Lecture 11 - Palliative Flashcards
What is the WHO definition of palliative care?
Care offered early in the course of the illness, in conjunction with other therapies that are intended to prolong life, and includes investigations to better understand and manage distressing clinical complications
What are 3 important concepts of palliative care?
Relief from pain, dying as part of the normal process of living, and to neither hasten nor prolong death
What does the model to guide palliative care suggest?
The initial focus of care is on therapy to modify disease, eventually replaced by palliative care. Then comes end-of-life care, followed by death. Death is followed by bereavement
What are common signs of imminent death?
Progressive weakness, bed bound, sleeping, decreased intake, darkened and decreased urine output, dysphagia, delirium, decreased LOC, noisy respiration, change in breathing pattern, mottling, cooling of extremities, dehydration
Which diseases are accompanied by chronic pain?
RA, liver failure, kidney failure, HIV, cancer, HF
Describe somatic pain
A localized achy, dull, throbbing or sore pain that arises from MSK
Describe visceral pain
A diffuse, difficult to localize, often referred gnawing, squeezing, cramping pain that arises from visceral organs
Describe neuropathic pain
A shooting, burning, tingling, stabbing pain that often follows a nerve path but can be diffuse due to injury to CNS or PNS
Pain assessment includes what acronym?
OPQRSTUV
What is the O component of pain assessment?
Onset - when did the pain (or new pain) begin? How long does it last? How often does the pain occur?
What is the P component of pain assessment?
Provoking/palliating - What brings the pain on? What makes the pain better? What makes the pain worse?
What is the Q component of pain assessment?
Quality - What does the pain feel like? Describe the pain.
What is the R component of pain assessment?
Region/radiation - Where is the pain? Can you point to the pain? Does the pain spread anywhere?
What is the S component of pain assessment?
Severity - What is the intensity of the pain? (Use age appropriate visual analog scale) On a scale of 0-10? Are there any other symptoms that accompany the pain?
What is the T component of pain assessment?
Treatment - What medications/ treatments are you currently using? How effective are these? What have you used in the past?
What is the U component of pain assessment?
Understanding impact - How is the pain affecting you/ your family? Sleep? Activity? What do you believe is causing the pain?
What is the V component of pain assessment?
Values - What is your comfort goal/ acceptable level of pain? (Use 0-10 scale or visual analog)
What are other factors that impact chronic pain?
Decreased/increased sensitivity, analgesic medication history, beliefs about pain and treatment, mental health, drug abuse, heart disease, diabetes
What is Stage 1 of WHO’s analgesic ladder?
Non-opioids
What are 2 examples of Stage 1 medications?
Acetaminophen and Cox-2 inhibitors
What is acetaminophen?
Non-opioid used for analgesic and antipyretic effects, not anti-inflammatory or anticoagulant.
What are potential complications of acetaminophen?
Hepatic and renal toxicities as well as overdose
What are Cox-2 inhibitors?
Non-opioid used for anti-inflammatory effects that can be used for patients with thrombocytopenia and has lower GI effects
What is a potential complication of Cox-2 inhibitors?
Risk of stroke and MI
What is a ceiling effect?
When a drug reaches its maximum effect. Increasing dose does NOT increase the therapeutic effect of the medication. Often the adverse effects of the drug continues to increase, outweighing the benefit of continuing medication
NSAIDS do have a ceiling effect. True or False?
True
What is the major benefit of using non-opioids?
It does not cause respiratory depression
What are examples of adjuvant drugs in pain management?
TCA, anticonvulsant, and dexamethasone
What are 2 things to watch for when starting TCA?
Risk for falls related to orthostatic hypotension and dry mouth related to anticholinergic effects
What are 2 things to be aware of when administering TCA?
Use with caution for those with UTI’s and potential to cause sedative effects if using with opioids
What are anticonvulsants?
An adjuvant medication that treats neuropathic pain and causes CNS depressant effects and has a higher benefit vs. side effect ratio
What is dexamethasone?
An adjuvant medication that can be used in cancer care that is useful in treating neuropathic pain
What is Stage 2 of WHO’s analgesic ladder?
Weak opioids
What is a side effect you must treat with using codeine?
Constipation
There is a ceiling effect for morphine. True or False?
False - dose can continue to be escalated to provide relief when pain increases
How strong is hydromorphone?
7x more potent than morphine
What is fentanyl?
Opioid for pain management that has a slow onset of action, causes less constipation, and available in a patch
X can alter the rae of dose delivery of fentanyl. What is X?
Diaphoresis
What route is ideal for opioid administeration?
Oral, as it gives more consistent and prolonged analgesia
What is an addiction?
Loss of control over drug use accompanied by chronic neurobiological, psychological dependence on drugs
What are signs of drug withdrawal?
Diaphoresis, nausea & vomiting, severe body aches, abdominal pain, twitching/ muscular spasms, and increase in vital signs
What are 4 examples of mechanical management of pain?
Transcutaneous electrical nerve stimulation (TENS), therapeutic touch, application of heat/ cold: decrease muscle spasm and massage
What are 5 examples of behavioral management of pain?
Distraction activities, music, biofeedback, imagery/visualization and play therapy
Children of what age range metabolize morphine more rapidly than adults?
6 months to 5 years
What are 5 ways to manage constipation?
Stool softener, colonic stimulant, colonic osmotic laxative, suppository, and enema
What is dyspnea?
Subjective discomfort related to breathing present in 40-80% of end-of-life patients
Where is dyspnea common?
With altered fluid volume such as ascites, CHF, pleural effusion and restrictive lung disease
What are 2 pharmacological interventions to manage dyspnea?
Benzodiazepines and low dose opioids
How would you position a dyspneic patient to optimize breathing?
Semi to high Fowlers to facilitates lung expansion. If ambulatory, sitting position maximize air expansion, lean forward. Side lying if patients who have secretions
What is delirium?
Cognitive impairment with 1) sudden onset, 2) fluctuating level of consciousness, sleep-wake cycle, psychomotor behaviour, confusion
Which class of drugs is ideal for delirium?
Antipsychotics
Which drug class can treat delirium but may contribute to cognitive impairment?
Benzodiazepines - it can contribute to agitation
