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PHM 704- Geriatrics > Palliative Care/Hospice Care > Flashcards

Palliative Care/Hospice Care Flashcards

1
Q

Palliative care definition

A

active total care of patients whose disease isn’t responsive to curative treatment

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2
Q

What does palliative care focus on?

A

Focuses on pain control, other symptoms, and psychological, social, and spiritual problems

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3
Q

What should be done with palliative care?

A

Should be provided in conjunction with curative care at the time of diagnosis of a potentially terminal illness

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4
Q

When is palliative care indicated?

A

Palliative care alone may be indicated when attempts at a cure are judged to be futile

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5
Q

What is hospice care?

A

philosophy and program that delivers palliative care

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6
Q

Hospice care team

A

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!!)

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7
Q

Medicare benefit with hospice

A

terminal illness with a prognosis of ≤6 months as certified by an attending physician and hospice medical director

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8
Q

Hospice care is provided under what types of mayors?

A

Part A
Private/public/government health insurance
Medicaid
Foundations if there is no payor

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9
Q

Palliative care vs. hospice care

A

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

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10
Q

Fatigue, weakness is manifested by…

A

Decreasing function, hygiene
Inability to move around bed
Inability to lift head off pillow

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11
Q

Cutaneous ischemia is manifested by…

A

Erythema over bony prominences
Skin breakdown, wounds

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12
Q

Decreasing appetite/food intake, wasting is manifested by…

A

Anorexia
Poor intake
Weight loss, muscle and fat, notable in temples

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13
Q

Cardiac dysfunction, renal failure is manifested by…

A

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

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14
Q

Decreasing level of consciousness is manifested by…

A

Increasing drowsiness
Difficulty awakening
Unresponsive to verbal or tactile stimuli

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15
Q

Decreasing ability to communicate is manifested by…

A

Difficulty finding words
Monosyllabic words, short sentences
Delayed or inappropriate responses
Verbally unresponsive

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16
Q

Terminal delirium is manifested by…

A

Day-night reversal
Confusion
Agitation, restlessness
Purposeless, repetitious movements
Moaning, groaning

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17
Q

Respiratory dysfunction is manifested by…

A

Change in respiratory rate—increasing first, then slowing
Decreasing tidal volume
Abnormal breathing patterns—apnea, Cheyne-Stokes respirations, agonal breaths

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18
Q

Loss of ability to swallow is manifested by…

A

Dysphagia
Coughing, choking, aspiration
Loss of gag reflex
Buildup of oral and tracheal secretions
Gurgling (“death rattle”)

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19
Q

Loss of sphincter control is manifested by…

A

Incontinence of urine or bowels
Maceration of skin
Perineal candidiasis

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20
Q

Pain is manifested by…

A

Facial grimacing
Moaning
Tension in forehead, between eyebrows

21
Q

Loss of ability to close eyes is manifested by…

A

Eyelids not closed
Whites of eyes showing (with or without pupils visible)

22
Q

Rare, unexpected events

A

Bursts of energy just before death occurs, the “golden glow”
Aspiration, asphyxiation

23
Q

Portmanteau properties

A

Multiple therapeutic effects
Minimal DDIs
Multiple routes of administration
Wide therapeutic window
Cost-effective
Convenient dosing schedule
Dose response and favorable ceiling effect

24
Q

Intensol products are what?

A

Concentrated liquid formulations of drugs

25
Q

Examples of Intensol products

A

Roxanol (morphine liquid)
Atropine 1%
Haloperidol 2mg/ml
Lorazepam liquid 2mg/ml

26
Q

N/V treatment: gut wall

A

Step 1: H2RA (Cimetidine, Famotidine, Nizatidine, Ranitidine), PPI (Omeprazole, Esomeprazole, Pantoprazole, Lansoprazole)
Step 2: metoclopramide
Step 3: ondansetron

27
Q

N/V treatment: area postrema

A

Step 1: haloperidol, metoclopramide
Step 2: step 1 meds + dexamethasone
Pamidronate for hypercalcemia
Step 3: ondansetron + dexamethasone

28
Q

N/V treatment: cerebral cortex

A

Step 1: dexamethasone
Step 2: amitriptyline, haloperidol, lorazepam
Step 3: limited free water +/- 3% saline +/- haloperidol

29
Q

N/V treatment: vestibular nuclei

A

Step 1: diphenhydramine, dimenhydrinate
Step 2: meclizine, cyclizine
Step 3: glycopyrrolate, scopolamine

30
Q

Dyspnea treatment: step 1

A

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)

31
Q

Dyspnea treatment: step 2

A

DuoNeb +/- dexamethasone

Dyspnea, DuoNeb- both start with D

32
Q

Dyspnea treatment: step 3

A

morphine/any opioid +/- dexamethasone

33
Q

Dyspnea treatment: step 4

A

morphine AND chlorpromazine, diazepam, OR midazolam

34
Q

Cough treatment

A

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

35
Q

Anxiety treatment

A

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

36
Q

Delirium treatment

A

Step 1: haloperidol
Step 2: haloperidol +/- lorazepam (sedation required)
Step 3: haloperidol + midazolam (Versed) or chlorpromazine (Thorazine), agitation in terminal stages

37
Q

Constipation prevention

A

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

38
Q

Acute constipation treatment

A

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

39
Q

Bowel obstruction treatment

A

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

40
Q

Asthenia treatment

A

Step 1: energy conserving measures
Step 2: methylphenidate or dexamethasone

41
Q

Depression treatment

A

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

42
Q

Anorexia-cachexia treatment

A

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

43
Q

Insomnia treatment: step 1

A

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

44
Q

Insomnia treatment: step 2

A

Difficulty initiating sleep: trazodone, melatonin (sundowning/dementia), temazepam or zolpidem (bed-bound)

Difficulty staying asleep (disturbing dreams): haloperidol, mirtazapine or amitriptyline in concomitant depression

45
Q

Insomnia treatment: step 3

A

Titrate doses of meds in step 2, combinations of the drugs in step 2, midazolam/Versed for <7 days or high-dose lorazepam

46
Q

Xerostomia treatment

A

Step 1: ice chips, gum, lemon drops
Step 2: saliva substitute
Step 3: pilocarpine 5mg PO BID

47
Q

Terminal secretions treatment

A

SL atropine 1% eye drops q2-3h PRN!!

48
Q

Palliative sedation treatment

A

opioids, BZDs, neuroleptics, barbiturates, anesthetics, or a combination of these agents

PHM 704- Geriatrics (15 decks)

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