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350 again > Palliative Care > Flashcards

Palliative Care Flashcards

1
Q

MAiD is NOT the same as: (3)

A
  1. Palliative care
  2. Palliative sedation
  3. Withholding or withdrawing life-sustaining or life-prolonging treatment
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2
Q

What is palliative sedation? (2)

A
  1. Ongoing sedation until natural death
  2. Use of medications (e.g., sedating antipsychotic, BZD) to reduce consciousness
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3
Q

What are the pharmacist scope limitations for MAiD? (6)

A
  1. No participation in MAID unless contacted by MD or NP
  2. We can provide educational information about MAID, but must not imply leading the process – refer to someone who can
  3. We do not assess a patient for eligibility
  4. We do not collect consent for MAID
  5. We do not prescribe or administer drugs for MAID
  6. We do not prescribe drugs for “office use”
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4
Q

What is palliative care? (4)

A

Addresses patient needs in the physical, psychological, social and spiritual domains via:
- Communication around goals of care
- Symptom management
- Practical support for patient and family needs

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5
Q

What are the elements of good palliative care? (8)

A
  1. Patient and family-centered
  2. Strives for the best possible quality of life
  3. An active approach to managing symptoms
  4. Affirms life and regards dying as part of the normal process of living
  5. Does not attempt to hasten nor postpone death
  6. Uses a team approach to address the needs of patients and their families
  7. Offers a support system to help the family cope during the patient’s illness and their own bereavement
  8. Is offered early in the course of illness, in conjunction with therapies intended to prolong life
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6
Q

When is palliative care meant to be used? (2)
What is a limitation in Saskatchewan?

A
  1. Is NOT meant exclusively for individuals who are imminently dying, and not exclusively for cancer patients
  2. Appropriate for any patient with a chronic, life-limiting illness who is experiencing symptoms related to their illness or treatment
    - e.g. renal dialysis, oxygen therapy, cancer chemotherapy
    - Includes patients still receiving treatment intended to prolong life!
  3. Unfortunately, access to specialized Palliative Care teams and services may be reserved for individuals with advanced terminal illness
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7
Q

What are some examples of palliative conditions? (5)

A

Life-threatening illnesses, including:
- Cancer
- Progressive/advanced organ failure e.g. HF, COPD, ESRD
- Advanced neurodegenerative disease e.g. dementia, Parkinson’s disease
- Sudden onset of a serious medical condition e.g. severe infection, bowel obstruction, MI or stroke

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8
Q

From time of diagnosis to time of death, palliative care encompasses what 2 things?

A
  1. End-of-life care
  2. Terminal care
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9
Q

What does end-of-life care entail? (4)

A
  1. Illness is non-curative
  2. Weeks or months to live
  3. Symptom management
  4. Psychosocial support
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10
Q

What does terminal care entail? (4)

A
  1. Hours or days to live
  2. Symptom management
  3. Spiritual care
  4. Support for family
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11
Q

Where can palliative care be done in the SHA? (4)

A
  1. At home with the support of Palliative Home Care
  2. In private personal care homes/assisted living facilities with
    support of Palliative Home Care as needed
  3. In Palliative Care hospital units (e.g. SPH in Saskatoon)
  4. In the hospital with consult support of the Palliative Care team
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12
Q

What is the goal of palliative care? (2)
What does that look like from a pharmacist perspective? (2)

A
  1. Limit physical and emotional suffering by adequately
    managing pain and other symptoms
  2. Support the ability to enjoy remaining life while avoiding
    inappropriate prolongation of death
  3. From a pharmacist’s perspective, this looks like:
    - Stopping non-essential drugs
    - Ensure ongoing administration of essential drugs
    – Management of symptoms
    – Appropriate route of admin
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13
Q

How to manage nutrition and hydration in palliative care? (2)

A
  1. Offer only food they want; calorie rich; moisten lips
  2. Minimal IV hydration due to vomiting, distressed breathing, choking, edema; may lengthen dying process
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14
Q

How to manage lethargy in palliative care?

A

Energy conservation for human interactions

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15
Q

How to manage CV changes in palliative care?

