Palliative Care Flashcards
What’s the goal of palliative care?
Relieve suffering (pain and other physical, psychological, spiritual problems)
T or F: Palliative care aims to hasten death.
F
It doesn’t intend to hasten nor postpone death
Who is palliative care for?
ANY pt w/ a chronic, life-limiting illness or tx
Who will most likely receive palliative care?
pts w/ advanced terminal illnesses
T or F: Palliative care is only for cancer pts
F
T or F: Palliative care is only for pts who are imminently dying
F
What’s the main diff b/w palliative care units and hospices?
Hospices are for palliative pts w/ STABLE probs
Palliative care units are for palliative care pts w/ acute or difficult-to-tx problems
What type of pts are most likely to receive palliative care?
Cancer pts
What kind of drug coverage is available for palliative pts?
Palliative Care Drug Coverage > covers 100% of Rx’ed drugs
Main drug used by those on palliative drug plans?
Opioids
What’re the three main trajectories of decline at the end of life?
Cancer, organ failure, and physical/cognitive frailty
Describe the functional trajectory of cancer patients
These pts have a high level of functioning throughout their lives until they near their death, where they have a sudden decline in functionality
Most common sx in cancer pts
Pain
T or F: Most cancer pts do not have satisfactory relief of their pain.
F
90% DO get relief from their pain
Goal of palliative pain mgmt?
Comfort
Palliative pain mgmt is managed mainly by…
opioids
What parenteral route is used for palliative pain mgmt?
subcutaneous butterfly route
T or F: Multiple drugs can be injected into the same butterfly subcut lne.
F (one line per medication)
What assessment algorithm is used to initially assess pain?
OPQRST
onset
palliation/provocation (what makes it better/worse?)
quality (nociceptive vs neuropathic)
radiation/region (does it travel? where is it located?)
severity
temporal (how long does it last? any particular time it gets worse/better? how long does med cause relief for?)
What is the analgesic ladder?
The medications recommended for persistent/increasing amts of pain
List the meds recommended on the analgesic ladder, starting with the lowest potency ones
- non-opioids (tylenol, NSAIDs +/- adjuvant)
- Opioids for mild-moderate pain (codeine, oxycodone, tramadol +/- adjuvant)
- Opioids for mod-severe pain (morphine, oxycodone, hydromorphone, fentanyl, methadone +/- adjuvant)
What’s an adjuvant wrt analgesic tx for palliative pts?
Agents used for neuropathic pain
What additional medication should be taken with opioids?
constipation meds
T or F: Opioid-induced constipation eventually goes away
F
T or F: Opioid-induced sedation eventually goes away
T (after 2-4d)
Opioid AEs:
N/V, constipation, sedation, delirium/confusion/hallucinations, pruritus, dry mouth, urinary retention, resp dep, myoclonus, hyperalgesia and allodynia
Opioid-induced pruritus is caused by…
histamine release
T or F: N/V are not common in advanced stages of cancer
F
What is used for: opioid-induced N/V that stimulates DA receptors in the CTZ?
D2 antagonist
What is used for: opioid-induced N/V that is the result of slow GI transit?
prokinetic agents (domperidone or metoclopramide)
What is used for: opioid-induced N/V that is the result of increased sensitivity of the vestibular apparatus?
antiH’s, antichols
N/V mediated by the chemoreceptors and mechanoreceptors of the GIT - what’re the NTs and receptors involved?
5-HT3, D2, and opioid receptors
N/V mediated by the CTZ - what’re the NTs and receptors invovled?
D2, 5-HT3, H1, ACh
N/V mediated by the cerebral cortex - what’re the NTs and receptors involved?
GABA
N/V mediated by the vestibular apparatus - what’re the NTs and receptors involved?
H1 and ACh
List D2 antagonists used for N/V.
metoclopramide, domperidone, haloperidol, methotrimprazine, prochlorperazine
List 5-HT3 antagonists for N/V.
ondansetron, granisetron
List histamine blockers for N/V (antihistamine).
dimenhydrinate
What steroid is used for tx’ing N/V?
dexamethasone
First line for opioid-induced N/V?
Metoclopramide > both a D2 antagonist and prokinetic
CI of metoclopramide?
Complete bowel obstruction
Why does domperidone have less risk of EPS relative to metoclopramide?
Bc it does NOT cross the BBB
If you want a broader spectrum D2 antagonists and prokinetic, would you use domperidone or metoclopramide? Why?
Metoclopramide since it crosses the BBB
1st line for N due to malignant bowel obstruction?
Haloperidol
This medication is good for most types of N
Methotrimeprazine
Why is methotrimeprazine good for most types of N?
It is an antagonist for D2, 5-HT2, H1, and ACh
1st line for chemotx/radiotx-induced N.
Ondansetron/Granistron
MOA of ondansetron/granistron?
5-HT3 antagonist
1st line for anticipatory or anxiety-related N?
BZDs
1st line for motion-induced nausea?
dimenhydrinate (Gravol)
MOA of dimenhydrinate?
H1 antagonist
T or F: dimenhydrinate is useful for opioid-induced nausea
F
Dimenhydrinate: AEs
drowsiness, dry mouth, confusion in older adults
2nd line for motion-induced N?
scopolamine
MOA of scopolamine?
anticholinergic
Scopolamine: AEs
dry mouth, urinary retention, palpitations
Constipation: What is the goal of tx’ing constipation in palliative pts on opioids?
Bowel movement at least q3 days
T or F: Nonpharm approaches to preventing/tx’ing constipation in palliative pts are usually the best.
F (risk of obstruction if not enough fluids are consumed)
T or F: Tolerance does NOT develop to opioid-induced constipation.
T
What should be used as prophylaxis for opioid-induced constipation?
Stimulant and/or osmotic laxative +/- stool softener
How to tx opioid-induced constipation?
Suppository or enema
What is used if stimulant/osmotic laxatives and stool softeners have failed?
Methylnaltrexone
MOA of methylnaltrexone?
Peripheral (intestinal) acting selective µ-opioid antagonist
When should methylnaltrexone be d/c’ed?
if it’s not effective after 4 doses
One of the most feared aspects of dying?
Dyspnea
First line for dyspnea?
Opioids
List why opioids are preferred in pts suffering from dyspnea?
- reduce resp effort
- central sedative effect > lowers ventilatory response
- lower sensitivity to hypercapnia and hypoxemia
- reduce O2 consumption
- reduce perception of dyspnea and anxiety
In pts suffering from dyspnea, what should be used if there’re respiratory panic attacks?
BZD
When does dyspnea increase dramatically in terms of occurrence and severity?
in the last 48h of life
What can develop in pts who’re undergoing cancer tx or chronic CS tx?
Oral and esophageal candidiasis
Tx for oral and esophageal candidiasis
Nystatin (local) or fluconazole (systemic)
What’s an important counseling point for antifungal meds?
to continue for 7d after lesions have healed
What’re some end-of-life symptoms/experiences experienced by the pt?
- Nearing-death awareness
- terminal restlessness
- respiratory congestion
T or F: MAiD is part of palliative care.
F
