Palliative Care Flashcards
Describe Palliative Care
Is the treatment that aims to improve quality of life without altering the disease course. Also provides bereavement services following death.
List the common symptoms palliative patients complain of:
Pain Dyspnea Anorexia/cachexia Fatigue Nausea Constipation Depression and anxiety
List the aspects of total pain control
Physical symptom control
Psychological
Spiritual
Social and cultural
List the ladder approach to pain control and specific medications used at each level
Foundational analgesia: - Acetaminophen 1000mg Q6H PO and Naproxen 500mg q8h PO (or other NSAID - celecoxib preferred in elderly or those with GI or platelet issues) Weak opioid: - Tramadol 50mg q4h PO Strong Opioid: - Morphine 20mg q4h PO - Oxycodone 10 mg q4h PO - Hydromorphone 4 mg q4h PO Long-acting opioid: - Fentanyl - Methadone Non-opioid adjuvants: - Anti-convulsantsGabapentin, pregabelin - NMDA antagonists: Ketamine - anti-depressants - corticosteroids
List the conversion between strong opioids and there IV doses
Morphine: Oxycodone: Hydromorphone = 10:5:2
Morphine PO/2 = morphine IV
List the contraindications to PO analgesia
Intractable nausea/vomiting Dysphagia Decreased gastric motility or absorption Bowel obstruction Require immediate affects
Morphine PO and SC have onset of action of ___ and ___
Fentanyl SC and IV have onset of action of ___ and ___
Morphine PO: 90 min, SC: 45min
Fentanyl SC: 20 min, IV: 10 min
Provide the breakthrough dose of morphine 10mg q4h PO
Breakthrough is 10% of total daily morphine equivalents
10% * 60 = 6mg
So breakthrough is morphine 6mg Q2H PO PRN
Provide a normal prescription of strong opioids
Morphine 5mg q4h PO
Morphine 5mg q2h PO PRN
Senna 1 tab PO OD or Lactulose 10mL PO OD for constipation (require 1 bowel movement every 3 days)
Metoclopramide 5-10mg PO/IV/SC q4h PRN for nausea
The patient is experiencing the below type of nausea, which anti-emetic should be prescribed? 1st-line 2nd-line Bowel obstruction Radiotherapy or chemotherapy induced Brain tumour Vestibular Anxiety
1st-line: Metaclopramide, Haloperidol 0.5-2mg IM/IV
2nd-line: Dexamethasone 4-10mg PO BID
Bowel obstruction: Octreotride, dexamethasone
Radiotherapy or chemotherapy induced: Ondansetron 8-16mg q8h IV/IM
Brain tumour: dexamethasone
Vestibular: Dimenhydrinate 50-100mg q6h PO/IV/IM
Anxiety: benzodiazepine
List the different types of agents for constipation management
Bulking agents: Fiber
Stool softener: Colace (not useful on its own)
Stimulant: Senna 1 tab PO Daily
Osmotic: Lactulose 40mg PO Daily, PEG-3350 17g powder in 8oz drink, Oral Fleet (fleet have risk for sodium and water retention)
Rectal: Fleet (phosphosodium), Glycerin
List the non-pharmacological and pharmacological management of dyspnea in palliative patients:
Non-pharmacological: - Comfortable position - Fan directed on face - Cool humid air - Open environment Pharmacological: - Oxygen if hypoxic - Morphine - benzodiazepine
List the non-pharmacological and pharmacological management of delirium
Non-pharmacological: - Reduce sensory overload - Provide sensory aids - Provide familiar objects in order to orient to environment - Talk directly to the individual - Allow family to be present Pharmacological: - Haloperidol - Atypical antipsychotics
What is the management for depression in palliative patients and how does it change depending on their prognosis?
Prognosis >4-6 weeks:
- 1st-line SSRIs
- 2nd-line SNRI
- 3rd-line NaSSA
- Re-evaluate in 4-6 weeks to see if have improvement. If none, then increase dose, add another agent or switch agents
Prognosis <4-6 weeks:
- Psychostimulant (methylphenidate). Can be used with longer prognosis in order to get effect sooner
Define cachexia and the different stages of cachexia
Cachexia is the irreversible loss of skeletal muscle mass that results in a progressive functional impairement.
Pre-cachexia:
- weight loss <=5% of baseline
Cachexia:
- weight loss >5% baseline or BMI <20 with weight loss >2% baseline
Refractory cachexia:
- is when cancer is no longer responsive to treatment and have <3 months to live
Death
List the non-pharmacological and pharmacological treatment for cachexia
Non-pharmacological:
- Nutrtional counselling focusing on eating when they want and smaller meals, frequent snacks, high protein/energy foods, and drink a lot of fluids
- Exercise
- Psychological counselling
Pharmacological:
- Prokinetics use for anxiety due to early satiety or nausea (metoclopramide)
- Progestogens use to improve appetite and weight (megestrol acetate)
- corticosteroids to improve appetite
- Cannabinoids to improve appetite
List the indications for artificial feeding
- Dysphagia due to obstruction from therapy responsive tumour
- Reversible weight loss
- Anorexia/cachexia in therapy responsive tumour
- pre-operative treatment for malnutrition
- malabsorption with localized disease
List the indications for artificial hydration
Patient who cannot take fluids orally but is not close to dying
Patient wishing to extend life
Hydration to improve symptoms
List the complications of artificial nutrition/hydration
Aspiration/choking
Infection
Electrolyte and sugar disturbances
Fluid overloaded patient
List the non-pharmacological and pharmacological management of fatigue
Non-pharmacological: - Exercise - Education - Psychological counselling Pharmacological: - Psychostimulants - Corticosteroids
List the types of end-of-life care and the advantages and disadvantages of each
Hospital:
- have access to care and investigations immediately
- Is non-familiar and may not have personal space
Nursing home
- have access to increased nursing care and may be more familiar if have been there for awhile
- May not always have access to physicia
Home
- Is the most personal and familiar
- Limited access to care and puts a greater burden on friends and family to take of
Differentiate between palliative and hospice care
Palliative care is for those with potentially fatal disease and curative treatment has been abandoned.
Hospice care is for those with fatal disease and less than 6 months to live
Differentiate between physician assisted suicide and euthanasia
Physician assisted suicide is when the physician provides all necessary materials for the patient to end their life by themselves
Euthanasia is the active process of ending another’s live to relieve suffering
____ is the technique by which sedation is used to provide comfort to the patient in the final days of life without hastening death
Palliative sedation
