Geriatrics - Palliative Care

Question 1

Define palliative care?

Answer 1

the active total care of patients whose disease is not responsive to curative treatment

Question 2

How does a patient qualify for hospice?

Answer 2

under Medicare (Part A) benefits, must have a terminal illness with a prognosis of six months or less as certified by the attending physician and the hospice medical director

Question 3

What is the difference between palliative care and hospice?

Answer 3

palliative care = improving QoL for those living with serious illness, hospice = subset of palliative care that involves end-of-life care

Question 4

What medications are in the palliative care toolkit for end of life? (6)

Answer 4

morphine/methadone/hydromorphone/oxycodone, lorazepam/alprazolam, haloperidol, atropine, dexamethasone, ondansetron/metoclopramide

Question 5

What are the three steps in gut wall nausea and vomiting treatment in end-of-life care?

Answer 5

1 = H2RA/PPI, 2 = metoclopramide, 3 = ondansetron

Question 6

What are the three steps in area postrema nausea and vomiting treatment in end-of-life care?

Answer 6

1 = haloperidol/metoclopramide, 2 = step 1 + dexamethasone and pamidronate (for hypercalcemia), 3 = ondansetron + dexamethasone

Question 7

What are the three steps in cerebral cortex nausea and vomiting treatment in end-of-life care?

Answer 7

1 = dexamethasone, 2 = amitriptyline/haloperidol/lorazepam, 3 = free water +/- 3% saline +/- haloperidol

Question 8

What are the three steps in vestibular nuclei nausea and vomiting treatment in end-of-life care?

Answer 8

1 = diphenhydramine/dimenhydrinate, 2 = meclizine/cyclizine, 3 = glycopyrrolate/scopolamine

Question 9

What are step 1 treatments for dyspnea in end-of-life care?

Answer 9

bronchodilators, diuretics, antibiotics +/- physiotherapy

Question 10

What are steps 2-4 treatments for dyspnea in end-of-life care?

Answer 10

2 = ipratropium/albuterol +/- dexamethasone, 3 = morphine (any opioid) +/- dexamethasone, 4 = morphine + chlorpromazine/diazepam/midazolam

Question 11

What are the five steps in cough treatment in end-of-life care?

Answer 11

1 = treat underlying cause, 2 = promote production (nebulized saline and/or guiafenesin), 3 = suppress cough (morphine/hydrocodone/dextromethorphan), 4 = dexamethasone or glycopyrrolate/atropine and NAC, 5 = nebulized lidocaine/gabapentin

Question 12

What are the two steps for anxiety treatment in end-of-life care?

Answer 12

1 = non-pharm (distracting/relaxation techniques), 2 = lorazepam/alprazolam/amitriptyline(depression) for short term, buspirone/SSRI (escitalopram/sertraline)/mirtazepine(depression, insomnia, anorexia) for long term

Question 13

What are the three steps for delirium treatment in end-of-life care?

Answer 13

1 = haloperidol, 2 = haloperidol + lorazepam, 3 = haloperidol + midazolam/chlorpromazine

Question 14

What are the three steps for constipation preventative treatment in end-of-life care?

Answer 14

1 = senna/bisacodyl +/- docusate +/- metoclopramide (opioid-induced) and fiber/fluids/docusate (aging- or disease-induced), 2 = sorbitol/lactulose/PEG3350, 3 = MOM/citrate of mag/bisacodyl

Question 15

What are treatments for acute constipation in end-of-life care? (6)

Answer 15

stimulant laxative (bisacodyl/senna as double dose), osmotic laxative (sorbitol), MOM, bisacodyl suppository then enema, PAMORAs, nuclear enema

Question 16

What are the four steps for bowel obstruction treatment in end-of-life care?

Answer 16

1 = metoclopramide +/- dexamethasone (unless complete obstruction), 2 = glycopyrrolate +/- morphine +/- haloperidol, 3 = octreotide +/- steps 1 and 2, 4 = PEG tube or stent

Question 17

What are the two steps for asthenia treatment in end-of-life care?

Answer 17

1 = energy conserving measures, 2 = methyplhenidate/dexamethasone

Question 18

What are the three steps for depression treatment in end-of-life care?

Answer 18

1 = escitalopram/sertraline +/- methylphenidate (until SSRI effective) if >4 weeks survival, 2 = amitriptyline/nortriptyline +/- methylphenidate if <4 weeks survival, 3 = methylphenidate/ketamine

Question 19

What are the four steps for anorexia (cachexia) treatment in end-of-life care?

Answer 19

1 = treat underlying cause, 2 = metoclopramide, 3 = dexamethasone if <3 months survival and mirtazapine/megestrol if >3 months survival, 4 = dronabinol

Question 20

What are the three steps for insomnia treatment in end-of-life care?

Answer 20

1 = treat underlying cause, 2 = trazodone/melatonin/temazepam/zolpidem (sleep initiation difficulty) and haloperidol (sleep maintenance) and mirtazepine or amitryptyline (concomitant depression), 3 = increase doses and combinations in step 2 or substitute midazolam/lorazepam for no more than 7 days

Question 21

What are the three steps for xerostomia treatment in end-of-life care?

Answer 21

1 = ice chips/gum/lemon drops, 2 = saliva substitute, 3= pilocarpine

Question 22

What is treatment for terminal secretions (death rattle) in end-of-life care? (3)

Answer 22

atropine 1% ophth gtts SL 2-3 q2-3hr PRN, scopolamine (patch), glycopyrrolate