Palliative Care Flashcards
What is the life expectancy of patients who are beneficiaries of the BC Palliative Care Benefits Program?
up to 6 months
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
- 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
The most common route of drug administration in palliative care settings is:
subcutaneous
What are first and second-line pharmacological treatments for delirium?
- 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)
- Midazolam SC
- Second Line = Ketamine SC/IM
- No dosing provided under BCEHS guidelines, consult clinicall
What are the inclusion criteria for the palliative care ASTaR pathway? (4)
- 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
How often should breakthrough doses be given?
- orally = q1h
- SC = q30m
breakthrough dosing does not replace regularly scheduled dosing!
Briefly describe equianalgesic doses of morphine, oxycodone, and hydromorphone. Describe differences between PO and SC dosing
- 2mg hydromorphone = 10mg morphine = 7.5mg oxycodone (1 , 5, 3.75)
- PO dosing is double the SC dosing
Are physical restraints effective in management of hyperactive delirium
No!
Avoid the use of physical restraints as they can increase the risk of delirium
What is the significance of a patient requiring 3 or more breakthrough doses in a 24hr period?
they will require adjustment of their daily dosing
What is the maximum SC dose of morphine which may be given?
20mg
Consult clinicall if this is not an effective dose
What are non-opioid pain medications which may be useful in the palliative care setting?
- Acetaminophen
- 500-1,000 mg PO
- May repeat once after 4 hours
- Entonox (PRN)
- Ketamine
- SC dosing not specified, but likely 0.5mg/kg
True or false, the goal of dyspnea management in palliative settings is correction of hypoxia
FALSE!
By definition, it is a subjective sensation and may or may not be associated with hypoxia
How is the TDD (todal daily dose) calculated for a drug given for pain management?
The total daily dose is the 24-hour total of a specific drug that is taken for regular and breakthrough pain
List 5 common causes of delirium in the palliative population
- 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
What is delirium, what are the three types, and is it a normal part of the dying process?
- 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
Describe signs of imminent death in palliative care patients (7)
- 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
The drug class of choice for managing palliative dyspnea is
opioids
Is it possible to enroll a patient in the palliative ASTaR pathway if you are not able to reach their primary care team?
YES!
Consultation with clinicall/EPOS required
Decribe non-pharmacological management of dyspnea in palliative care patients
- Adjust positioning
- Use fan, open windows, improve airflow
- Provide reassurance
Describe common non-pharmological and pharmacological treatments for nausea in the palliative setting
- 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
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?
- 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.
How is breakthrough dosing calculated for pain management drugs? Does breakthrough dosing replace regularly scheduled drugs?
- 10% of TDD from previous 24 hrs.
- May need to use opioid equivalency table to calculate
- Does NOT replace normally scheduled dose
Describe pharmacological management of dyspnea in palliative care settings
- 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
Describe management of secretions in end-of-life care
- Gentle suctioning only if excessive secretions
- Position upright/sitting
- Consider atropine IM
- 0.6mg
- Consider glycopyrrolate IM
- Consult with care team
Describe the incidence and common causes of nausea in palliative care patients
- Affects 40-60% of all individuals receiving palliative care
- Gastroparesis and chemical disturbances are the most common causes
What is required Siren documentation for the palliative care ASTaR Pathway?
- 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
Are breakthrough dosing calculations used for non-opioid medications in the pre-hospital palliative care setting?
No!
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?
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.
Describe situations where a palliative care patient is not appropriate for the ASTaR pathway (3)
- 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
What are general guidelines for subcutaneous morphine and midazolam dosing in palliative care patients (not considering breakthrough dosing)
- 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
