Palliative care

Question 1

What Do Palliative Care Specialists Do?

Answer 1

Manage pain, dyspnea, anxiety, N/V
*Hospice care
*Medication reconciliation
*Withdraw life support
*Outpatient PC
*Resource utilization
*Insurance issues

Question 2

What is Advanced Care Planning

Answer 2

*Code status
*Goals of care
*Spiritual issues
*Consultant etiquette
*Surrogacy
*Ethical challenges

Question 3

3 Pillars of palliative care

Answer 3

Acute Distress: How am I suffering now?

Communication: What do I understand and what decisions should I make?

Disposition: How does my care proceed from here?

Question 4

Symptoms treated in palliative care

Answer 4

*Pain
*Fatigue
*Dyspnea
*Nausea and vomiting
*Constipation
*Delirium
*Anorexia
*Depression and anxiety
*Insomnia
*Spiritual and existential suffering

Question 5

Pain tx Objectives

Answer 5

Improve quality of life
Decrease the frequency and/or severity of the pain
General sense of feeling better
Increased level of activity
Return to work
Decrease health care utilization
Elimination or reduction in medication usage

Question 6

Treatment for Fatigue

Answer 6

*Dextroamphetamine (Procentra®) 5-10 mg/d
*Methylphenidate (Ritalin®, Concerta®) 2.5 - 5mg/d

*Both drugs are CNS stimulants

Give in the AM to enhance energy levels

Question 7

Concepts for treating fatigue and what can cause this

Answer 7

**Universal therapy for terminally ill patients
*Direct consequence of the disease and the cytokines produced in response to that process
Other contributing factors: Anemia, Depression, Hypothyroidism, Infection, Dehydration

Question 8

What is the difference between treating dyspnea in COPD patient versus treating dyspnea in a patient at the end of life?

Answer 8

Treating the underlying process - COPD, CF, malignancy, superior vena cava syndrome, CHF

Question 9

Dyspnea tx for end of life

Answer 9

treat nonspecifically with opioids
*Lower than necessary to treat moderate pain
*Morphine 5-10 mg q4h PO or 5-10 mg IV q4h
*Oxygen when patient is hypoxic
*Fresh air from window if patient is not hypoxic
*Meditation for relaxation
*Benzodiazepines for dyspnea-related anxiety

Question 10

what conditions have treatments that are mostly palliative

Answer 10

COPD and heart failure

Question 11

what sxs is common at end of life

Answer 11

N/V; can be some of most disabling sxs

Question 12

Highest rate of nausea/vomiting occurs in what disease(s)

Answer 12

advanced gynecological and gastrointestinal cancer

Question 13

causes of n/v in pts w serious illness

Answer 13

*Chemotherapy and radiation
*Drug irritation - opioids, NSAIDs, iron, antibiotics
*Constipation (from opioids)
*Gastroparesis
*Gastric outlet or bowel obstruction
*End-stage cardiac, renal and liver disease

Question 14

How should nausea and vomiting be managed differently in palliative care?

Answer 14

*Regular dosing
*Multiple medications

Question 15

Causes of constipation

Answer 15

Opioids for management of pain and dyspnea
Tricyclic antidepressants with anticholinergic effects
Inactivity
Poor diet
Hypercalcemia

Question 16

tx for constipation in palliative care

Answer 16

Pharmacologic and non-pharmacologic therapies
Improved physical activity
Adequate hydration

Question 17

Delirium is.. preceded by … and associated w ….

Answer 17

Usually sudden in onset and preceded by anxiety
Associated with altered cognition and consciousness

Question 18

Tx of delirium: things to implement and meds

Answer 18

*Stop any medication that may have this side effect
*Provide orienting signals - calendar, clock, newspaper, etc.

Pharmacologic interventions:
*Antipsychotics - Haloperidol (Haldol®): 1st gen, Olanzapine (Zyprexa®), Risperidone (Risperdal®), Quetiapine (Seroquel®): all second gen
*Anxiolytics - Lorazepam (Ativan®), Midazolam (Versed)

Question 19

Are high levels of depression and anxiety normal of the dying process

Answer 19

No; but normal level are expected

Question 20

General idea for Tx of depression and anxiety

Answer 20

should depend on:
*Intensity
*Persistence
*Disruption of basic life functioning

Treatment:
*Counseling with patient and family
*Medications

Question 21

Meds for tx of depression and anxiety

Answer 21

*Selective Serotonin Reuptake Inhibitor (SSRIs)
*Serotonin-Norepinephrine Reuptake Inhibitor (SNRIs)
*Tricyclic antidepressants
*Benzodiazepines for anxiety

Question 22

Causes of Insomnia

Answer 22

Fear
Anxiety
Depression
Panic
Racing thoughts associated with terminal diagnosis

Question 23

Medication and other tx options for insomnia

Answer 23

*Herbal teas
*OTC options:
Antihistamines (i.e., diphenhydramine)
*Side Effects: Anticholinergic adverse effects - dry mouth, blurred vision, urinary retention, confusion in older patients
*Melatonin: Available OTC, 3-5 mg PO qhs
*Ramelteon (Rozerem®), 8 mg PO 30 minutes of bedtime; Melatonin receptor agonist

Question 24

Prescribed rx for insomnia

Answer 24

Short or intermediate acting benzodiazepine or benzodiazepine receptor antagonists: Temazepam (Restoril®), Zolpidem (Ambien®), Eszopiclone (Lunesta®), Zaleplon
*Side effects: Headache, unpleasant taste, abnormal dreams

Antidepressants: Amitriptyline, Mirtazapine (Remeron®) - Also useful in patients experiencing decreased appetite, Trazodone: increases risk of falls risk in elderly

Question 25

Short term tx for insomnia

Answer 25

Restoril, Temazepam –> aka Benzodiazepines

Question 26

Counseling pt family on anxiety and depression concepts

Answer 26

Include:
*Expectations
*Treatment
*Prognosis
*Correct Misconceptions
*Educate on side effects of psychological, biological, and pharmacological factors contributing to anxiety and depression