Palliative Care/Hospice Care Flashcards
Palliative care definition
active total care of patients whose disease isn’t responsive to curative treatment
What does palliative care focus on?
Focuses on pain control, other symptoms, and psychological, social, and spiritual problems
What should be done with palliative care?
Should be provided in conjunction with curative care at the time of diagnosis of a potentially terminal illness
When is palliative care indicated?
Palliative care alone may be indicated when attempts at a cure are judged to be futile
What is hospice care?
philosophy and program that delivers palliative care
Hospice care team
Interdisciplinary team which provides expert medical care, pain management, and emotional and spiritual support expressly tailored to the patient’s wishes (pharmacists are included too!!)
Medicare benefit with hospice
terminal illness with a prognosis of ≤6 months as certified by an attending physician and hospice medical director
Hospice care is provided under what types of mayors?
Part A
Private/public/government health insurance
Medicaid
Foundations if there is no payor
Palliative care vs. hospice care
Palliative care is improving the QoL for those with serious illness; it doesn’t require a terminal diagnosis and doesn’t have to forego curative treatment
Hospice is a subset of palliative care with a timeline (≤6 months or less), it’s more comfort care and you’re not really curing any diseases anymore vs. giving life-sustaining treatment
Fatigue, weakness is manifested by…
Decreasing function, hygiene
Inability to move around bed
Inability to lift head off pillow
Cutaneous ischemia is manifested by…
Erythema over bony prominences
Skin breakdown, wounds
Decreasing appetite/food intake, wasting is manifested by…
Anorexia
Poor intake
Weight loss, muscle and fat, notable in temples
Cardiac dysfunction, renal failure is manifested by…
Tachycardia
Hypertension followed by hypotension
Peripheral cooling
Peripheral and central cyanosis (bluish color of extremities)
Mottling of the skin (livedo reticularis)
Venous pooling along dependent skin surfaces
Dark urine
Oliguria, anuria
Decreasing level of consciousness is manifested by…
Increasing drowsiness
Difficulty awakening
Unresponsive to verbal or tactile stimuli
Decreasing ability to communicate is manifested by…
Difficulty finding words
Monosyllabic words, short sentences
Delayed or inappropriate responses
Verbally unresponsive
Terminal delirium is manifested by…
Day-night reversal
Confusion
Agitation, restlessness
Purposeless, repetitious movements
Moaning, groaning
Respiratory dysfunction is manifested by…
Change in respiratory rate—increasing first, then slowing
Decreasing tidal volume
Abnormal breathing patterns—apnea, Cheyne-Stokes respirations, agonal breaths
Loss of ability to swallow is manifested by…
Dysphagia
Coughing, choking, aspiration
Loss of gag reflex
Buildup of oral and tracheal secretions
Gurgling (“death rattle”)
Loss of sphincter control is manifested by…
Incontinence of urine or bowels
Maceration of skin
Perineal candidiasis
Pain is manifested by…
Facial grimacing
Moaning
Tension in forehead, between eyebrows
Loss of ability to close eyes is manifested by…
Eyelids not closed
Whites of eyes showing (with or without pupils visible)
Rare, unexpected events
Bursts of energy just before death occurs, the “golden glow”
Aspiration, asphyxiation
Portmanteau properties
Multiple therapeutic effects
Minimal DDIs
Multiple routes of administration
Wide therapeutic window
Cost-effective
Convenient dosing schedule
Dose response and favorable ceiling effect
Intensol products are what?
Concentrated liquid formulations of drugs
Examples of Intensol products
Roxanol (morphine liquid)
Atropine 1%
Haloperidol 2mg/ml
Lorazepam liquid 2mg/ml
N/V treatment: gut wall
Step 1: H2RA (Cimetidine, Famotidine, Nizatidine, Ranitidine), PPI (Omeprazole, Esomeprazole, Pantoprazole, Lansoprazole)
Step 2: metoclopramide
Step 3: ondansetron
N/V treatment: area postrema
Step 1: haloperidol, metoclopramide
Step 2: step 1 meds + dexamethasone
Pamidronate for hypercalcemia
Step 3: ondansetron + dexamethasone
N/V treatment: cerebral cortex
Step 1: dexamethasone
Step 2: amitriptyline, haloperidol, lorazepam
Step 3: limited free water +/- 3% saline +/- haloperidol
N/V treatment: vestibular nuclei
Step 1: diphenhydramine, dimenhydrinate
Step 2: meclizine, cyclizine
Step 3: glycopyrrolate, scopolamine
Dyspnea treatment: step 1
Treat underlying cause
Obstruction by tumor: radiotherapy, steroids
Carcinomatous lymphangitis: steroids
Bronchospasm: bronchodilators
Cardiac failure: diuretics, etc.
