Part 2 Flashcards
Children aged 1 to 9 die from
- unintentional injuries such as drowning, motor vehicle accidents, falls,
- congenital abnormalities, cancer
- intentional injuries such as murder and suicide.
Youth aged 10 to 19 die from
intentional and unintentional injuries, cancer, heart disease.
4 pathways of death in children
1) sudden death (ex. S.I.D.S., automobile accident)
2) death from a potentially curable disease (an initial positive response to treatment followed by return of the disease or complications )
3) death from a congenital abnormality that is lethal
4) death from a progressive condition (ex. neuromuscular disorders where the child survives one crisis after another until they finally die)
false beliefs about children and pain
children do not experience pain,
children cannot tell you where they hurt,
opioids are dangerous for use in children,
children will become addicted to opioids if they are used for pain relief.
List 3 Challenges in Ethical Decision Making
Respecting Autonomy
Fostering Social Justice
Avoiding Killing while Relieving Suffering
If no one has been chosen as a SDM the following have decision making authority in descending order;
spouse, adult children, parents, and siblings.
three types of pain
1) Acute pain, which is a warning sign that indicates damage or injury
2) Chronic or persistent pain
3) Cancer pain that is associated with malignancy – this pain is often multifactorial
Routes of Administration of pain meds
- Use the least invasive route for the administration of analgesia
- Oral administration is the first choice
- Sublingual fast acting medications that are absorbed through buccal mucosa are useful when swallowing reflex is diminished
- Rectal suppositories often provide effective pain and nausea relief
- Injections and intravenous routes should be the last choices as they involve more pain for the patient, restrict movement and if the patient experiences terminal restlessness or delirium they may pull lines out, therefore the patient may require restraints
- Continuous pain infusion of opioids into the epidural space is used for patients with intractable pain
The Three Step Ladder
Step One
Non-opioid (acetaminophen or NSAID) and perhaps the addition of an adjuvant medication
Step Two
Opioid for mild to moderate pain and maybe and non-opioid medication with the possibility of the addition of an adjuvant
Step Three
Strong opioid, a PRN pain medication, a non-opioid medication and perhaps the addition of an adjuvant
Feat of opiod Respiratory Effects
Contrary to previously held medical beliefs that opioids depress respirations, research evidence now shows that the respiratory depression caused by opioids tens to occur in patients receiving opioids for the first time
Even in opioid naïve patients, the presence of pain counteracts the respiratory depressant side effect of opioids
Side Effects of Regular Opioid Administration
Constipation
Nausea and Vomiting
Sedation and Impaired Cognition
Neurotoxicity
End of Life symptom control
Task1: Treat the treatable – establish what may be causing the symptom and treat if possible and appropriate
Task 2: Care for the patient – focus on comfort, involve the patient and loved ones in symptom control
Task 3: Prescribe palliative drugs – we may use medications in different ways and at different doses to achieve desired effects – concern about escalating doses and issues about dependence con result in under dosing and reduced effectiveness
Common Physical Symptoms that Cause Distress
Pain
Fatigue
Breathlessness
Constipation
Complications from stasis include
urinary and pulmonary infection, skin breakdown associated with immobility, catheterization, intravenous therapy, and problems maintaining cleanliness of the peri-anal area.
Impaired Fluid Balance
Most dying people reduce their oral intake of fluids before they die related to lack of thirst, weakness, anorexia, depression, cognitive impairment, nausea and vomiting, dysphagia and bowel obstruction.
The Hospice movement has challenged the idea that hydration is good for all patients and that dehydration causes suffering at the end of life (Zerwekh, 1997). Dying people have surprisingly normal blood chemistries
Culture with Truth and Consent
Informed consent causes many cross-cultural dilemmas because views of telling the truth about medical diagnoses and decision making practices vary across cultures.
Some cultures believe that talking about death will bring it closer.
Consent is critical at the end-of-life; some want the doctors to make all the decisions, others rely on traditional leaders and/or healers, whereas other people have a culturally designated family member who is expected to make decisions on the patient’s behalf.
In some cultures patient autonomy is not considered liberating, instead it is viewed as burdensome and causes loss of hope
Grief According to Kubler-Ross
Denial – Refusal to accept loss or to believe prognosis which can occur consciously or unconsciously.
Anger – Strong feelings or resentment, blame that are expressed towards family members, loved ones, health care personnel, god and other external forces.
Bargaining – Trying to strike an agreement with god or fate to postpone death in return for a change of behavior.
Depression – Deep sadness when the person believes that life will soon be over.
Acceptance – a sense of peace and calm that death is imminent.
Emotions of Grief
Absence of feeling, numbness, shock and denial.
anger, guilt and depress
feel bitter and look for someone or something to blame
Depression and despair
immobilized by sadness, become withdrawn with loss of pleasure , hope and meaning in life.
Cognitive manifestations of grief
disbelief, confusion, difficulties with concentration, problem-solving and decision-making
Sleep often suffers
restless, withdrawn, hyperactive, disorganized, absent-minded
Effects of Grief on the Body
Disturbed sleep, appetite changes, changes in level of activity, sex drive are common.
Other bodily complaints include; trembling, shortness of breath, heaviness in the chest, pounding heart, headaches stomach aches and muscle weakness.
Common Myths
- It is always good to talk about your feelings.
- Confronting feelings after death is better than avoiding those feelings.
- You cannot heal following bereavement unless you express intense feelings.
- Bereaved individuals who continue to feel a connection to their deceased loved ones require therapy for their pathological grief.
the Truth
1. It may or may not be good to talk about your feelings.
- Confronting feelings should notbe forced. The value of expression is determined by individual personality, family values, and religious beliefs.
- Healing from loss proceeds over time whether you express intense feelings or not.
- It is common to feel a continued connections with loved ones who have died.
