Geriatrics - Palliative Care Flashcards
Palliative Care - Definition & Focus
improving QOL for those with serious illness unresponsive to curative treatment
control of pain and other symptoms
psychological, social, and spiritual problems
Dying Process - 1-3 Months Before Death
withdrawal from the world and people
decreased communication
decreased food intake
increased sleep
Dying Process - 1-2 Weeks Before Death
mental: agitation, confusion, talking with the unseen, picking at clothes
physical: decreased blood pressure, change in pulse, change in skin color, respiration irregularities, change in body temperature
Dying Process - Days to Hours Before Death
surge of energy
decrease in BP
eyes glassy, tearing
restlessness or no activity
weak pulse, hard to find
decreased urine output
Dying Process - Minutes Before Death
“fish out of water” breathing
cannot be awakened
loss of ability to swallow
End of Life - Nausea & Vomiting Types
- gut wall (due to gastric irritants)
- area postrema (due to morphine, digoxin, hypercalcemia, clonidine, chemo)
- cerebral cortex (due to fear, anxiety, increased ICP, hyponatremia)
- vestibular nuclei (due to movement, vertigo)
End of Life - Nausea & Vomiting - Gut Wall Treatment
- H2RA or PPI
- metoclopramide
- ondansetron
End of Life - Nausea & Vomiting - Area Postrema Treatment
- haloperidol or metoclopramide
- add dexamethasone; pamidronate if hypercalcemia
- ondansetron and dexamethasone
End of Life - Nausea & Vomiting - Cerebral Cortex Treatment
- dexamethasone
- amitriptyline or haloperidol or lorazepam
- limit free water +/- 3% saline +/- haloperidol
End of Life - Nausea & Vomiting - Vestibular Nuclei Treatment
- diphenhydramine or dimenhydrinate
- meclizine
- glycopyrrolate or scopolamine
End of Life - Dyspnea Causes
- obstruction by tumor
- carcinomatous lymphangitis
- bronchospasm
- cardiac failure
- chest infections
- pleural effusions
- ascites
- anemia
End of Life - Dyspnea - Obstruction by Tumor Treatment
radiotherapy
End of Life - Dyspnea - Carcinomatous Lymphangitis Treatment
steroids
End of Life - Dyspnea - Bronchospasm Treatment
bronchodilators
End of Life - Dyspnea - Cardiac Failure Treatment
diuretics
End of Life - Dyspnea - Chest Infections Treatment
antibiotics +/- physiotherapy
End of Life - Dyspnea - Pleural Effusions Treatment
pleural aspiration
End of Life - Dyspnea - Ascites Treatment
abdominal paracentesis
diuretics
End of Life - Dyspnea - Anemia Treatment
transfusion if hemoglobin < 8 g/dL
End of Life - Dyspnea - General Next Steps
- ipratropium / albuterol
- morphine +/- dexamethasone
- morphine and chlorpromazine / diazepam / midazolam
End of Life - Cough Treatment
- treat underlying cause
- promote production: nebulized saline and / or guaifenesin
- suppress cough - morphine / hydrocodone / dextromethorphan
- dexamethasone or glycopyrrolate / atropine / NAC
- nebulized lidocaine if triggered by lung tumor
End of Life - Anxiety Treatment
- non-pharmacological measures
- short-term lorazepam / alprazolam / amitriptyline if depression
- long-term buspirone / escitalopram / sertraline / mirtazapine if insomnia or anorexia
End of Life - Delirium Treatment
- haloperidol
- haloperidol + lorazepam
- haloperidol + midazolam or chlorpromazine
End of Life - Constipation Prevention
- senna or bisacodyl +/- docusate +/- metoclopramide if OIC; fiber or docusate if not OIC
- sorbitol, PEG, lactulose
- MOM, magnesium citrate, bisacodyl suppository - improve preventive therapy if got to this step
End of Life - Bowel Obstruction Treatment
- metoclopramide +/- dexamethasone if not a complete obstruction
- glycopyrrolate +/- morphine +/- haloperidol
- octreotide +/- above
- PEG tube or stent
End of Life - Depression Treatment
- escitalopram or sertraline +/- methylphenidate until SSRI effective
- amitriptyline +/- methylphenidate
- if less than 4 weeks survival, methylphenidate or ketamine
End of Life - Anorexia & Cachexia Treatment
- treat underlying causes
- metoclopramide if early satiety / gastroparesis
- dexamethasone if survival < 3 months; mirtazapine or megestrol if survival > 3 months
- dronabinol
End of Life - Insomnia Treatment
- treat underlying causes, remove offending drugs
- trazodone or melatonin if sundowning
- temazepam or zolpidem if bed-bound
- haloperidol if disturbing dreams
- mirtazapine or amitriptyline if concomitant depression
End of Life - Xerostomia Treatment
- ice chips, gum, lemon drops
- saliva substitute
- pilocarpine 5 mg QID
End of Life - Terminal Secretions Treatment
atropine 1% ophthalmic drops SL every 2-3 hrs prn
scopolamine patch
glycopyrrolate
Insomnia - Drugs That Worsen
diuretics
steroids
caffeine
sympathomimetics
sedative withdrawal
alcohol
End of Life - Asthenia Treatment
methylphenidate or dexamethasone