Chest infections: ABX +/- physiotherapy
Pleural effusions: Pleural aspiration
Gross ascites: Abd paracentesis (diuretics)
Anemia: Transfusion (Hg < 8g/dl)
Dyspnea treatment: step 2
DuoNeb +/- dexamethasone
Dyspnea, DuoNeb- both start with D
Dyspnea treatment: step 3
morphine/any opioid +/- dexamethasone
Dyspnea treatment: step 4
morphine AND chlorpromazine, diazepam, OR midazolam
Cough treatment
Step 1: treat underlying causes
Step 2: promote production → nebulized saline and/or guaifenesin
Step 3: suppress cough → morphine, hydrocodone, dextromethorphan
Step 4: dexamethasone or glycopyrrolate/atropine, NAC
Step 5: nebulized lidocaine, gabapentin, others
Anxiety treatment
Step 1: non-pharm care
Step 2: short-term care: lorazepam, alprazolam, amitriptyline with depression
Step 3: long-term care: buspirone, SSRI (escitalopram, sertraline), mirtazapine with depression/insomnia/anorexia
Delirium treatment
Step 1: haloperidol
Step 2: haloperidol +/- lorazepam (sedation required)
Step 3: haloperidol + midazolam (Versed) or chlorpromazine (Thorazine), agitation in terminal stages
Constipation prevention
Step 1: opioid induced → senna or bisacodyl +/- docusate +/- metoclopramide
Aging or disease-induced → fiber, fluids, docusate
Step 2: sorbitol, lactulose, MiraLax
Step 3: MOM, magnesium citrate, bisacodyl suppository, peripherally-acting mu-opioid receptor antagonists
Acute constipation treatment
Stimulant laxative: bisacodyl or senna
Double dose
Osmotic laxative → sorbitol
MOM
Bisacodyl suppository, then enema in 2 hours; repeat QD X3 days
Peripherally-acting mu-opioid receptor antagonists
Naloxegol, methylnaltrexone
Nuclear enema
Bowel obstruction treatment
Step 1: metoclopramide +/- dexamethasone; not used if complete obstruction
Step 2: glycopyrrolate +/- morphine +/- haloperidol
Step 3: octreotide +/- the above agents
Step 4: PEG-tube or stent
Asthenia treatment
Step 1: energy conserving measures
Step 2: methylphenidate or dexamethasone
Depression treatment
Step 1 (>4 weeks survival): escitalopram, sertraline, +/- methylphenidate until the SSRI becomes effective
Step 2 (>4 weeks survival c/ other signs/symptoms): amitriptyline or nortriptyline +/- methylphenidate until the TCA becomes effective
Step 3: methylphenidate (<4 weeks survival), ketamine
Anorexia-cachexia treatment
Step 1: treat underlying causes
Anxiety, depression, N/V, stomatitis, constipation, dysphagia, PAIN
Step 2: early satiety, dysmotility, gastroparesis → metoclopramide
Step 3: appetite loss, weight loss
Survival <3 months: dexamethasone
Survival >3 months: mirtazapine, megestrol
Step 4: dronabinol
Insomnia treatment: step 1
Step 1: treat underlying causes
Wakeful stimuli, daytime sleep, normal aging (you sleep less when you get older)
Anxiety, depression, fear of dying
Pain, dyspnea, N/V, incontinence, diarrhea, pruritus, restless legs
Diuretics, steroids, caffeine, sympathomimetics, night sedative withdrawal, BZDs, alcohol
Insomnia treatment: step 2
Difficulty initiating sleep: trazodone, melatonin (sundowning/dementia), temazepam or zolpidem (bed-bound)
Difficulty staying asleep (disturbing dreams): haloperidol, mirtazapine or amitriptyline in concomitant depression
Insomnia treatment: step 3
Titrate doses of meds in step 2, combinations of the drugs in step 2, midazolam/Versed for <7 days or high-dose lorazepam
Xerostomia treatment
Step 1: ice chips, gum, lemon drops
Step 2: saliva substitute
Step 3: pilocarpine 5mg PO BID
Terminal secretions treatment
SL atropine 1% eye drops q2-3h PRN!!
Palliative sedation treatment
opioids, BZDs, neuroleptics, barbiturates, anesthetics, or a combination of these agents
