Palliative Care Flashcards
- A 75-year-old man with lung cancer metastatic to the bones is receiving hospice care in his home. His predominant symptom is nociceptive and neuropathic right chest wall pain caused by a fourth rib metastasis. In recent days he has experienced a dramatic increase in his pain, and hospice staff have titrated his pain regimen to gabapentin
900 mg three times daily, extended release morphine 100 mg three times daily, and immediate release morphine 30 mg every 2 hours as needed. The hospice nurse calls you to ask about next steps, and reports that he is still in severe pain but is now nonverbal, and his family is struggling to administer his medication orally because of his somnolence. The patient’s family is exhausted. What is the best next step to assure the patient’s comfort?
a. Admit to an inpatient facility under the General Inpatient Hospice benefit.
b. Discharge from hospice, admit to the hospital.
c. Call 911.
d. Instruct the family to give the immediate release morphine every 30 minutes instead of every 2 hours.
a. Admit to an inpatient facility under the General Inpatient Hospice benefit.
- An 85-year-old woman with congestive heart failure, end-stage chronic obstructive pulmonary disease, chronic kidney disease stage 4, and frailty is brought to your office for a routine appointment. She has preserved cognition and her last Mini-Mental State Examination was 26. Affect is normal, and she has no history of depression. She has a loving and supportive family with whom she lives. During the visit, she shares that her quality of life is no longer acceptable, and asks about options to hasten the end of her life. Which of the following means of hastening death is legal throughout the United States?
a. Euthanasia
b. Palliative sedation
c. Voluntary stopping of eating and drinking
d. Physician-assisted death
c. Voluntary stopping of eating and drinking
- A 78-year-old woman with atherosclerotic cardiovascular disease (ASCVD), peripheral vascular disease, and a history of transient ischemic attacks s/p carotid endarterectomy is seen as part of an annual wellness visit. She is advised to create an advance directive
but declines, saying “I don’t know who to pick” for a healthcare agent. Which one of the following is a necessary characteristic of a healthcare agent?
a. Geographic proximity to the patient’s home
b. Knows how the patient defines quality of life
c. Is a member of the patient’s immediate family
d. Has medical training or experience
b. Knows how the patient defines quality of life
Domains of Palliative Care: Structure/Process of Care
The structure and processes of care domain outlines the composition of the palliative care team. The domain describes the professional qualifications, education, training and support necessary to provide optimal care and defines the elements of palliative care.
Domains of Palliative Care: Physical Aspects of Care
This domain addresses the assessment and treatment of physical symptoms such as pain, nausea, vomiting, and shortness of breath. The care provided is client and family-centered.
Domains of Palliative Care: Psychological and Psychiatric Aspects of Care
This domain address mental and emotional anguish like anxiety, depression, anger, etc., experienced by clients and families facing incurable or serious illnesses.
Domains of Palliative Care: Social Aspects of Care
This domain emphasizes the social support needs of clients and their caregivers.
Domains of Palliative Care: Spiritual, Religious and Existential Aspects of Care:
This domain supports the client and family to exercise their spiritual, religious and existential beliefs. A chaplain or clergy member usually works with clients and families to help meet these needs.
Domains of Palliative Care: Cultural Aspects of Care
This domain considers the culture preferences of the client and family from the time of diagnosis through the death, dying, grief, and bereavement process.
Domains of Palliative Care: Care of the Client at the End of Life
This domain is of critical importance during the final days and weeks of the client’s life. Managing symptoms and minimizing suffering allow the client to die with dignity.
Domains of Palliative Care: Ethical and Legal Aspects of Care:
This domain involves the development of advanced directives or the identification of healthcare surrogates to support end-of-life care. Advanced directives are signed statements by the client that communicate their wishes. Health surrogates are designated by the client to make decisions for them when they can no longer make independent decisions. The interprofessional team has a responsibility to ensure client autonomy through this and every domain.
o Advance care planning (ACP)
is the process by which client preferences regarding future medical care, values, and goals are communicated with healthcare providers and families. Ideally, ACP should be proactive and integrated into routine care regardless of the client’s health condition. ACP may include an advance directive (AD) which is a legal document dictating how medical decisions are to be made if the client can no longer speak for themselves. There are different types of ADs. Pre- written medical orders based on the documents are also considered an AD.
DNRCC includes
- no resuscitative therapies will be undertaken from the time the DNR order is signed
- no chest compressions
- no cardiac defibrillation or cardioversion
- no insertion of an artificial airway
- no resuscitative drugs (vasopressors, antiarrhythmics, etc.)
DNRCC-Arrest includes:
- activates the DNR order when a cardiac or respiratory arrest occurs
- all resuscitative therapies are given before but not during an arrest
Durable Power of Attorney -HC
- a signed legal document authorizing another person (family or friend) to make all medical routine and life-sustaining decisions on the client’s behalf if the client loses decisional capacity
- selection of a surrogate is not a legal requirement
- most jurisdictions have specific legislation authorizing who can make medical decisions in the absence of a formal designation
