Pallitative Care Flashcards
What is Palliative Care?
services designed to provide relief of symptoms that interfere with quality of life
List 3 different interprofessional team members that the patient/family may interact with.
-doctors
-nurses
-social workers
-phamracists
What are advanced directives?
defines the type of care you would like to have if you become unable to make medical decisions
Explain Do not resuscitate (DNR) order
Advanced directive
an order that determines how to treat the patient in the event of cardiac or respiratory arrest
(cardiopulmonary resuscitation (CPR), automated external defibrillator (AED), compressions, assisted ventilation, meds)
Explain Durable power of attorney for healthcare (DPA)
Advanced directive
it states whom the person has chosen to make health care decisions for them if they become unconscious or unable to make medical decisions for themselves.
Explain Living will
Advanced directive
a written legal document that conveys the wishes of someone who is no longer able to communicate
What kind of nutrition and/or hydration does evidence-based medicine support providing to a patient receiving end-of-life care?
Offer small, frequent meals high in protein throughout the day (5-6 light meals)
-Purée family meals (when difficulty swallowing)
-small, frequent sips of fluid throughout the day between meals
-don’t force feed
-lemon drops, mints or gum (for relief of metallic or bitter taste)
What criteria does a patient need to meet to be eligible for hospice?
the patient’s physician and medical director of hospice must certify that the patient is terminally ill and has a life expectancy of 6 months or less
List 3 disease states that may qualify a patient for hospice care.
Cancer
End-stage kidney or liver disease
adv
advanced lung disease (COPD)
Where can hospice care be delivered?
in the patient’s home, a Hospice House, or other environment.
How may a pharmacist be involved in hospice care?
-pharmacists may partially fill CIIs for patients with terminal illness for up to 60 days
-Both the pharmacist and the prescriber must make sure that the controlled substance is for a terminally ill patient
-the pharmacist must record on the Rx: “terminally ill” or an “LTCF patient.
Prescribers are allowed to fax C-II prescriptions for patients in what type of facility?
A doctor or their assistant can send a prescription for a C-II narcotic by fax to the pharmacy if the patient is in a hospice program
When a patient is in the dying process, what are the indications for morphine, opioids, and
scopolamine patch?
morphine sulfate: pain, dyspnea (SOB), and tachypnea (rapid breathing)
scopolamine: terminal secretions
What are the 8 “Super Star” medications as named by Dr. Flores?
What is the administration route and dose for Roxanol in end-of-life care?
5-10 mg q4h
oral concentrate
pain, dyspnea, tachypnea
What is the administration route and dose for Chlorpromazine in end-of-life care?
25-50 mg
PO/IV q6h PRN
for hiccups
What is the administration route and dose for Lorazepam in end-of-life care?
0.5-2 mg
2mg/ml oral concentrate PO q 4h
for dyspnea, delirium, restlessness
What is the administration route and dose for Haloperidol in end-of-life care?
1.5mg every 12 hours for nausea/vomiting
0.5mg-5mg Q1-4H for delirium, agitation (oral or injection)
What is the administration route and dose for Megestrol in end-of-life care?
Daily doses of 400-800mg
suspension (not equivalent mg to mg)
for anorexia/cachexia
What is the administration route and dose for Scopolamine in end-of-life care?
-1mg: 1 to 3 patches behind ear every 3
days, effective in 2-3 hours
also SC/IV
for terminal secretions
What is the administration route and dose for Atropine in end-of-life care?
-1% ophthalmic drops
-1-2 drops SL every 1-4 hours PRN
for terminal secretions
What is the administration route and dose for Hyoscyamine in end-of-life care?
-0.125mg Q8H PRN
oral solution, elixir, SL, or disintegrating tablet
for Terminal secretion
What are the 10 common problems/symptoms that may be managed with medications?
Pain
Constipation
Dyspnea
Fatigue
Depression
Delirium
Anorexia/cachexia
Dehydration
N/V
Terminal secretions “Death rattle”
Describe a stepwise approach to Pain management. Are opioids okay?