A

Keep warm and comfortable; sit up if able

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16
Q

How to manage the lungs in palliative care?

A

Opioids relieve dyspnea; sound not distressing for patient unless accompanied by dyspnea

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17
Q

How to manage the GI tract in palliative care? (3)

A
  1. Anti-emetics help with vomiting
  2. Enemas or suppositories for constipation
  3. Keep clean
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18
Q

How to manage the CNS in palliative care? (2)

A
  1. Talk to the patient all the time
  2. Keep calm, peaceful environment (often more about caregivers)
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19
Q

How to manage mental health in palliative care? (3)

A
  1. Normalize visions, detachment
  2. Encourage goodbyes
  3. Encourage spiritual practices
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20
Q

What are big symptoms that we can help manage in palliative care? (6)

A
  1. Pain
  2. GI (NV, constipation, anorexia)
  3. Dyspnea, respiratory congestion
  4. Delirium
  5. Hallucinations, delusions
  6. Anxiety
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21
Q

What to know about palliative drug coverage in SK? (4)

A
  1. Is available for individuals with a life expectancy measured in months, for whom curative or life-prolonging treatment is not an option
  2. Patient’s physician must complete a “Palliative Care Drug Coverage” form and submit to SPDP
  3. 100% coverage for prescription medications and adjunctive OTC therapies such as laxatives or antiemetics
  4. Also may cover dietary supplements as required
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22
Q

Goal of palliative pain management is _______

A

comfort

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23
Q

How is palliative pain typically managed? (4)

A
  1. Managed primarily by opioids
  2. Provide around-the-clock (scheduled) plus breakthrough (PRN) analgesia
  3. Anticipate & prevent analgesic side effects
  4. Use oral route when possible
    - Subcutaneous is the preferred parenteral route
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24
Q

What are 3 advantages to subcut med administration?

A
  1. Less equipment versus IV
  2. May be administered by patient or family member
  3. Absorption is slower than IV, but complete
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25
Q

What are 4 disadvantages to subcut med administration?

A
  1. Potential discomfort
  2. Local tissue irritation
  3. Limited volume for injection (5mL maximum)
  4. Requires one subcut line per medication
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26
Q

Go through the WHO analgesic ladder (3)

A

Bottom:
1. Non-opioid
- Acet
- NSAID
- +/- adjuvant
If persistent or increasing pain then:
2. Opioid for mild to moderate pain
- Codeine
- Buprenorphine
- Tramadol
- +/- Non-opioid
- +/- adjuvant
If persistent or increasing pain then:
3. Opioid for moderate to severe pain
- Morphine
- Oxycodone
- Hydromorphone
- Fentanyl
- Methadone
- +/- Non-opioid
- +/- adjuvant

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27
Q

In palliative care, _____ doses of ______ opioids are preferred

A

small; strong

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28
Q

The often preferred analgesic in the palliative setting is?

A

Hydromorphone (Dilaudid)

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29
Q

What are the benefits of hydromorphone? (3)

A
  1. Higher potency vs morphine (5:1)
    - Lower subcut injection volume
  2. No active metabolite
  3. Low induction of histamine release vs. morphine
30
Q

What are the 2 types of fentanyl used in palliatve care? How/when might they be used?

A
  1. Injectable
    - Can be administered subcut or bucally for relief of incident pain
  2. Patch
    - Stable, chronic pain
    - Not suitable for pts requiring opioid titration
31
Q

What are 10 ADEs of opioids to be aware of in palliative care?

