Hospice and Palliative Medicine Flashcards
Define Hospice
The study of and care for patients with active, progressive, far-advanced disease whose prognosis is limited, and thus the focus becomes quality of life
Define Palliative Care
- The “relieving or soothing the symptoms of a disease or disorder.”
- Means specialized medical care for people with serious illnesses. This type of care is focused on providing patients with relief from the symptoms, pain and stress of serious illness, whatever the diagnosis.
Who can receive Palliative care?
- Palliative care is for people of any age, and at any stage in an illness, whether that illness is curable, chronic, or life-threatening. In fact, palliative care may actually help patients recover from illness by relieving symptoms like pain, anxiety, or loss of appetite, as they undergo sometimes-difficult medical treatments or procedures, such as surgery or chemotherapy. 1
- Palliative care is appropriate at any age and at any stage in a serious illness and can be provided together with curative treatment. The goals to improve quality of life for both the patient and the family.
Synonyms for Palliative Care
“comfort care” and “supportive care”
False Belief about palliative care
Many people mistakenly believe this means patients receive palliative care only when they can’t be cured. Actually, palliative medicine can be provided by one doctor while other doctors work with you to try to cure the illness.
Hospice is a _____ and not a ____.
Hospice is a service and a philosophy,not a place
What to consider for end of life preparation and advanced directives
- Families/medical durable power of attorney (May be in conflict with the patients wishes)
- DNR, Intent for CPR, DNAR
- POLST/MOST (Physician orders for life sustaining treatment, medical orders of sustaining treatment)
- Five Wish
- Artificial nutrition and hydration
- Organ/tissue donation
- Risk-benefit ratio
4 recognized ethical priciples and their meanings
- Autonomy - Patient self-determination
- Beneficence -Serving the patient’s well-being
- Nonmaleficence - Do no harm
- Justice - Fairness
Competence vs. Capacity
Capacity is the medical decision you make at the bed side; Competence is the legal preceding side
Best way to understand treatment Goals?
- Talk to the patients/families
- most conflicts are communication issues and misunderstandings
When to have end of life discussions?
When pt is first diagnosed with disease
Risk - benefit ratio
does the greater good outweigh what we are doing?
What is futility?
- Every one has their own definitions
- Justice Stewart - “ I don’t know how to define it, but I know what it is when I see it”
Treatment Goals and Ethical Dilemmas
- Talk to the pts and families
- *Treatments are ETHICALLY NEURAL
- *There is no ethical distinction between withholding and withdrawing life sustaining treatment
- Find out what the patient wants to know and who they may want to be in charge of their decision making, in whole or in part.
What is the double effect?
The doctrine (principle) of double effect is often invoked to explain the permissibility of an action that causes a serious harm, such as the death of a human being, as a side effect of promoting some good end
Ethical Dilemma of the double effect?
This theory is based upon the caregiver’s intent which is problematic
Primum non nocere
- First do no harm
- requires risk-benefit ratio
Hospice Requires a ___
- Interdisciplinary Team
- Must consist of a physician, nurse case manager, dietary counselor, medical social worker, and bereavement counselor
Define Physician Assisted Suicide/Physician Assisted Death
“The deliberate action taken by the physician to help a patient commit suicide.”
Define Euthanasia
“The act of ending a patient’s life when carried out by the physician personally.”
Most common reason pts ask to end their lives?
The reasons that patients ask to end their lives are a sense of hopelessness, loss of control, or an unmet symptom control (pain).
What is required to asses symptom management?
- A complete History and Physical
- Almost always the answer to “what to do next”
Pain assessment
- Pain must be continually reassessed, including patient and care-giver compliance with a prescribed program.
- Patient self reporting of pain is the single most reliable method of evaluating pain
What is “total pain”? What is the meaning of pain to the patient?
- The recognition of pain that is beyond the just the physical.
- Patients often suffer from spiritual/existential, emotional/psychological and social/interpersonal pain.
- meaning? Some patients believe that this is something that they must endure.
Two possible roads patients can take to die? Which does hospice try to address?
- Usual road - sleepiness/lethargic
2. Difficult Road - restless/confused/anxious/neuro-psych problems –> hospice helps this one
What must be treated first in order to address the other sources of total pain?
- Physical pain
- there is no cap on pain medication dosing for hospice patients
What they types of physical pain and what do they include?
- Nociceptive
(a) Somatic = aching, stabbing, throbbing
(b) Viceral = poorly localized, spastic, cramping, squeezing pressure - Neuropathic = buring, shooting, tingling, numbness, “needles and pins”
Opioids MOA
Modulation of pain through mu, kappa, and delta receptors in the peripheral and central nervous systems. These receptors work by inhibiting calcium channels which prevents or induces the release of neurotransmitters (i.e., Substance P).
