Palliative Care Flashcards
Palliative care addresses patient needs in physical, psychological, social, and spiritual domains via…
Communication around goals of care
Symptom management for patient comfort
Practial support for patient + family needs
Elements of good palliative care involve…
Patient + family centered
Strive for best possible QoL - active approach to symptom management, team approach
Affirms life + regards dying as part of the process - no attempt to hasten nor postpone death
Offer support system to help family cope
Ideally, palliative care is offered…
When?
Early in the course of illness, in conjunction with therapies intended to prolong life
Palliative care is not exclusively for individuals who are imminently dying or for cancer patients. Palliative care is appropriate for…
ANY patient with a chronic, life-limiting illness who is experiencing symptoms related to their illness or treatment
Includes patients still receiving treatment intended to prolong life
Unfortunately, most patients only receive in last month of life
Palliative conditions includes life-threatening illnesses, such as…
Cancer
Progressive/advanced organ failure (heart failure, COPD, ESRD)
Advanced neurodegenerative disease
Sudden onset of serious medical condition
The goal of palliative care is to…
Limit physical + emotional suffering by adequately managing pain + other symptoms - support ability to enjoy remaining life while avoiding inappropriate prolongation of death
Pharmacist role in palliative care involves…
Stopping non-essential drugs
Ensure ongoing administration of essential drugs - management of symptoms, appropriate route of administration
When stopping non-essential drugs, things we should consider include…
Time to benefit
What will happen when drug is stopped
AE’s
Timeframe
Patient + family preference
The Beers’ criteria…
Does not apply for end-of-life patients - again, more focused on providing comfort
The goal of palliative pain management is…
Comfort - often we cannot eliminate all pain
Pain is managed primarily by ____ and provided…
Opioids - scheduled + breakthrough PRN analgesia
Can anticipate + prevent AE’s
Route of administration preferred with pain management is…
Oral - SC preferred parenteral route
Onset of SC medication administration is…
15-30 minutes (slower than IV push but still quick)
Advantages of SC administration includes…
Less equipment vs IV
Can be administered by patient or family member
Still get complete absorption (but slower than IV)
Disadvantages of SC administration includes…
Potential discomfort
Loacal tissue irritation
Limited volume for injection
Requires 1 SC line per medication
For pain management in palliative care, ____ doses of ____ are preferred.
Small doses of strong opioids are preferred.
The most often preferred analgesic is ____, it has these advantages…
Hydromorphone
High potency vs morphine (lower SC injection volume)
No active metabolite
Fentanyl is often given for ____ pain, and can be given…
Severe, chronic pain - available as injectable, buccal, or patch
Patch not suitable for opioid titration
Constipation with opioid use is managed…
Pharmacologically - very common with opioid + low hydration, mobility, fibre
Sedation with opioid use is managed…
Tolerance develops ~2-4 days - may occur when initiating or increasing dose. Persistent = lower dose or switch opioids
Can use a low dose psychostimulant to avoid sedation + wanting interaction
Delirium, confusion, and hallucinations with opioid use is managed…
Resolves in 3-4 days
Avoid increasing opioid until resolved, if possible (remember pain can cause delirium) - rule out other causes
Can use low dose haloperidol and discontinue when resolved
Itchiness with opioid use is often caused by…
Histamine release (not true allergy)
If itchiness is persistent with opioid use, we can try…
Reduce dose or switch to other opioid
Pre-treat with antihistamine (diphenhydramine SC or second-gen antihistamine orally)
Dry mouth with opioid use is managed by…
Non-pharm: mouth care, ice chips, frequent sips
Pilocarpine - cholinergic agonist
Urinary retention with opioid use is managed by…
Usually improves within 1 week - catheter if complete retention evident
Mild respiratory depression (>8 breaths/minute) with opioid use is managed via…
Close monitoring - patient should build tolerance
Hold further opioid + BZD doses until resolved, then review/reduce dose
Severe respiratory depression (<8 breaths/minute) with opioid use is managed via…
Naloxone IV/SC Q2-3 minutes - close monitoring since opioids have longer duration of action than naloxone
Myoclonus involves spontaneous jerking movements - if this is experienced with opioid use, it is managed via…
Likely develop tolerance in few days - wait it out if not distressing
If pain is controlled, can reduce opioid dose
Switch to other opioid
Add BZD (risk of excessive sedation)
Hyperalgesia + allodynia with opioid use is managed via…
Significant dose reduction +/- switch to other opioid (methadone)
