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704 Geriatrics > Palliative Care > Flashcards

Palliative Care Flashcards

1
Q

How should curative care be switched to palliative?

A

Gradual increase in palliative and decrease in curative

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2
Q

When should full palliative care be iniated?

A

Attempts at a cure are futile

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3
Q

What is the prognosis for Medicare benefit?

A

Terminal illness with prognosis <6 months by attending physician and hospice medical director

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4
Q

What is hospice care?

A

Subset of palliative care initiated in last 6 months

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5
Q

What symptoms can be seen in the last 1-3 months of life?

A
  • Withdrawal from world and people
  • Decreased food intake
  • Increase in sleep
  • Going inside self
  • Less communication
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6
Q

What mental changes can be seen in the last 1-2 weeks of life?

A
  • Disorientation
  • Agitation
  • Talking with the unseen
  • Confusion
  • Picking at clothes
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7
Q

What physical changes can be seen in the last 1-2 weeks of life?

A
  • Low BP
  • Paler/bluish
  • Respiratory irregularities
  • Sleeping but responding
  • Not eating, taking little fluids
  • Hot or cold temperature
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8
Q

What can be seen in the last days to hours?

A

A sudden burst in energy

Intensification of previous symptoms

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9
Q

What are symptoms of the last minutes of life?

A

“Fish out of water” breathing
Cannot be awakened

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10
Q

What cardiac/renal changes are seen while dying?

A
  • Tachycardia
  • HTN -> hypotension
  • Cyanosis
  • Mottling of skin (livedo reticularis)*
  • Venous pooling
  • Dark urine, decreased/no output
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11
Q

What are the 3 stages of cognitive decline while dying?

A
  1. Decreasing level of consciousness
  2. Decreasing ability to communicate
  3. Terminal delirium
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12
Q

T/F: Eyes usually become closed while dying

A

FALSE: loss of ability to close eyes

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13
Q

What are rare, unexpected events during death?

A
  • “Golden glow”
  • Aspiration
  • Asphyxiation
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14
Q

What are the properties of portmanteau medications?

A
  • Multiple therapeutic effects
  • Minimum interactions
  • Multiple routes
  • Wide therapeutic window
  • Cost effective
  • Convenient dosing schedule
  • Dose response and favorable ceiling effect
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15
Q

Which drugs do we use for palliative care?

A
  • Morphine
  • Methadone, hydromorphone, oxycodone
  • Lorazepam, alprazolam (has ODT)
  • Haloperidol
  • Atropine drops
  • Dexamethasone
  • Ondansetron ODT
  • Metoclopramide
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16
Q

What is an “intensol”?

A

Highly concentrated liquid form

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17
Q

What treatments do we use for gut wall N/V?

A
  1. H2 antagonist/PPI
  2. Metoclopramide
  3. Ondansetron
18
Q

What are causes of gut wall N/V?

A
  • Gastric irritants
  • Abdominal radiotherapy
  • Intestinal distention
  • Cytotoxic chemo
19
Q

What are causes of area postrema N/V?

A
  • Morphine, digoxin
  • Hypercalcemia/uremia
  • Clonidine
  • Cytotoxic chemo
20
Q

How can we treat area postrema N/V?

A
  1. Haloperidol, metoclopramide
  2. Step 1 + dexamethasone
    Pamidronate for hypercalcemia
  3. Ondansetron + dexamethasone
21
Q

What are causes of cerebral cortex N/V?

A
  • Fear/anxiety
  • Raised intracranial pressure
  • Hyponatremia
22
Q

How can we treat cerebral cortex N/V?

A
  1. Dexamethasone
  2. Amitriptyline, haloperidol, lorazepam
  3. Limited free water, saline, haloperidol
23
Q

What are causes of vestibular nuclei N/V?

A
  • Movement
  • Vertigo
24
Q

How can we treat vestibular nuclei N/V?

