Palliative Flashcards
Describe levels of pain pyramid
Etiology, assessment, principles, analgesic, Adjuvants
What Is cancer pain often related to
o Direct tumor involvement (bone invasion, nerves plexus)
o Viscera or ducts or vessels (Obstruction or pressure)
o SX, chemotherapy, radiation, constipation, gastric bloating
Describe Key Principles of Pain control
By the clock (no delay), educate all involved, individualize, use adjuvants, communicate, PO is best, re evaluate (titration), layer analgesics, scheduled plus breakthroughs (>3 BTD = change in scheduled)
Describe some non pharmacological option for pain control
Cutaneous stimulation, Distraction, Relaxation, Positioning, Companioning, Bearing witness
What is the BEST medication for Dyspnea in EOL care
Opioids #1 for dyspnea (dec SOB feeling, Dec c02 sensitivity)
What are some basic approaches to reducing dyspnea
Reduce demand, control anxiety, tx pathology, control perception of SOB
What are some medications that might be used to control dyspnea
Consider Bronchodilators, diuretics, steroids, anti anxiety, 02 (best to trial early in palliation), cough suppression
What should be avoid in the environment for palliative patients with dyspnea
Avoid triggers, smoke perfumes instead provide fresh air
Describe non pharmacological interventions r/t dyspnea
Positioning of HOB or pillow under arms/loosen clothes to expand chest.
Provide Reassurance, control anxiety
Is hunger common in EOL care?
Hunger is not common in EOL. Family may push food, provide a balanced approach
Is thirst common in EOL care?
Yes. Dehydration and thirst/ dry mucous membranes common
Artificial hydration (tube feed) may be tempting but should be based on Patient goals
What are the advantage of Dehydration?
Benefits: Natural anaesthetic effect, reduction in resp secretions, decreased GI fluid, reduced urine output
What are common effect of poor nutritional intake during EOL
Anorexia and cachexia (Muscle Wasting) caused by metabolic disturbance of CA and loss of protein
Describe 3 options for managing delirium
Options for delirium MNGMT include :
o Reversal: Pt wishes? And is it possible to reverse
o Sedation: reduced delirium severity through management
o Observation: comfort and support (prepare for sedation)
Describe changes in EOL that may lead to delirium
Hypoxemia, Metabolic imbalance, Acidosis, Toxin accumulation due to liver and renal failure, Adverse effects of medication, Sepsis, Disease-related factors, Reduced cerebral perfusion
What is the most basic and important intervention for delirium management
Create safe and pleasant environment
How common is NV at EOL
Very common nearing EOL. Inc in prevalence closer to the EOL
Name the 4 sites influencing Nausea and give examples of what might be influencing them
- CTZ- opioids, chemo, Ca imbalance, liver/kidney failure, sepsis
- Vestibular- tumor/opioids
- Cortical- anxiety, association, inc icp
- Peripehral- radiation, chemo, GI irritation/obstruction
What are the non pharmacological interventions to confront NV in EOL
Environment, oral hygiene, acupuncture, distraction, nutrition, small meals, fizzy drinks
What other complications may need to be treated in EOL to deal with NV
Electolytes, fluid balance, acid-base, etc
Why might Tetrahydrocannabinoids be used in palliative care?
- Nauseaandvomitingfromchemotherapy
- Chronic pain (neuropathic pain in MS and cancer)
- Anorexia associated with HIV/AIDS
- PTSD
- Anxiety
- Insomnia
- Spasticity
- LowerUrinarytractsymptoms(MS)
- Improving bladder symptoms associated with MS
- Neuropathic/nociceptive/mixed pain
- Chronic daily headache
- Fibromyalgia
- Anorexiaandcachexia
- Spasticity
- Epilepsy
What is Nabilone
Nabilone is a synthetic cannabinoid with therapeutic use as an antiemetic and as an adjunct analgesic for neuropathic pain.
Describe neuroleptics used in EOL
Haloperidol is the gold standard drug therapy for the treatment of patients with delirium near the end of life. It is a longer acting drug
Chlorpromazine may be an acceptable alternative if a small risk of slight cognitive impairment is not a concern.
Methotrimeprazine is effective and used as an alternative to haloperidol. High does used for sedation. Very low doses are used for nausea
What is Midazolam and use in EOL
Midazolam- Benzo. - frequently used in delirium, but is more helpful for the restlessness aspect. In acute dosing, it is short-acting and rapidly effective.
Name some antiemetics that may be used in EOL
- Gravol- antihistamines- vestibular
- Scopolamine- Anticholinergic- vestibular
- Ondansetron- 5 HT antagonist – all center
What is Hyoscine Butylbromide used for in EOL
Anticholinergic- Antidiarrheal
Glycopyrrolate used for in EOL
anticholinergic- Reduce salivation and reduce excessive respiratory and GI secretions
Common changes at end of life
Weakness/Fatigue Decreasing Appetite/Food Intake, Wasting Decreasing Fluid Intake, Dehydration Decreasing Blood Perfusion, Renal Failure Neurological Dysfunction: Decreasing Level of Consciousness Terminal Delirium Changes in Respiration Loss of Ability to Swallow Loss of Sphincter Control Loss of Ability to Close Eyes Changes in Medication Needs
What % of patients experience moderate to severe pain in late stages.
70%
What is cheyne stokes
Cheyne–Stokes respiration /ˈtʃeɪnˈstoʊks/ is an abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing, followed by a gradual decrease to apnea and repeats
3 step of pain control
non -opioid + adjuvant
non opioid + opioid and adjuvant
MORE/Stronger opioid plus (level 2)
Why use Artificial hydration?
Artificial hydration may not be effective or prolong life
Most common physical reasons for initiating AH are to treat delirium caused by opioid toxicity and hypercalcemia
..but generally doesn’t improv quality of life
