lecture 20: palliative care Flashcards
what is palliative care
approach to care that aims to improve quality of life of person’s and their families facing problems associated w life-limiting
palliative care is provided at the same time as curative care, maximizing quality of life throughout the course of disease
when does palliative come into play
when all interventions have been tried
words to avoid in palliative
- he’s palliative / she was made palliative
- are they palliative now?
- there’s nothing more we can do
is “being palliative” a diagnosis
no!
preferred words for palliative pts
- he has palliative care needs
- we are now using a palliative approach to their care
- goals are symptom-directed
6 components of a good death
- accepted
- good sympt control
- planned
- adequate support/resources
- appropriate setting and site
- in keeping w pt wishes
goals of care for palliative pts
- guide the convo
- what is ur understanding w where ur illness it @
- how much info would you like shared
- if your health worsens what are your most important goals
- what are ur biggest fears and worries w ur health
- act on the convo
- etc…
how is SDM determined
person who is/are highest on this hierarchy
- attorney for personal care
- spouse or partner
2 screening and assessment tools for palliative
- edmonton sympt assessment sys
- palliative performance scale
if no SDM is identified who acts as the SDM
the public guardian and trustee (treatment decisions unit)
what can we do at EOL
- make family and treating team aware of changes in final stages
- treating goal is to minimize discomfort
- anticipate and identify pt and family needs
4 aspects of dying
- social (distancing; withdrawal)
- emotional (fluctuations; existing concerns)
- spiritual (suffering; existential concerns)
- cultural (rituals; ceremonies; information sharing)
what are the sympt prevalence in final days
dyspnea:
secretions:
delirium:
families who would be grateful for support and guidance:
dyspnea: 80%+
secretions: as high as 92%
delirium: 80%+
families who would be grateful for support and guidance: 100%
signs of death
- urine output decreases and may become tea-coloured
- decreased awareness, insight and perception
- HR increased irregular and thready
- sleeping increases
- eating or drinking sto[
- eyes might b slightly open
- oral and ocular mucosal dryness
- breathing shallow, apnea, terminal secretions
- change in skin temp and colour
- restlessness and agitation
- incontinence of urine and stool may occur
visceral pain examples
cramping, twisting, sore, bloating, aching, throbbing
somatic pain examples
sharp, sore, aching, stabbing
neuropathic pain
burning, numb, tingling, pins and needles, etc
is most pain visible
no its mostly under the surface like an iceberg
somatic pain pharmacological treatments
NSAIDS
opioids
bisphosphonates
calcitonin
chemo
dexamethasone
somatic pain
(other modalities)
radiotherapy
splints/braces
surgical fixation
positioning +/- support surfaces
what is neuropathic pain
- caused by injury to nerve tissue, either central or peripheral and could include the ANS
- burning, tingling/numbness
pharmacologic options for neuropathic pain
- TCA (amitriptyline)
- anticonvulsants (baclofen, gabapentin)
- dexamethasone
- opioids
- methadone
other modality options for neuropathic pain
- acupuncture
- nerve blocks (intercostal, celiac plexus)
mild pain cancer management (1-3/10)
- non-opioid
- +/- adjuvant
moderate pain cancer management (4-6/10)
- weak opioid (codeine, tramadol)
- +/- adjuvant
severe pain cancer management (7-10)
- strong opioid
1st line: morphine, oxycodone, hydromorphone
2nd line: fentanyl
3rd line: methadone
+/- adjuvant
EOL facts about opioids
- not every dying pt has pain, however if they are pain can be controlled
- in right doses opioids control sympt not hasten death*
- when titrated properly, resp depression is not a concern in a dying pt
- decreased LOC is expected at EOL; continue the opioid to ensure comfort
pharmacologic ways for managing dyspnea
- supplemental o2 is recommended for hypoxic pts w dyspnea
- supplemental o2 is NOT recommended for non-hypoxic dyspneic pts, but is may be given for comfort, prn
- systemic opioids can be used to decrease sensation of SOB in advanced cancer pts
goals for terminal delirium at EOL
- result of metabolic encephalopathy resulting from organ failure, electrolyte imbalance, nutritional abnormalities or sepsis
- often distressing for families to witness; teaching and reassurance is needed
- goal is to control the distress, not to correct cause
- normalize the behaviour for the family
how do you treat terminal delirium
- trial prn analgesic and assess response
- if analgesic ineffective, trial one dose of antipsychotic and assess response
what to do for secretions in EOL
- positioning
- meds
- suctioning
circulation in EOL
- extremities usually get colder to touch
- BP lowers and HR may increase, but get weaker
- skin becomes waxy and pale
- fingers, lips, nail beds may look bluish (cyanosis)
- mottling: puplish or blotchy red-blue colouring on knees and/or feet
interventions for circulation problems in EOL
keep pt warm w light blankets
turn pt every 2 hrs if warranted
metabolism/dehydration of pt in EOL
- decreased intake orally
- eventually unable to swallow
- decreased appetite
- pt often doesn’t feel hunger
what happens if you misinterpret sympt of agitation, restlessness, and moaning in a pt w terminal delirium
potentially aggravate sympt and cause opioid neurotoxicity
interventions for pt w metabolism/dehydration problems in EOL
ice chips/sips of fluid
swab mouth w cool water
