Palliative CLASS PPT Flashcards

Question

What should a physician consider when switching between opioids?

Answer 1

Due to incomplete cross-tolerance clinicians should consider reducing the dose by 20 to 25% when ordering and titrate from there depending on the clinical situation. Must be individualized – consult if necessary.

Answer 2

Equianalgesic doses need to be calculated when switching from one drug to another, when changing routes of administration or both An equianalgesic table should be used as a guide in dose calculation.

Answer 3

No, Always look for a short acting form of same drug if possible for BTP

Answer 4

Meslon, Oxycontin, Hydromorph Contin, Fentanyl patch

Answer 5

If pain not controlled, revert to short acting and re-titrate

Answer 6

24 hours Give BTDs in first 12 hours if necessary

Answer 7

T Meslon can be opened and sprinkled on food but cannot be put down NG tubes

Answer 8

``` A synthetic opioid Doesn’t release histamine Lipophilic and high bioavailability Forms subcutaneous pool Less likely to cause nausea/constipation ```

Answer 9

Demerol (Meperidine)

Answer 10

``` Opioids NSAIDs Corticosteroids Bisphosphonates Calcitonin Radiation External bracing ```

Answer 11

Constant, worse with movement Mets, compression or pathologic fractures Prostaglandins from inflammation, mets Rule out cord compression

Answer 12

Neuropathic pain Gabapentin only helpful in 15% of population but tends to work really well in those it does. Don’t stop abruptly!

Answer 13

Tricyclic antidepressants Gabapentin Methadone SSRIs usually not useful

Answer 14

``` Cutaneous stimulation Distraction Relaxation Positioning Companioning Bearing witness ```

Answer 15

60% of patients with terminal cancer, ALS, or end stage lung and heart disease will experience some degree of dyspnea, especially during last 6 weeks of life.

Answer 16

``` Treat the cause if possible Obstruction: Radiation/Chemotherapy/Meds Pleural effusion: Thoracentesis Ascites: Abdominal paracentesis Antibiotics: Pneumonia Anemia: Transfusion ``` ``` Bronchodilators (for bronchospasm) Diuretics Steroids Anti-anxiety medications Neuroleptics, esp if dying (CPZ, Nozinan) Tranquilizers if the above do not settle Cough suppressants Oxygen ```

Answer 17

IT will prolong life...need to make sure this is what they want!

Answer 18

Haldol + dexamethazone

Answer 19

Opioids! Decreases the sense of breathlessness Decreases sensitivity to CO2 If on an opioid for pain control adding or increasing the dose my be sufficient to relieve air hunger. Doses may need to be increased by as much as 200% or a little as 25% in mild dyspnea.

Answer 20

Early in disease process | Not in last hours of dying (unless pt panicking and finds it comforting

Answer 21

No perfumes Avoid triggers such as smoke, smells, memories, anxiety Limit number of people in the room Encourage fresh air with an open window or fan

Answer 22

``` Positioning Elevate HOB Recliner Pillows under arms to expand chest Loosen clothing Touch, support, information ```

Answer 23

More common than hunger not related to dehydration and unrelieved by artificial hydration (AH)

Answer 24

caused by metabolic disturbance of Ca – loss of protein

Answer 25

to treat delirium caused by opioid toxicity and hypercalcemia

Answer 26

Fighting back - The knowledge that reduced intake is normal for someone who is dying is in direct conflict with a family’s desperate attempt to prevent Letting nature take it’s course - Understand that no amount of nutrition of fluids with prevent the patient from dying Waffling - Go between accepting approaching death and wanting to keep fighting Some care givers fit in here as well

Answer 27

Natural anaesthetic effect, reduction in resp secretions, decreased GI fluid, reduced urine output

Answer 28

Edema, ascites, resp congestion and distress, diarrhea, nausea, pain

Answer 29

No evidence that AH prolongs or increases quality of life

Answer 30

``` Hypoxemia Metabolic imbalance Acidosis Toxin accumulation due to liver and renal failure Adverse effects of medication Sepsis Disease-related factors Reduced cerebral perfusion ```

Answer 31

Intent to Relieve by Reversal Intent to Relieve by Sedation Intent to Observe Delirium

Answer 32

In this approach, there is some likelihood of reversing delirium, particularly where the patient has a higher functional status. Criteria for this include: Known patient wish for intervention where possible, even if chances are low If readily reversible If potentially reversible e.g. opioid neurotoxicity If not dying, i.e. earlier stages If dying, trial attempts – only if patient had wanted active treatments and reverse is likely; otherwise no.