A
  1. N/V
  2. Constipation
  3. Sedation
  4. Delirium/confusion/hallucinations
  5. Pruritis
  6. Dry mouth
  7. Urinary retention
  8. Resp depression
  9. Myclonus
  10. Hyperalgesia & Allodynia
32
Q

How to manage opioid-caused sedation in palliative care? (4)

A
  1. Tolerance develops ~ 2-4 days
  2. May occur when initiating or increasing dose
  3. If persistent, ↓ dose or switch to another opioid
  4. Palliative Care: can use a psychostimulant
    - Methylphenidate 5-10mg po OD-BID (Avoid if opioid-induced neurotoxicity present)
33
Q

How to manage opioid-caused delirium/confusion/hallucinations in palliative care? (3)

A

(Usually resolves within 3-4 days)
Management:
1. Avoid increasing opioid until resolved (if possible)
2. Rule out other causes (e.g. infection, hypercalcemia, etc)
3. Palliative Care: Haloperidol 0.5-5mg po/subcut daily-BID

34
Q

How to manage opioid-caused pruritis in palliative care? (3)

A

[Secondary to histamine release (not a true allergy)]
If persistent, reduce dose, switch to another opioid or pre-treat with an antihistamine
- Diphenhydramine 25-50mg po/subcut 15-30 mins before opioid
- Use a second-generation antihistamine if can administer orally to avoid drowsiness!

35
Q

How to manage opioid-caused dry mouth in palliative care? (3)

A
  1. May be exacerbated by other drugs
  2. Mouth care, ice chips, frequent sips
  3. Palliative Care: Pilocarpine 5mg orally TID-QID
    - Can use eye drops orally
    - 0.25ml (or 4 drops) of 2% = 5mg
36
Q

How to manage opioid-caused urinary retention in palliative care? (2)

A
  1. Usually improves within one week
  2. Catheter in the meantime if complete retention
37
Q

How to manage opioid-caused resp depression in palliative care? (2)

A

(Rare in the palliative care setting)
1. If mild (> 8 breaths/min)
- Monitor patient closely
- Hold further doses of opioids, benzodiazepines until resolved – then review/reduce dose
2. If severe (< 8 breaths/min)
- Naloxone 0.1mg IV/subcut q2-3 minutes
- Monitor closely - opioids have a longer duration of action than naloxone!

38
Q

How to manage opioid-caused myoclonus in palliative care? (3)

A
  1. If pain is controlled, reduce opioid dose
  2. Switch to another opioid
  3. Add a benzodiazepine
39
Q

How to manage opioid-caused hyperalgesia & allodynia in palliative care? (2)

A
  1. Significantly reduce dose and/or switch to another opioid
    - Methadone
  2. Palliative Care: may add a NMDA antagonist (e.g. ketamine) if severe
40
Q

What are adjuvant agents for pain (meaning, define it)?
When might they be added?

A
  1. Have primary indications other than pain but also have analgesic properties
    - e.g., anticonvulsants, antidepressants
  2. Added to opioid regimens to offset ADEs or specifically manage neuropathic pain
41
Q

In palliative care, what is a big adjuvant for pain to know?
When would we use it and why?

A

Dexamethasone
- Used in metastatic bone pain, neuropathic pain (for example)
- Less mineralocorticoid activity

42
Q

What are some side effects to be aware of of dexamethasone? (4)

A
  1. Insomnia
  2. Hyperglycemia
  3. Gastric irritation
  4. Candidiasis
43
Q

Nausea and vomiting in palliative care is often multifactorial. What are some potential causes? (9) (don’t need to memorize, but just read it over)

A
  1. Constipation
  2. Medications (e.g. opioids, NSAIDs)
  3. Reduced GI motility
  4. Metastatic disease/obstruction
  5. Metabolic changes (e.g. hypercalcemia, hyponatremia, uremia)
  6. Increased intracranial pressure
  7. Uncontrolled pain
  8. Anxiety
  9. Candidiasis
44
Q

How can we manage nausea and vomiting in palliative care? (6)

A
  1. Identify and correct likely cause(s)
  2. Optimize non-pharmacological strategies
  3. Select an antiemetic based on cause and appropriate route. Reassess every 2-3 days
    - If patient vomits oral dose within 30 minutes, repeat the dose
    - Titrate the dose up or down as needed
    - Scheduled vs. prn vs. scheduled + prn
  4. If nausea persists after 48 hours, add another agent with a different mechanism of action
  5. Anticipate need for antinauseants
  6. Proactively assess for and manage side effects (e.g. constipation, dry mouth)
45
Q

What are some non-pharm ways to manage nausea and vomiting? (6)

A
  1. Cold food may be associated with less nausea
  2. Separating solid and liquid foods may decrease early satiety
  3. Offer preferred foods and textures, allow eating at own pace
  4. Don’t pressure a person to eat or drink against their will
  5. Peppermint oil or ginger tea if patient finds soothing
  6. Cold, lightly carbonated beverages
46
Q

What are the 2 first-line anti-nauseant agents in palliative care?

