusted dose gabapentin
sertraline
capsaicin cream QID
Sx tx in ESRD: restless leg syndrome
Treat iron deficiency
Ropinirole
Pramioexole
Sx tx in ESRD: sleep disturbance
Temazepam 15mg PO qhs
zolpidem 5mg PO qhs
When is there no survival benefit for dialysis patients?
older than 80yo
older than 70 with comorbidities
5 yr survival for pts on HD
40.2%
5 year survival for pts on PD
50%
5 yr survival in pt with ESRD >75 yo
17%
Mean survival after discontinuation of dialysis
7.4 days
predictors of shorter survival after discontinuation of dialysis
worse functional status (PPS 10-20)
initial site of care inpt hospice or hospital
nonwhite
peripheral edema
Classification in HF
NYHA (I-IV) function
- can change with symptoms
- Correlates with hospital use and life expectancy
AHA- (A-D) progression and sx
- Can not go backwards
- A: no disease but at risk
- B: no dz but structural dz
- C: clinical HF with structural dx + sx
- D: refractory HF
Prognostic models for HF
Seattle HF model (only HFrEF)
HF Survival Score (used for transplant pts)
Factors used for seattle HF model
NYAH class
EF
ischemic etiology
low SBP
sodium levels
HF survival score factors
Peak O2 uptake or 6MWT
Contraindications for LVAD
active malignancy or infection
active substance use
severe RV dysfunction
HD
cirrhosis
insufficient social support
inability to take AC
When to stop warfarin
- high risk of fall
- dietary intake drops 50% or more, or eating is erratic
- Liver failure
- no longer checking INR
- Bleeding
frame work for deprescribing (Holmes model)
4 factors:
1. goals of care
2. prognosis
3. treatment target (primary prevention vs. secondary)
4. time-until-benefit
Antimicrobial therapy at then end of life
- no symptomatic relief in dying pts (depended on type of infection, UTI and otitis media better)
- Little evidence that there is survival benefit if prognosis is weeks to months. (if longer then worth treating)
- Can treat symptoms of infection without antibiotics
Potential harms of antibiotics at the end of life
- Adverse effects (diarrhea, seizures)
- burden of taking meds
- Cost