- Nonopioids (Tylenol, NSAIDs)
- mild opiods (hydrocodone)
- stronger opioids (morphine)
- Adjuncts/alternatives:
calcitonin; TCA, SSRI/SNRI, anticonvulsants;
corticosteroids; topicals; nerve blocks;
radiotherapy; radiofrequency ablation
What must be given with opioids?
use stimulant laxatives to prevent constipation
Is dosing frequency or starting dose more important for the onset of analgesia?
Dosing frequency
What else may opioids be utilized for?
dyspnea (SOB) or tachypnea (rapid breathing) in end-of-life care
What drug is first line for Constipation in End-of-life care?
- Stimulant laxatives (Senna 2-4 tablets/day or bisacodyl)
- osmotic laxatives and other forms of laxatives or enemas
What medication would you NOT recommend in a patient with constipation who is NPO and immobile due to a recent stroke?
bulk-forming laxatives due to risk of obstruction
in patients with little intake and movement
How can you prevent constipation?
-mobility
-hydration
-adequate caloric intake
-increase fiber if possible
What are 3 medications, including dose and route, that may be used for Dyspnea?
-morphine (oral or IV) - 5-10 mg q4h
-Lorazepam (oral or IV) - 0.5-2 mg
-Diazepam (oral or IV)
What is the treatment of choice for pain? What is it titrated to?
Opioids are the treatment of choice, titrated to respiratory effort
What should be done related to medication use when managing Fatigue?
Reduce any medications that worsen fatigue
Which drugs are used for fatigue in end-of-life care?
Modafinil, Stimulants, or Glucocorticoids
(rest and education is the primary treatment)
Should Depression be treated as a part of end-of-life care?
hard to assess, but should be treated when present
Which drugs should be used for depression in end-of-life care?
-fluoxetine
-stimulants: dextroamphetamine or methylphenidate if rapid onset is needed
What is the first medication intervention to employ in addressing Delirium?
reduce medications
Which type of delirium is the most common in palliative/end-of-life care?
Hypoactivity
others are: Hyperactivity and mixed
What are the potential causes of delirium that should be addressed?
-metabolic abnormalities
-medications
-infection
-brain tumors
What are 3 nonpharmacologic interventions that may be beneficial for delirium in end-of-life care?
-clock and calendar placement
-noise minimization
-family presence
help orient the patient and minimize sensory overload
What is the most commonly used medication/medication combination for delirium in end-of-life care?
Haloperidol
-may combine with a benzo
What do studies say about the use of additional nutrition in the treatment of Anorexia?
additional nutrition whether oral or artificial is unlikely helpful -> increases discomfort
What, medications have a positive risk/benefit analysis to treat anorexia in end-of-life
patients?
-Progestins (Megestrol), corticosteroids, and cannabinoids (Dronabinol) may be used in some patients to increase appetite
-Megestrol and medroxyprogesterone
ADE: of thrombotic events and edema
-Dronabinol improves mood and appetite, no weight gain
ADE: cognitive impairment, euphoria, dizziness
Which meds are used to increase appetite in patients with short life expectancy?
Dexamethasone and methylprednisolone
short-term effects:
stimulate appetite, decrease N/V, better pain control, increase weight
What is best for the management of Dehydration?
offering ice chips, oral hydration as tolerated, and lubricating mouth/nose/lips
-may use Subcutaneous infusion of fluids
What drug class are the agents of choice for Nausea and Vomiting?
- Dopamine antagonists (phenothiazines – Promethazine, etc. or butyrophenones – Haloperidol, etc.)
- antihistamines, anticholinergics, serotonin antagonists, and prokinetic agents
When should treatment be initiated for Terminal Secretions?
at the first sign of terminal secretions
Anticholinergic agents inhibit additional secret production but don’t remove what is already there
What non-pharmacologic option should be AVOIDED for treating terminal secretions and why?
Suctioning can worsen edema, ascites, and
pulmonary congestion
What medications are used for terminal secretions?
anticholinergics
-hyoscyamine
-glycopyrrolate
-atropine
-scopolamine (also N/V)
What is the most appropriate pharmacologic agent(s) for terminal secretions in a patient who is already experiencing hallucinations and restlessness?
glycopyrrolate and hyoscyamine bc they don’t cross the BBB barrier and cause side effects of hallucinations and restlessness (atropine and scopolamine do cross the BBB)
