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ACP Practical Exam Preparation > Palliative Care > Flashcards

Palliative Care Flashcards

1
Q

What is the life expectancy of patients who are beneficiaries of the BC Palliative Care Benefits Program?

A

up to 6 months

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2
Q

A patient currently takes 2mg hydromorphone q4h PO and had 2 x 0.5mg breakthrough doses yesterday. Describe breakthrough SC morphine dosing for this person today

A
  • TDD = 13mg hydromorphone PO
  • Convert to morphine PO
    • 65mg morphine PO
  • Convert to morphine SC
    • 32.5mg morphine SC
  • Convert to breakthrough dose (10% of TDD)
    • 3.25mg SC
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3
Q

The most common route of drug administration in palliative care settings is:

A

subcutaneous

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4
Q

What are first and second-line pharmacological treatments for delirium?

A
  • First Line = Benzodiazepines
    • Midazolam SC
      • 2.5-10mg sc q20 mins to settle
      • frail older adults: 1.25-5mg sc q20 mins to settle
    • Ativan/lorazepam SL
      • 1 mg SL (only if prescribed for patient)
  • Second Line = Ketamine SC/IM
    • No dosing provided under BCEHS guidelines, consult clinicall
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5
Q

What are the inclusion criteria for the palliative care ASTaR pathway? (4)

A
  • Patient is diagnosed with an advanced life-limiting illness OR;
  • Care is currently focused on symptom management rather than curative interventions AND;
  • Presenting symptoms are considered related to the patient’s palliative condition AND;
  • Patient and family agree to treatment in place
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6
Q

How often should breakthrough doses be given?

A
  • orally = q1h
  • SC = q30m

breakthrough dosing does not replace regularly scheduled dosing!

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7
Q

Briefly describe equianalgesic doses of morphine, oxycodone, and hydromorphone. Describe differences between PO and SC dosing

A
  • 2mg hydromorphone = 10mg morphine = 7.5mg oxycodone (1 , 5, 3.75)
  • PO dosing is double the SC dosing
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8
Q

Are physical restraints effective in management of hyperactive delirium

A

No!

Avoid the use of physical restraints as they can increase the risk of delirium

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9
Q

What is the significance of a patient requiring 3 or more breakthrough doses in a 24hr period?

A

they will require adjustment of their daily dosing

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10
Q

What is the maximum SC dose of morphine which may be given?

A

20mg

Consult clinicall if this is not an effective dose

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11
Q

What are non-opioid pain medications which may be useful in the palliative care setting?

A
  • Acetaminophen
    • 500-1,000 mg PO
    • May repeat once after 4 hours
  • Entonox (PRN)
  • Ketamine
    • SC dosing not specified, but likely 0.5mg/kg
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12
Q

True or false, the goal of dyspnea management in palliative settings is correction of hypoxia

A

FALSE!

By definition, it is a subjective sensation and may or may not be associated with hypoxia

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13
Q

How is the TDD (todal daily dose) calculated for a drug given for pain management?

A

The total daily dose is the 24-hour total of a specific drug that is taken for regular and breakthrough pain

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14
Q

List 5 common causes of delirium in the palliative population

A
  • Sepsis
  • Metabolic or electrolyte disturbances
  • Hypoxia
  • Organ failure
  • Withdrawal from alcohol or medications
  • Unmanaged or undermanaged pain
  • Sleep deprivation
  • Constipation or urinary retention
  • Dehydration
  • Changes to the patient’s environment or psychosocial situation
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15
Q

What is delirium, what are the three types, and is it a normal part of the dying process?

A
  • abrupt fluctuating disturbances in attention and awareness that represents a change from baseline status
  • hypoactive, hyperactive, or mixed
  • Not normal! Common, but should be treated to reduce distress of pt + family
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16
Q

Describe signs of imminent death in palliative care patients (7)

A
  • Patient uncommunicative, unresponsive, and difficult to arouse
  • Cold, purple, blotchy feet and hands
  • Drowsiness or impaired cognition
  • Decreased urine output
  • Restlessness
  • Congestion and gurgling in the chest
  • Alterations in breathing patterns
17
Q

The drug class of choice for managing palliative dyspnea is

A

opioids

18
Q

Is it possible to enroll a patient in the palliative ASTaR pathway if you are not able to reach their primary care team?

A

YES!

