Palliative care Flashcards
What Do Palliative Care Specialists Do?
Manage pain, dyspnea, anxiety, N/V
*Hospice care
*Medication reconciliation
*Withdraw life support
*Outpatient PC
*Resource utilization
*Insurance issues
What is Advanced Care Planning
*Code status
*Goals of care
*Spiritual issues
*Consultant etiquette
*Surrogacy
*Ethical challenges
3 Pillars of palliative care
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?
Symptoms treated in palliative care
*Pain
*Fatigue
*Dyspnea
*Nausea and vomiting
*Constipation
*Delirium
*Anorexia
*Depression and anxiety
*Insomnia
*Spiritual and existential suffering
Pain tx Objectives
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
Treatment for Fatigue
*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
Concepts for treating fatigue and what can cause this
**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
What is the difference between treating dyspnea in COPD patient versus treating dyspnea in a patient at the end of life?
Treating the underlying process - COPD, CF, malignancy, superior vena cava syndrome, CHF
Dyspnea tx for end of life
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
what conditions have treatments that are mostly palliative
COPD and heart failure
what sxs is common at end of life
N/V; can be some of most disabling sxs
Highest rate of nausea/vomiting occurs in what disease(s)
advanced gynecological and gastrointestinal cancer
causes of n/v in pts w serious illness
*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
How should nausea and vomiting be managed differently in palliative care?
*Regular dosing
*Multiple medications
Causes of constipation
Opioids for management of pain and dyspnea
Tricyclic antidepressants with anticholinergic effects
Inactivity
Poor diet
Hypercalcemia
tx for constipation in palliative care
Pharmacologic and non-pharmacologic therapies
Improved physical activity
Adequate hydration
Delirium is.. preceded by … and associated w ….
Usually sudden in onset and preceded by anxiety
Associated with altered cognition and consciousness
Tx of delirium: things to implement and meds
*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)
Are high levels of depression and anxiety normal of the dying process
No; but normal level are expected
General idea for Tx of depression and anxiety
should depend on:
*Intensity
*Persistence
*Disruption of basic life functioning
Treatment:
*Counseling with patient and family
*Medications
Meds for tx of depression and anxiety
*Selective Serotonin Reuptake Inhibitor (SSRIs)
*Serotonin-Norepinephrine Reuptake Inhibitor (SNRIs)
*Tricyclic antidepressants
*Benzodiazepines for anxiety
Causes of Insomnia
Fear
Anxiety
Depression
Panic
Racing thoughts associated with terminal diagnosis
Medication and other tx options for insomnia
*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
Prescribed rx for insomnia
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
Short term tx for insomnia
Restoril, Temazepam –> aka Benzodiazepines
Counseling pt family on anxiety and depression concepts
Include:
*Expectations
*Treatment
*Prognosis
*Correct Misconceptions
*Educate on side effects of psychological, biological, and pharmacological factors contributing to anxiety and depression