Answer 33

Reversal may be unrealistic or unwanted. Latimer(46) used the term ‘sedation as therapy’ in recognizing that the goal may be reduction of severity of delirium via use of sedative medication. Criteria for this approach include: * If delirium unpleasant and/or worsening * If patient did not want active treatment * If treatment is futile or unlikely to improve delirium * If conditions are unsafe for patient, family or staff e.g. wild agitation, violence

Answer 34

There are occasional times when, in known imminently dying patients, the patient develops hallucinations, visions or physical movements which appear comforting, or at least not disturbing, and possibly have interpretable meaning to family. In these cases, it may be prudent to observe the patient, provide support to family, but be prepared to initiate sedative therapy if circumstances change to agitation.

Answer 35

Plan ahead! * The last hours of life are the time when they most want to communicate with their loved one (but may be less able to do this as pt becomes less present) * As many clinicians have observed, the degree of family distress seems to be inversely related to the extent to which advance planning and preparation occurred * Time spent preparing families is likely to be very worthwhile

Answer 36

experience suggests that at times their awareness may be greater than their ability to respond •Given our inability to assess dying patient’s comprehension and the distress that talking "over" the patient may cause, it is prudent to presume that the unconscious patient hears everything •Advise families and professional caregivers to talk to the patient as if he or she was conscious

Answer 37

Neuroleptics Anxiolytics

Answer 38

Haloperidol (haldol) is generally considered the gold standard

Answer 39

It is a longer acting drug(48) can be given PO, SC, IM or IV. In delirium, a suggested regimen is 0.5–1.5mg PO (mild), 1.5– 5.0mg PO (severe) or 10mg SC or IV (very severe) [one report of up to 250mg/24hr.

Answer 40

Haldol Chlorpromazine Methotrimeprizaine

Answer 41

may be an acceptable alternative to haldol if a small risk of slight cognitive impairment is not a concern.

Answer 42

is effective and used as an alternative to haloperidol(66,67). It is a higher sedation drug at doses of 15mg or above. It can be given PO, SC, IV as well as SL. Very low doses are used for nausea (0.5–2.5mg) but control of delirium usually requires 10–15mg for mild and up to 50mg for severe delirium. These may be given q4–8h initially, then less often once controlled

Answer 43

do not clear the sensorium or improve cognition, and should not be used for delirium unless as an adjunct to primary therapy with haloperidol or anther neuroleptic. Particular caution should be used in the elderly or those with hepatic failure.

Answer 44

Lorazepam Midazolam Propofol Phenobarbital

Answer 45

Lorazepam alone appears to be ineffective and is in fact associated with treatment-limiting adverse effects, but in combination may provide quicker and more effective control. In mild cases of delirium, it should be avoided as noted above or used on a PRN only basis for agitation until the neuroleptic provides overall control, especially if the goal is reversal of delirium.

Answer 46

is also frequently used in delirium, but is more helpful for the restlessness aspect. In acute dosing, it is short-acting and rapidly effective.

Answer 47

Short-acting anesthetic

Answer 48

may be helpful or in combination if midazolam fails to provide adequate sedation in refractory cases.

Answer 49

Occurs intermittently in 60% of terminally ill cancer patients 40% in patients during last week of life Occur in up to 60% of patients receiving opioids, particularly at the initiation of therapy

Answer 50

Often multi-faceted – ongoing assessment critical - Ongoing assessment and trial of drugs – if it is not working change the regime

Answer 51

a vestibular component.

Answer 52

cortical component.

Answer 53

impaired gastric emptying.

Answer 54

obstruction.

Answer 55

chemical cause.

Answer 56

increased intracranial pressure

Answer 57

``` drugs - opioids - chemoTx etc... biochemical - Ca++ - renal failure - liver failure sepsis radiotherapy ```

Answer 58

tumor | opioids (not CTZ??)

Answer 59

- anxiety - association - ICP

Answer 60

``` radiotherapy chemotherapy GI irritation inflammation obstruction paresis compression ```

Answer 61

1) Neuroleptics - Stemetil, Haldol, Nozinan, CPZ, Loxapine, Olanzapine ``` 2) Antihistamines Gravol 3) Anticholinergics Scopolamine Atropine 4) Steroids Dexamethasone 5) Anxiolytics 6) 5-HT antagonists Ondansetron ```

Answer 62

Avoid spicy, fatty and salty foods, or ones with strong odours Avoid mixing liquids and solids. Use small frequent, bland meals when hungry. Drinking cool, fizzy drinks. Avoid lying flat after eating.