Consultation with clinicall/EPOS required

19
Q

Decribe non-pharmacological management of dyspnea in palliative care patients

A
  • Adjust positioning
  • Use fan, open windows, improve airflow
  • Provide reassurance
20
Q

Describe common non-pharmological and pharmacological treatments for nausea in the palliative setting

A
  • Non-pharmacological interventions
    • provide the best relief for mild and moderate nausea and vomiting.
    • Keep air and room fresh
    • Eliminate strong odors
  • For moderate to severe nausea, consider
    • Metoclopramide 5 mg SC
    • Ondansetron SC
    • DimenhyDRINATE PO/SC
21
Q

What are specific situations where paramedics may be called to assist in a MAiD event? What are they NOT permitted to do in these circumstances?

A
  • Inserting an intravenous line that has been ordered by a physician or nurse practitioner for MAiD (paramedics only).
  • Conveying a patient from one destination to another for the purposes of MAiD.
  • Paramedics and EMRs are NOT permitted to administer medication for MAiD under any circumstance.
  • Paramedics and EMRs are NOT considered health professionals for the purposes of witnessing an eligibility assessment, nor for death confirmation.
22
Q

How is breakthrough dosing calculated for pain management drugs? Does breakthrough dosing replace regularly scheduled drugs?

A
  • 10% of TDD from previous 24 hrs.
    • May need to use opioid equivalency table to calculate
  • Does NOT replace normally scheduled dose
23
Q

Describe pharmacological management of dyspnea in palliative care settings

A
  • Manage bronchoconstriction if present
    • Salbutamol (4x100mcg MDI)
    • Ipratropium (8x20mcg MDI)
  • Oxygen
    • Only if patient is hypoxic!
  • Morphine
    • 0.1 mg/kg SC OR
    • 2.5-5 mg SC
    • May repeat every 10-30 minutes as required based on blood pressure (> 100 mmHg) or as per CliniCall/palliative care team plan
  • Midazolam for agitation
    • 2.5-10mg SC or 1.25-5mg SC in frail, older adults
24
Q

Describe management of secretions in end-of-life care

A
  • Gentle suctioning only if excessive secretions
  • Position upright/sitting
  • Consider atropine IM
    • 0.6mg
  • Consider glycopyrrolate IM
    • Consult with care team
25
Q

Describe the incidence and common causes of nausea in palliative care patients

A
  • Affects 40-60% of all individuals receiving palliative care
  • Gastroparesis and chemical disturbances are the most common causes
26
Q

What is required Siren documentation for the palliative care ASTaR Pathway?

A
  • Patient phone number
    • to ensure clinicall / care team follow-up is possible
  • Palliative impression code
  • Complete care plan section
  • Consent to referral signature (refusal of care not required)
  • Attach pictures of goals of care

Paramedics should still complete a full assessment

Notify pt/family to expect a follow-up consultation

27
Q

Are breakthrough dosing calculations used for non-opioid medications in the pre-hospital palliative care setting?

A

No!

28
Q

A patient’s family has asked you to prepare palliative medications for deferred use as they do not feel comfortable doing so. Is this allowed? If so, under what conditions?

A

YES!

Short form rules: Their meds, their care plan, your call, your license

  • The medication is specified and prepared in accordance to a palliative care management plan developed and authorized by a physician or nurse practitioner; and
  • The medication has already been prescribed to the patient and is in the possession of the patient (i.e., the paramedic is not providing the medication from BCEHS supply); and
  • Authorization from CliniCall has been obtained if the medication is not specified within the Regulation; and
  • The ACP has successfully completed the BCEHS, ‘Schedule 2 Endorsement: Palliative Medication,’ on the PHSA Learning Hub; and
  • The ACP has received the EMA Regulation Schedule 2, Section 4(b) endorsement for administration of drug therapy on the direct order of a medical practitioner who is designated by BCEHS as a Transport Advisor.
29
Q

Describe situations where a palliative care patient is not appropriate for the ASTaR pathway (3)

A
  • Presentation is not related to their palliative condition
    • ex:acute injury, new illness
  • Patient/family do not consent to treatment in place
  • Inability to appropriately treat in place
    • ex: patient’s opioid requirements exceed dosing limits for ACPs
30
Q

What are general guidelines for subcutaneous morphine and midazolam dosing in palliative care patients (not considering breakthrough dosing)

A
  • Morphine
    • 0.1 mg/kg SC OR
    • 2.5-5 mg SC
    • May repeat every 10-30 minutes as required based on blood pressure (> 100 mmHg) or as per CliniCall/palliative care team plan
  • Midazolam (per iPal app)
    • 2.5-10mg sc q20 mins to settle
    • frail older adults: 1.25-5mg sc q20 mins to settle
  • Rough starting point
    • 2.5mg of morphine and midazolam, q.20minutes

ACP Practical Exam Preparation (10 decks)

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