A
  • Diphenhydramine
  • Dimenhydrinate
  • Meclizine or cyclizine
  • Glycopyrrolate
  • Scopolamine
25
Q

What should we give if we hear wheezing?

A

Ipratropium/Albuterol +/- dexamethasone

26
Q

T/F: Morphine or other opioids should be avoided with dyspnea

A

FALSE: they can be used in low doses to treat it - reduces shortness of breath

27
Q

How do you treat cough in end of life?

A
  1. Treat underlying cause
  2. Promote production (saline +/- mucinex)
  3. Suppress cough (morphine, hydrocodone, DXM)
  4. Dexamethasone or glycopyrrolate/atropine, NAC with bronchodilator
  5. Nebulized lidocaine, gabapentin
28
Q

What are symptoms of EOL anxiety?

A
  • Worry
  • Tense
  • Unable to relax
29
Q

What are symptoms of EOL delirium?

A
  • Disorientation
  • Hallucinating
  • Aggressive
30
Q

How can we treat anxiety in EOL?

A
  • Non-pharm
  • Lorazepam, Alprazolam
  • Buspirone/SSRI (long-term)
31
Q

What can we use to treat delirium in EOL?

A
  • Haloperidol
  • Haloperidol + Lorazepam
  • Haloperidol + Midazolam
32
Q

How can we treat constipation in EOL opioid use?

A
  • Senna or bisacodyl + docusate + metoclopramide
  • Double the dose
  • Fiber, fluids, docusate if aging or disease induced
  • Sorbitol, lactulose, PEG
  • MOM, citrate of mag, bisacodyl sup
  • Naloxegol
  • Nuclear enema
33
Q

How can we treat bowel obstruction

A
  • Metoclopramide +/- dexamethasone (if incomplete obstruction)
  • Glycopyrrolate + morphine + haloperidol
  • Octreotide + above
  • PEG tube or stent
34
Q

What should we use if a depressed patient has >4 weeks left?

A
  • Escitalopram
  • Sertraline
  • +/- methylphenidate
  • Amitriptyline or nortriptyline
  • +/- methylphenidate
35
Q

What should we use if a depressed patient has <2 weeks left?

A
  • Methylphenidate
  • Ketamine
36
Q

How should we treat anorexia/cachexia in EOL?

A
  1. Treat underlying cause
  2. Metoclopramide
  3. Dexamethasone <3 months left
  4. Mirtazapine/megestrol >3 months left
  5. Dronabinol
37
Q

How should we treat insomnia in EOL?

A
  1. Treat underlying cause
  2. Trazodone or melatonin
  3. Temazepam or zolpidem
  4. Haloperidol
  5. Mirtazapine or amitriptyline (w/ depression)
  6. Increase doses of above
  7. Substitute midazolam or high dose lorazepam <7 days
38
Q

How can we treat xerostomia in EOL?

A
  1. Ice chips, gum, lemon drops
  2. Saliva substitute
  3. Pilocarpine
39
Q

How do we treat death rattle gurgling?

A

Atropine 1% eye drops
Not earlier than end stage terminal time

Also glycopyrrolate or scopolamine patch

40
Q

What should we use if intolerable symptoms are causing suffering and we should induce unconsciousness?

A
  • Opioids
  • Benzodiazepines
  • Neuroleptics
  • Barbiturates
  • Anesthetics
  • A combination of these agents
41
Q

What are signs that death occurred?

A
  • Heart stops
  • Breathing stops
  • Pupils fixed and dilated
  • Body color pale
  • Body temperature low
  • Muscles and sphincters relax until rigor mortis (4-6 hours later)
  • Urine and stool released
  • Eyes may remain open
  • Jaw can fall open
  • Trickling of fluids may be audible
42
Q

What is a “good death”

A
  • Treated as individual with dignity and respect
  • Without pain or other symptoms
  • Familiar surroundings
  • Company of close family/friends

704 Geriatrics (8 decks)

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