Opioids and the respiratory center
- Opiates modulate the sensation of shortness of breath in the respiratory center of the brain.
- With proper medical supervision, these medications are safe and effective and the drugs of choice in patients near the end of life that are having pain or dyspnea.
Which opioids to choose?
- Mild to Moderate Pain
- Codeine, Hydrocodone - Moderate to Severe Pain
- Morphine, Hydromorphone, Oxycodone, Fentanyl, Methadone (NMDA antagonist as well as an opiate agonist)
Which delivery method is preferred and which is undesired for opiods?
preferred = oral
undesired = IM
Opioid Side effects?
- *CONSTIPATION
- nausea
- somnolence
- Myoclonus and neurotoxicity -unusual
–> side effects should be investigated during reassessments
Barriers to effective narcotic use and misconceptions about opiates:
- Physicians are reluctant to prescribe for fear of DEA retribution and/or lack of experience with high doses.
- Nurses can be reluctant/uncomfortable to administer for fear of causing harm/respiratory depression.
- Fear of causing addiction.
- “Morphine is what they give people to help kill them or when they are going to die.”
- No maximum dosage.
How to patients control pain if their physician will not give them pain medication?
they turn to heroin
Adjuvant Pain Medications
- Acetaminophen
- NSAIDS
- Inflammation (bone pain) - Corticosteroids
- Edema (cerebral), inflammation (bone pain), appetite stimulation - Anticholinergics
- Antispasmodic, reduce secretions - Antidepressants,
-anticonvulsants, antiarrhythmics
Inhibitors ion channels and/or mediators of neurotransmitters (dorsal spinal columns descending pathways modulate pain responses)
What is Palliative Sedation?
- alternative form of pain management
- Generally believed not to hasten death, but to allow the patient to die peacefully from the natural course of the terminal illness, or allow for a “WIND-DOWN” period.
- Used for a SHORT period of time followed by reassessment and reduction.
- rare; only used with other avenues have been exhausted
Constipation:
- Cause?
- Treatments?
- What to avoid?
- Often caused by low fluid intake, inactivity, autonomic dysfunction metabolic abnormalities, MEDICATIONS.
- (a) Opioid antagonists - Methylnaltrexone, Naloxegol - are expensive (b) stimulant laxatives, senna, dulcolax - cheaper and work just as well (c) other - enemas/prophylaxis
- Avoid bulk laxatives
Treatment to dyspnea
- Treat the underlying cause (ie CHF, COPD, pleural effusions, pneumonia, anemia, muscle weakness, emotional distress, acidosis (sepsis), hypoxia)
- responds well to systemic opioids
Nausea:
Cerebral Cortex -
1. Causes?
2. Treatment?
- Cuases
- Emotional – anxiety, memories
- Malignancies, increased intra-cranial pressure
- Pain - Treatment
- Dexamethasone
- Counseling
- Anti-anxiety, antidepressant and opioid medications
Nausea:
Vestibular Apparatus -
1. Causes?
2. Treatment?
- Infection, motion sickness, CN VIII tumor
2. Antibiotics, Anticholinergics, Antihistamines
Nausea: Chemo Trigger zones 1. Cause 2. Approach 3. Treatment
- Lack of a true blood brain barrier - drugs, uremia,
electrolytes imbalances - Find the underlying cause - metabolic or electrolyte abnormalities
- 5-HT3 receptor antagonists
Nausea: GI
- Cause?
- Treatment?
- Obstruction, gag reflex, irritation/distention
- (a) Remove inciting agents as possible (odors, tube feedings, GI bleeding, medications, etc.); Oral candidasis, constipation/obstruction (tumor)
(b) meds: Anti-inflammatory medication– steroids, Anticholinergics. Octreotide
Causes of Delirium/Restlessness
- Medication (anticholinergics, opioids, steroids, sedatives, etc.)
- Metabolic abnormalities
- Infections
- Emotional distress/isolation
- Uncontrolled pain
- Terminal delirium
Anticholinergic Side Effects
- dry secretions
- blurred vision
- constipation
- delirium/confusion
- urination difficulties
- Flushing/warm skin
Delirium/Restlessness Treatment
- Address the underlying cause
- Antipsychotic medication
- Haldoperidol
- Chlopromazine
- Benzodiazepines, can be useful but also can have paradoxical exacerbation of terminal delirium
- Anticonvulsants: Valproic Acid - Palliative Sedation
- Midazolam, propofol, thiopental
- Goals of treatment
- Reassess
_______Has lead to a reduction of request for physician-assisted euthanasia in the Netherlands.
Palliative Sedation
Other Palliative Treatments
- Complementary and alternative therapies
- Aromatherapy, massage and manipulation, music, relaxation, companionship, TENS unit, etc. - Cannabinoids – potentially hallucinogenic
- Dronabinol - Permission to die
