General palliative care Flashcards by Julia Newman

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

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Prognosis in ARDS

40-50% mortality

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Prognosis in sepsis with AKI

35% mortality

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Signs of poor prognosis in colon cancer

Location- right sided
Signet rind, poorly differentiated and undiff
KRAS gene mutation
High preop CEA levels

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30 day mortality after STEMI

2.5-10%

(NSTEMI has worse longer term outcomes)

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Scale to assess performance status in adults

Palliative performance scale
OR
Karnofsky performance status scale

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Scale to assess functional status in childern

Lansky score

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Score to assess symptom intensity

Edmonton symptom assessment (ESAS)
OR
Memorial symptom assessment scale (MSAS)

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Timing for diagnosis of complicated grief

requires 12mo since death of someone close to them

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Characteristics of complicated grief

maladaptive thoughts, dysfunctional behaviors, dysregulated emotions, serious psychosocial problems that impede adaptation to loss.

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Contraindications to organ donation

active heme malignancy
active melanoma
hx of creutzfeldt-jakob dz

HIV + can only go to HIV+ pts

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Sx tx in ESRD: Agitation

Haldol 1mg q12h

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Sx tx in ESRD: Anorexia

Tx: gastroparesis, depression, dry mouth. Appetite stimulants do not increase QoL

Dronabinol
megestrol
Prednisone 10mg daily

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Sx tx in ESRD: Dyspnea

Hydromorphone 1mg PO q4h
Morphine (only if actively dying)
Fentanyl (acute care setting and short duration of action)

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Sx tx in ESRD: Fatigue

Causes: Anemia, depression, malnutrition, meds, dialysis associated

Epo for anemia
fluoxetine 20mg daily
sertraline

NO TCA

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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