Palliative Care Flashcards
How should curative care be switched to palliative?
Gradual increase in palliative and decrease in curative
When should full palliative care be iniated?
Attempts at a cure are futile
What is the prognosis for Medicare benefit?
Terminal illness with prognosis <6 months by attending physician and hospice medical director
What is hospice care?
Subset of palliative care initiated in last 6 months
What symptoms can be seen in the last 1-3 months of life?
- Withdrawal from world and people
- Decreased food intake
- Increase in sleep
- Going inside self
- Less communication
What mental changes can be seen in the last 1-2 weeks of life?
- Disorientation
- Agitation
- Talking with the unseen
- Confusion
- Picking at clothes
What physical changes can be seen in the last 1-2 weeks of life?
- Low BP
- Paler/bluish
- Respiratory irregularities
- Sleeping but responding
- Not eating, taking little fluids
- Hot or cold temperature
What can be seen in the last days to hours?
A sudden burst in energy
Intensification of previous symptoms
What are symptoms of the last minutes of life?
“Fish out of water” breathing
Cannot be awakened
What cardiac/renal changes are seen while dying?
- Tachycardia
- HTN -> hypotension
- Cyanosis
- Mottling of skin (livedo reticularis)*
- Venous pooling
- Dark urine, decreased/no output
What are the 3 stages of cognitive decline while dying?
- Decreasing level of consciousness
- Decreasing ability to communicate
- Terminal delirium
T/F: Eyes usually become closed while dying
FALSE: loss of ability to close eyes
What are rare, unexpected events during death?
- “Golden glow”
- Aspiration
- Asphyxiation
What are the properties of portmanteau medications?
- Multiple therapeutic effects
- Minimum interactions
- Multiple routes
- Wide therapeutic window
- Cost effective
- Convenient dosing schedule
- Dose response and favorable ceiling effect
Which drugs do we use for palliative care?
- Morphine
- Methadone, hydromorphone, oxycodone
- Lorazepam, alprazolam (has ODT)
- Haloperidol
- Atropine drops
- Dexamethasone
- Ondansetron ODT
- Metoclopramide
What is an “intensol”?
Highly concentrated liquid form
What treatments do we use for gut wall N/V?
- H2 antagonist/PPI
- Metoclopramide
- Ondansetron
What are causes of gut wall N/V?
- Gastric irritants
- Abdominal radiotherapy
- Intestinal distention
- Cytotoxic chemo
What are causes of area postrema N/V?
- Morphine, digoxin
- Hypercalcemia/uremia
- Clonidine
- Cytotoxic chemo
How can we treat area postrema N/V?
- Haloperidol, metoclopramide
- Step 1 + dexamethasone
Pamidronate for hypercalcemia - Ondansetron + dexamethasone
What are causes of cerebral cortex N/V?
- Fear/anxiety
- Raised intracranial pressure
- Hyponatremia
How can we treat cerebral cortex N/V?
- Dexamethasone
- Amitriptyline, haloperidol, lorazepam
- Limited free water, saline, haloperidol
What are causes of vestibular nuclei N/V?
- Movement
- Vertigo
How can we treat vestibular nuclei N/V?
- Diphenhydramine
- Dimenhydrinate
- Meclizine or cyclizine
- Glycopyrrolate
- Scopolamine
What should we give if we hear wheezing?
Ipratropium/Albuterol +/- dexamethasone
T/F: Morphine or other opioids should be avoided with dyspnea
FALSE: they can be used in low doses to treat it - reduces shortness of breath
How do you treat cough in end of life?
- Treat underlying cause
- Promote production (saline +/- mucinex)
- Suppress cough (morphine, hydrocodone, DXM)
- Dexamethasone or glycopyrrolate/atropine, NAC with bronchodilator
- Nebulized lidocaine, gabapentin
What are symptoms of EOL anxiety?
- Worry
- Tense
- Unable to relax
What are symptoms of EOL delirium?
- Disorientation
- Hallucinating
- Aggressive
How can we treat anxiety in EOL?
- Non-pharm
- Lorazepam, Alprazolam
- Buspirone/SSRI (long-term)
What can we use to treat delirium in EOL?
- Haloperidol
- Haloperidol + Lorazepam
- Haloperidol + Midazolam
How can we treat constipation in EOL opioid use?
- 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
How can we treat bowel obstruction
- Metoclopramide +/- dexamethasone (if incomplete obstruction)
- Glycopyrrolate + morphine + haloperidol
- Octreotide + above
- PEG tube or stent
What should we use if a depressed patient has >4 weeks left?
- Escitalopram
- Sertraline
- +/- methylphenidate
- Amitriptyline or nortriptyline
- +/- methylphenidate
What should we use if a depressed patient has <2 weeks left?
- Methylphenidate
- Ketamine
How should we treat anorexia/cachexia in EOL?
- Treat underlying cause
- Metoclopramide
- Dexamethasone <3 months left
- Mirtazapine/megestrol >3 months left
- Dronabinol
How should we treat insomnia in EOL?
- Treat underlying cause
- Trazodone or melatonin
- Temazepam or zolpidem
- Haloperidol
- Mirtazapine or amitriptyline (w/ depression)
- Increase doses of above
- Substitute midazolam or high dose lorazepam <7 days
How can we treat xerostomia in EOL?
- Ice chips, gum, lemon drops
- Saliva substitute
- Pilocarpine
How do we treat death rattle gurgling?
Atropine 1% eye drops
Not earlier than end stage terminal time
Also glycopyrrolate or scopolamine patch
What should we use if intolerable symptoms are causing suffering and we should induce unconsciousness?
- Opioids
- Benzodiazepines
- Neuroleptics
- Barbiturates
- Anesthetics
- A combination of these agents
What are signs that death occurred?
- 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
What is a “good death”
- Treated as individual with dignity and respect
- Without pain or other symptoms
- Familiar surroundings
- Company of close family/friends