May add ketamine if severe
____ may be added to opioid regimens to offset AE’s or manage neuropathic pain.
Anticonvulsants
Antidepressants
____ may be added to opioid regimens to…
Corticosteroids - decrease pain + inflammation
Ex: neuropathic pain, metastatic bone pain
This corticosteroid is often used in palliative care…
Dexamethasone - less mineralocorticoid activity (sodium, water retention)
Just watch for nausea, insomnia - increased appetite is good
Nausea and vomiting in palliative care is often caused by…
Multitude of factors
Constipation
Medications
Disease state
Metabolic changes, GI motility
Uncontrolled pain
Nausea and vomiting is managed via…
Identifying + correcting likely causes (changing medications)
Optimizing non-pharm strategies
Selecting antiemetic based on cause + appropriate route; reassess q2-3 days.
Non-pharmacological management of nausea and vomiting includes…
Cold food - cold, lightly carbonate beverages
Separating solid + liquid foods, NO pressuring to eat or drink against their will
1st line agents for nausea + vomiting are…
Haloperidol
Metoclopramide
Fast-onset, mild sedation
Metoclopramide can help with constipation
2nd line agents for nausea and vomiting are…
Methotrimeprazine
Olanzapine
Very anticholinergic, very sedating
Other common anti-nauseantsin in palliative care include…
Dexamethasone
PPI - alleviate GI symptoms
Octreotide - malignant bowel obstruction
1st line for chemotherapy/radiation induced nausea and vomiting is…
Ondansetron
Dyspnea refers to…
Subjective experience of difficulty breathing, or unsatisfactory breath
Very common, can be very distressing
Non-pharmacological options for dyspnea management include…
“Fresh, moving air” - open window, or direct a fan at face
Oxygen if hypoxic
Nebulized saline
Reduce room temp, use humidifier if air is dry
Can plan rests around activities if dyspnea results from fatigue
Pharmacologic options for dyspnea management include…
Opioids
BZD’s for respiratory panic attacks
Asthma/COPD = bronchodilators, corticosteroids
Care around bronchodilators + corticosteroids since they could increase anxiety
Opioids reduce dyspnea via…
Acting on respiratory center to reduce respiratory effect
Central sedative effect to diminish perception of dyspnea + anxiety
Lower sensitivity to hypercapnia and hypoxemia, reduce oxygen consumption
Use same principles as for pain control - scheduled/PRN dosing, dosing increases, AE management
End-of-life dyspnea tends to increase in last 48 hours of life. This is not a problem unless…
Causes distress to family - altered breathing is not distressing to the patient
Delirium may be abrupt onset with fluctuating course - first action we should take is to…
Look for + address underlying causes
Infection, metabolic disturbances, uncontrolled pain, urinary retention, constipation, medications
Drug therapy for delirium is given…
Only as needed to calm agitation + relieve distress
These medications may be given to help relieve delirium…
Haloperidol 1st line
If more sedation required = methotrimeprazine, olanzapine, benzodiazepine
These medications are considered essential - all others may no longer be needed during palliative care.
Analgesics, antiemetics, antipsychotics, anxiolytics, sedatives
Review need for cardio-protective agents, vitamin + mineral supplements, hormone replacement therapy, hypoglycemics
Shared decision making with family - consider time to benefit, rationality of timeframe
Decreased appetite + fluid intake during end-of-life care is…
A natural part of the dying process, not neglect
Providing nutrition + fluids may actually increase some distressing symptoms such as respiratory congestion, nausea, vomiting
Respiratory congestion is…
Rattling, gurgling sound caused by accumulation of secretions in the airway
Often signals death is near
Non-pharmacological measures for respiratory congestion may include..
Repositioning head, or lie patient on their side
Discontinuation of IV fluids
Pharmacological measures for respiratory congestion may include…
Anticholinergics to dry up secretions (needs to be started at first sign of congestion)
Glycopyrrolate if conscious (does not cross BBB)
Atropine
Scopolamine
Terminal restlessness is a form of agitated delirium. These medications may be necessary to relieve distress…
Haloperidol first line
If ineffective or more sedation needed, BZD’s may be used
Lorazepam, midazolam
Palliative sedation refers to…
Use of sedating medications to relieve symptoms, or reduce awareness when symptoms are intractable to other measures and causing intolerable suffering.
Used when all possible treatment has failed - may be appropriate in final stages of illness
