Palliative Care

Question 1

palliative care

Answer 1

• aims to receive suffering
• improve QOL and dying
• physical, psychosocial, social, and spiritual needs
• started at time of diagnosis

Question 2

starting palliative care early

Answer 2

• extending life
• relationship with care team
• improves QOL early on

Question 3

when palliative care is indicated

Answer 3

• if not surprised if person died in 6-12 months

Question 4

palliative care requires:

Answer 4

• set of knowledge, attitudes, and skill based competencies

Question 5

most effective palliative care

Answer 5

• delivered by interdisciplinary collaboration

Question 6

integral part of palliative care

Answer 6

• grief and bereavement care

Question 7

palliative assessments

Answer 7

• Edmonton symptom assessment

- palliative performance scale

Question 8

causes of pain

Answer 8

• disease itself
• treatment of disease
• factors unrelated to disease

Question 9

barriers to pain control

Answer 9

• not being able to voice
• sedation
• stigma
• worry about addiction/tolerance
• past experience with pain meds
• HCP feelings regarding pain control

Question 10

goal of palliative care

Answer 10

to provide comfort

Question 11

only med that has a ceiling

Answer 11

codeine

Question 12

types of pain

Answer 12

• nociceptive
• neuropathic
• central
• sympathetically maintained

Question 13

nociceptive pain

Answer 13

• damage to bone and soft tissue
• somatic - localized sharp dull
• visceral - regional

Question 14

neuropathic pain

Answer 14

• from injury to central, peripheral, or autonomic NS
• dysphasia - burning
• neuralgic - shock
• mixed

Question 15

central pain

Answer 15

• from damage to CNS

- post stroke

Question 16

sympathetically maintained pain

Answer 16

• regional pain syndrome

- disproportionate to what you would expect

Question 17

10 principles of pain management

Answer 17

• avoid delay
• by the ladder
• by the mouth
• by the clock (scheduled)
• with breakthrough
• for the individual
• all aspects of suffering
• monitor efficacy
• identify and treat underlying cause
• pain is multidimensional

Question 18

WHO pain ladder - mild pain

Answer 18

• 1-3/10
• non-opioid
• +/- adjuvant

Question 19

WHO pain ladder - moderate pain

Answer 19

• 4-6/10
• weak opioid (codeine, tramadol)
• +/- adjuvant

Question 20

WHO pain ladder - severe pain

Answer 20

• 7-10/10
• strong opioid
• +/- adjuvant

Question 21

1st line opioids

Answer 21

• morphine
• hydromorphone
• oxycodone

Question 22

2nd line opioids

Answer 22

• fentanyl

Question 23

3rd line opioids

Answer 23

• methadone

Question 24

opioid conversion always based on what dose

Answer 24

morphine dose

Question 25

cross allergy between what opioids

Answer 25

• codeine and morphine

Question 26

adjuvants

Answer 26

• NSAIDs
• cannabis
• corticosteroids (dexamethasone)
• anticonvulsants (gabapentin, pregamblin)
• antidepressants
• radiation
• biphosphonates (bone mets)

Question 27

breakthrough pain is what % of total daily dose

Answer 27

• 10%

- q1hr PRN

Question 28

opioid routes

Answer 28

• PO
• subcue
• IV
• transdermal
• intranasal
• intrabuccal
• IM

Question 29

starting an opioid

Answer 29

• immediate release form q4hrs

Question 30

switching to fentanyl patch

Answer 30

• changed q3days
• convert to morphine dose
• not used as breakthrough
• continue q4h dosing for 8-16hrs while patch kicks in
• dose change = take off low dose patch and put on new high dose

Question 31

opioid side effects

Answer 31

• depressed respiratory rates
• constipation
• itchy
• nausea (metoclopramide 1st line)
• sedation

Question 32

signs of opioid toxicity (7)

Answer 32

• myoclonus (decreased movement)
• hallucinations
• agitation
• somnolence
• cognitive dysfunction
• hyperalgesia
• delirium/confusion

Question 33

treatment for opioid toxicity

Answer 33

• hydration

- decrease/switch opioid

Question 34

what % to decrease dose by for opioid toxicity

Answer 34

decrease 24hr dose by 20% due to cross tolerance

Question 35

what antiemetic can cause long QT syndrome

Answer 35

domperidone

Question 36

what antiemetic works for hiccups

Answer 36

metoclopramide

Question 37

what not to give if risk for bowel obstruction

Answer 37

metoclopramide

Question 38

malignant bowel obstruction treatment

Answer 38

• IV fluids
• NPO (alternate med routes)
• octreotide (decrease secretions)
• dexamethasone (decrease inflammation)
• bucospan (decrease spasms)

Question 39

dementia

Answer 39

• onset months - years

- symptoms generally stable with some fluctuations

Question 40

depression

Answer 40

• onset weeks - months

- symptoms generally stable

Question 41

delirium

Answer 41

• onset hours - days

- symptoms fluctuate

Question 42

types of delirium

Answer 42

• hyperactive
• hypoactive
• mixed

Question 43

hyperactive delirium

Answer 43

• increases risk of harm

- more urget management

Question 44

hypoactive delirium

Answer 44

• may be overlooked
• easily missed
• “pleasantly confused”

Question 45

mixed delirium

Answer 45

• more variable

Question 46

depression, anxiety, and grief

Answer 46

• major depression in a minority of pts
• supportive counselling in mainstay
• some pts require antidepressants
• rely on non-pharm for anxiety
• identify individuals with complicated grief

Question 47

why do people ask to end life

Answer 47

• uncontrolled pain
• psychological factors
• social concerns
• loss of dignity or control
• mostly r/t fear of future suffering
• MAID is not component of palliative care

Question 48

last days & hours of life (10)

Answer 48

• prepare early
• plan setting of death
• encourage funeral planning
• educate family
• spiritual and religious needs
• review goals of care
• d/c meds no longer needed
• benefits/burden of hydration
• prepare for inability to swallow (different med routes)
• identify those at risk for massive bleeding

Question 49

sign death is imminent (6)

Answer 49

• increased sleeping/unconsciousness
• decreased intake
• change in resp rate and rhythm (Cheyne stokes)
• decreased peripheral perfusion
• skin mottling
• airway secretions (death rattle)

Question 50

what to do when death is imminent

Answer 50

• d/c vitals and O2 sats
• continue to use O2 if have been
• apply O2 if looks distressed