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Mandatory Selectives > Palliative Care > Flashcards

Palliative Care Flashcards

1
Q

Describe Palliative Care

A

Is the treatment that aims to improve quality of life without altering the disease course. Also provides bereavement services following death.

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2
Q

List the common symptoms palliative patients complain of:

A 
Pain
Dyspnea
Anorexia/cachexia
Fatigue
Nausea
Constipation
Depression and anxiety
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3
Q

List the aspects of total pain control

A

Physical symptom control
Psychological
Spiritual
Social and cultural

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4
Q

List the ladder approach to pain control and specific medications used at each level

A 
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
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5
Q

List the conversion between strong opioids and there IV doses

A

Morphine: Oxycodone: Hydromorphone = 10:5:2

Morphine PO/2 = morphine IV

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6
Q

List the contraindications to PO analgesia

A 
Intractable nausea/vomiting
Dysphagia
Decreased gastric motility or absorption
Bowel obstruction
Require immediate affects
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7
Q

Morphine PO and SC have onset of action of ___ and ___

Fentanyl SC and IV have onset of action of ___ and ___

A

Morphine PO: 90 min, SC: 45min

Fentanyl SC: 20 min, IV: 10 min

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8
Q

Provide the breakthrough dose of morphine 10mg q4h PO

A

Breakthrough is 10% of total daily morphine equivalents
10% * 60 = 6mg
So breakthrough is morphine 6mg Q2H PO PRN

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9
Q

Provide a normal prescription of strong opioids

A

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

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10
Q 
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
A

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

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11
Q

List the different types of agents for constipation management

A

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

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12
Q

List the non-pharmacological and pharmacological management of dyspnea in palliative patients:

A 
Non-pharmacological:
- Comfortable position
- Fan directed on face
- Cool humid air
- Open environment
Pharmacological:
- Oxygen if hypoxic
- Morphine
- benzodiazepine
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13
Q

List the non-pharmacological and pharmacological management of delirium

A 
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
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14
Q

What is the management for depression in palliative patients and how does it change depending on their prognosis?

A

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

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15
Q

Define cachexia and the different stages of cachexia

A

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

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16
Q

List the non-pharmacological and pharmacological treatment for cachexia

A

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

17
Q

List the indications for artificial feeding

A
  • 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
18
Q

List the indications for artificial hydration

A

Patient who cannot take fluids orally but is not close to dying
Patient wishing to extend life
Hydration to improve symptoms

19
Q

List the complications of artificial nutrition/hydration

A

Aspiration/choking
Infection
Electrolyte and sugar disturbances
Fluid overloaded patient

20
Q

List the non-pharmacological and pharmacological management of fatigue

A 
Non-pharmacological:
- Exercise
- Education
- Psychological counselling
Pharmacological:
- Psychostimulants
- Corticosteroids
21
Q

List the types of end-of-life care and the advantages and disadvantages of each

A

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

22
Q

Differentiate between palliative and hospice care

A

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

23
Q

Differentiate between physician assisted suicide and euthanasia

A

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

24
Q

____ is the technique by which sedation is used to provide comfort to the patient in the final days of life without hastening death

A

Palliative sedation

25
Q

Differentiate between withdrawing and withholding treatment

A

Withdrawing treatment is when treatment is stopped when it no longer meets patients goals of care, physician determines it is futile, or when the risks outweigh the benefits
Withholding treatment is not commencing treatment due to above reasons

Mandatory Selectives (9 decks)

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