A
  1. Haloperidol
  2. Metoclopramide
47
Q

What are the 2 second-line anti-nauseant agents in palliative care?

A
  1. Methotrimeprazine
  2. Olanzapine
48
Q

What are some ‘other’ common anti-nauseant agents that can be used in palliative care? (3)

A
  1. Dexamethasone
    - Broad-spectrum antinauseant
    - Unknown mechanism of action
  2. PPI
    - Pantoprazole or lansoprazole
    - Add-on therapy may help provide relief regardless of cause
  3. Octreotide
    - Nausea associated with malignant bowel obstruction
49
Q

What are the 5 third-line anti-nauseant agents in palliative care?

A
  1. 5HT3 antagonists e.g., ondansetron
    - First line for chemotherapy/radiation-induced N/V
  2. Dimenhydrinate
    - Anticholinergic –> constipation/confusion
  3. Scopolamine
    - Also anticholinergic
  4. Nabilone
    - Sedation, dysphoria
  5. BZDs
50
Q

What are some non-pharm ways to manage dyspnea? (6)

A
  1. Provide ‘fresh air’ - open a window or direct a fan towards the patient’s face
    - Receptors in the trigeminal nerve area influence intensity of dyspnea.
  2. Oxygen if the patient is hypoxic
  3. Nebulized saline
  4. Reduce room temperature
  5. Use a humidifier if air is dry
  6. Plan rests around activities
51
Q

What are some pharmacologic ways to manage dyspnea? (3)

A
  1. Opioids – treatment of choice
  2. If respiratory panic attacks: benzodiazepine
    - E.g. lorazepam 0.5-2mg po/sL/subcut q4-12h
  3. If history of asthma or COPD:
    - Bronchodilators (e.g. salbutamol, ipratropium) (Caution: may cause or exacerbate anxiety)
    - Corticosteroids
52
Q

How do opioids help with dyspnea (MOA) (5)

A

Multiple MOAs:
1. Act on respiratory centre, reducing respiratory effort
2. Central sedative effect, attenuating the ventilatory response
3. Lower sensitivity to hypercapnia and hypoxemia
4. Reduce oxygen consumption
5. Diminish perception of dyspnea and anxiety

53
Q

What to note about dyspnea in end of life? (2)

A
  1. Occurrence & severity increases in last 48 hours of life
  2. Actively dying patients can have altered breathing patterns
    - Unresponsive patient ≠ dyspnea
    - Reassure family that altered breathing is not distressing to the patient
54
Q

Do we treat delirium in patients in palliative care?

A

It honestly depends on if it is distressing or bothersome to the patient. If yes, then appropriate to treat, but if not distressed, then no need to give medications. The meds given (APs and/or sedatives) only manage the symptoms, they don’t really treat the delirium

55
Q

How to manage delirium in palliative care? (non-pharm)

A

Look for and address underlying cause(s)
- Infection, metabolic disturbances, uncontrolled pain, urinary retention, constipation, medication(s)

56
Q

If needed, what drugs can be given for delirium in palliative care? (4)

A
  1. Haloperidol first-line
    If more sedation required:
  2. Methotrimeprazine
  3. Olanzapine
  4. BZD if needed
57
Q

What drugs are considered essential in palliative care? (5)

A
  1. Analgesics
  2. Antiemetics
  3. Antipsychotics
  4. Anxiolytics
  5. Sedatives
58
Q

Go through the process of re-evaluating medications in palliative care (4)

A
  1. As patient nears end of life, certain medications may no longer be warranted
  2. Advanced terminal disease may result in malnourishment, hypotension, dehydration or dizziness.
    - Reassess hypoglycemics, diuretics and antihypertensives
  3. Review the need for cardio-protective agents, vitamin and mineral supplements, hormone replacement therapy, etc
  4. Discussion should occur with the patient/family before stopping medications!
59
Q

In the last few days of life, when someone is dying they may: (4)

A
  1. Sleep for longer periods and be difficult to arouse
  2. Eat and drink less
  3. Have difficulty swallowing
  4. Become restless or confused -> “Terminal Restlessness”
60
Q

What are 2 things that commonly occur in the last few days of life?

