Palliative Care Flashcards
True or False: Child must be terminally ill or at the end of life for palliative care
False
True or false: Child must have a DNR to have hospice care
False
True or false: child must abandon all disease directed treatment to receive palliative care
False
True or false: child must abandon primary care team and movie to a different unit for palliative care
False
True or False: Administering opioids causes respiratory depression and quickens death
False
What is the consequence of mislabelling in palliative care?
the CARE is palliative not the patient
What do consequences of myths foster:
Doing nothing, leading to feelings of giving up, losing hope, last resort
WHO definition of palliative care
an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.
Pediatric Palliative Care Definition
for those 17 minus a day
o A combination of active and compassionate therapies to comfort and support children and families living with a life threatening/limiting illness
o To provide a framework for discussion of balancing the benefits and risks of any intervention
What are life threatening/limiting illnesses
Conditions where survival into adulthood is a challenges
Malignancies, respiratory, CNS degeneration/abnormalities, syndromes, CV, neuromuscular, metabolic, transplants
Old palliative care paradigm
- clear demarcation between curative and palliative
- palliative when close to death
- little bereavement > only involved at end of life
New palliative care model
- no demarcation between curative and palliative
- benefit long before death
- involvement throughout care and extends beyond death
- care in the home
- encompasses family
Benefit of early involvement of palliative care
for symptom management and decreases feeling of stress when increased services are necessary.
Less stress when they know ahead of time/before end of life care is necessary
Keys to good palliative care
Effective communication and impeccable planning
How does disease trajectory in pediatric palliative effect care?
often means support for years – diagnosis at birth causes palliative to follow into adulthood
What considerations are made for familial life limiting illnesses?
some families have to go through this more than one time and make decisions re limiting family (future children) – autosomal diseases
What do families want from palliative care?
- positive consistent relationships with caregivers/care team
- comprehensive information from familiar staff
- adequate pain management
- contact after the child’s death
- cultural awareness
- support for siblings
- care in setting of choice
What symptoms are mainly managed in palliative?
- pain
- dyspnea
- bleeding
- N/V
- secretions
- constipation/obstruction
- fatigue
- seizures
- irritability/agitation
- decreased appetite
4 difficult decisions in palliative care
- goals of care: what do parents want if child stops breathing
- resuscitation guidelines
- withdrawal of artificial support
- ethical decisions
3 criteria for withdrawal of artificial support
- imminent death
- brain death
- child with no small bowel
True or false: resuscitation guidelines are set in stone
False
What is important in providing parents guidance on resuscitation guidelines
Assure understanding of prognosis and that regardless of interventions, outcome is the same. What differs is the interventions/how we get to the outcome regardless of choice
In saskatchewan, we see the highest incidence per capita of
Perinatal palliative care
What is the perinatal period?
20th/28th week gestation to 1-4 weeks postnatal
Describe the patient population for perinatal care?
- limit of viability: 22-23 weeks around 500g
- overwhelming illness unresponsive to treatment or suffering from the treatment
- congenital anomies of life-threatening nature
What is the birth plan for perinatal palliative care?
“Wish List” – location of delivery (close to home?), resuscitation, DNR, symptom management (pain, agitation, seizures, hypoxia)
Define pain
an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
Nociceptive Pain and types
Damage to underlying soft and bone tissues by disease
somatic or visceral
Description of somatic pain
- Well localized
- Sharp, throbbing, squeezing or aching
Description of visceral Pain
- Diffuse, poorly localized
- Dull, crampy or colicky
Neuropathic Pain
o Invasion of or traction on nerves arising from injury to:
Central Nervous System
Peripheral Nervous System
Description and examples of neuropathic pain
- Burning, stinging, tingling, prickly
- Stabbing, lancinating, shock-like
- Ex: tumors, phantom pain, referred pain
What is the CRIES assessment tool?
Neonatal post-op pain
Score indication of CRIES tool
< 4 = initiate nonpharmacologic measures
> 4 = initiate pharmacologic and nonpharmacologic measures
What 5 things does the CRIES tool assess?
Crying, oxygen, vitals, expression, sleeplessness
What is the FLACC scale?
Post op pain assessment for 2-7 year old
What 5 things does the FLACC scale assess
Face, legs, activity, cry and consolability scale
When would you use the FLACC scale
Assesses behaviour -
You would use this scale with patients who have difficulty verbalizing pain
3 Limitations of Pain Assessment Tools
- Only assess behaviour, not fear or anxiety that children combine with pain
- self report of child
- not holistic assessment of emotional, psychological, spiritual pain
Describe the WHO Pain Management Ladder
Pt presents w pain
- Non opioid +/- adjuvant
Pain persists/increases
- Opioid for mild/moderate pain +/- non opioid +/- adjuvant
Pain persists/increases
- Opioid for moderate/severe pain +/- non-opioid +/- adjuvant
True or false: if a patient comes in with severe pain, according to WHO ladder you begin with non opioid +/- adjuvant
False - You do not need to go up each step. If a patient presents with severe pain, you should not treat them on step 1.
Pain Management “by the ladder”
utilize WHO ladder
Pain Management “by the clock”
(scheduling something regularly, usually q4h with breakthrough)
Pain Management “by the mouth”
(start with PO, least invasive first)
Pain Management “by the child”
(assessing patient not parent)
Describe pediatric palliative pain management dosing
- started at standard pediatric dose and titrated for pain from there
- no expected ceiling or cap on doses
- The key to this is close communication
Opioid side effects
- Constipation
- Nausea/Vomiting
- Pruritus
- Respiratory Depression
- Confusion and/or Hallucinations
- Myoclonus: build up of morphine
- Somnolence: common, wears off in 24-48 hours
In what 3 instances should you consult palliative care?
- life threatening/limiting illness at any age or with any diagnosis
- consideration of forgoing life saving therapy
- early involvement is crucial
How is dyspnea managed in palliative?
- fan
- upright position
- opening window
- O2 dependent on insurance
- ativan
- midazolam
How is bleeding managed in palliative?
- dark linen and midazolam
How is nausea and vomiting managed in palliative?
- small meals
- hydration
- nabilone
- alternate routes for meals
- decradon, onasetron, metoclopramide
How are secretions managed in palliative?
- suction
- scopalomine patch
- glycopyrotate
- mouth care
how is constipation managed in palliative
- laxatives/supps
- miralax
How is fatigue managed in palliative
- methylphenidate for older
- scheduling visits accordingly
How is decreased appetite managed in palliative
- small frequent meals
- awareness patient may choose not to eat
- megace
Most common interventions for perinatal palliative care
Tube feeding
Pain usually not an issue but codeine can be prescribed for dyspnea and agitation
