Palliative Care

Question 1

N/V management secondary to cytotoxic chemo

Answer 1

Step 1:
- Haloperidol
- Metoclopramide

Step 2:
- above + dexamethasone
- pamidronate for hypercalcemia

Step 3:
- Ondansetron + Dexamethasone

Question 2

N/V management secondary to fear/anxiety, raised intracranial pressure, or hyponatremia

Answer 2

Step 1:
- Dexamethasone
Step 2:
- Amitriptyline
- Haloperidol
- Lorazepam
Step3:
- limited free water +/-
- 3% saline +/-
- Haloperidol

Question 3

N/V management secondary to vertigo

Answer 3

Step 1:
- diphenhydramine
- dimenhydrinate
Step 2:
- Meclizine or Cyclizine
Step 3:
- Glycopyrrolate
- Scopolamine

Question 4

Dyspnea management

Answer 4

Step 1:
- treat underlying cause
Step 2:
- Ipratropium/Albuterol +/- dexamethasone
Step 3:
- Morphine +/- dexamethasone
Step 4:
- Morphine AND Chlorpromazine, Diazepam, or Midazolam

Question 5

Cough Management

Answer 5

Step 1:
- treat underlying cause
Step 2:
- promote production -> nebulized saline and/or guaifenesin
Step 3:
- Suppress cough -> morphine, hydrocodone, dextromethorphan
Step 4:
- Dexamethasone or Glycopyrrolate/atropine
- NAC
Step 5:
- Nebulized lidocaine or gabapentin

Question 6

Anxiety management

Answer 6

Step 1:
- non pharm
Step 2 (short term):
- lorazepam
- alprazolam
- amitriptyline
Step 2 (long term):
- Buspirone
- SSRI
- Mirtazapine

Question 7

Delirium management

Answer 7

Step 1:
- Haloperidol
Step 2:
- Haloperidol + lorazepam
Step 3:
- Haloperidol + midazolam or chlorpromazine

Question 8

Bowel obstruction management

Answer 8

Step 1:
- metoclopramide +/- dexamethasone (not in complete obstruction)
Step 2:
- Glycopyrrolate +/- morphine or haloperidol
Step 3:
- octreotide +/- above
Step 4:
- PEG tube or stent

Question 9

Depression management

Answer 9

Step 1: (> 4 weeks survival)
- escitalopram
- sertraline
- +/- methylphenidate until SSRI effective
Step 2: (> 4 weeks survival)
- amitriptyline or nortriptyline
- +/- methylphenidate
Step 3: (< 4 weeks survival)
- methylphenidate
- ketamine

Question 10

Anorexia management

Answer 10

Step 1:
- treat underlying cause
Step 2:
- metoclopramide
Step 3:
- dexamethasone
- Mirtazepine
- Megestrol
Step 4:
- Dronabinol

Question 11

Insomnia management

Answer 11

Step 1:
- underlying cause
Step 2:
- Falling asleep: trazadone, melatonin, temazepam, zolpidem
- Staying asleep: haloperidol
- Depression: mirtazapine, amitriptyline
Step 3
- increase doses of step 2
- combo step 2
- substitute midazolam or high dose lorazepam

Question 12

Death rattle management

Answer 12

Atropine 1% ophthalmic drops SL 2-3 q 2-3h PRN
Scopolamine patch
Glycopyrrolate