A
  1. The Rally
    - Close to ’normal’ functioning (eating, talking, mobile) within hours-days of end
    - ~1/3rd patients (pets too!)
  2. Seeing loved ones or pets who have passed, speaking childhood languages, talk of ‘going home’
    - Pleasant, peaceful, eager to share – respect their reality
61
Q

In the last hours of life, as death nears, the individual may: (6)

A
  1. Become unresponsive to touch/voices
  2. Develop “wet” or rattley-sounding breathing
  3. Have an irregular pulse or heartbeat
  4. Lose control of bladder or bowels
  5. Have cool limbs
  6. Have irregular or shallow breathing
62
Q

Decreased appetite and fluid intake is common at end of life. What to note here? (2)

A
  1. Providing nutrition or fluids artificially may actually increase some distressing symptoms, such as resp congestion, nausea, and vomiting
  2. Artificial hydration does not prevent thirst or relieve a dry mouth
    - Mouth care more helpful for this
63
Q

What is one of biggest signals that death is near?

A

Respiratory congestion - rattling, gurgling sounds caused by an accumulation of secretions in the airway
(~75% of pts will die within 48 hours)

64
Q

What are 2 non-pharm ways to deal with resp congestion?

A
  1. Reposition head or lie pt on their side
  2. Avoid/discontinue IV fluids
65
Q

What pharmacological treatment may be given to deal with resp congestion?

A
  1. Anticholinergics may be given to dry up secretions
  2. Must be started at the first sign of congestion, as will not dry up secretions already present
    - Glycopyrrolate 0.1-0.2mg subcut q6h prn (Preferred if patient is conscious, as does not cross the BBB)
    - If unconscious:
    – Atropine 0.4-0.8mg subcut q4h prn
    – Scopolamine 0.3-0.6mg subcut q4h prn
66
Q

How to manage terminal restlessness? (2)

A
  1. Still important to assess for other causes/contributors that may be addressed (e.g. pain, infection)
  2. Medications may be necessary to relieve distress
    - Haloperidol often first-line (Haloperidol 0.5-2 mg every hour as needed)
    - If ineffective or more sedation is needed, benzodiazepines may be used:
    – Lorazepam 0.5-2mg po/SL/subcut Q4h prn
    – Midazolam 1-2 mg subcut Q1h prn or continuous subcutaneous infusion 0.5-1mg/hr
67
Q

When might palliative sedation be used? (2)

A
  1. When all possible treatment has failed
  2. May be appropriate in the final stage of illness (final days/hours of life)
    - Delirium, dyspnea, psychological distress, pain, nausea/vomiting, bleeding, airway obstruction, seizures
68
Q

How does palliative sedation differ from MAiD? (2)

A
  1. MAiD – patient must be alert and competent to access
  2. Palliative sedation is usually implemented gradually and consent of substitute decision maker is sufficient
69
Q

Give an example of a palliative sedation regimen (4)

A
  1. Target of palliative sedation can range from mildly drowsy <-> continuously asleep
  2. Opioid
    - Continue existing opioid via subcutaneous route
  3. Midazolam
    - Administered via continuous subcutaneous infusion
  4. Methotrimeprazine
    - Helps dry oropharyngeal secretions
    - 25-50 mg subcut q6hours
70
Q

What is the role of the pharmacy after death? (3)

A
  1. Condolences and care to loved ones
    - I’m so sorry to hear of your loss
    - If you cared for them, share something you remember
    - If you didn’t, ask about them
    - If you cared for them, tell them something you remember
    - Hugs are ok if you feel comfortable (also you can ask)
  2. Disposing of medications
  3. Taking care of loved ones

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