Witches and Wizards: Palliative Care Flashcards
hospice qualifiaton
- Medicare benefit: termina illness with a prognosis of 6 mo or less as certified by the attending md and the hospice medical director
- hospice is provided under
- medicare part a
- private/public/gov health ins
- edicai
hospice vs palliative care
- palliative: improving qol of those with serious illness
- does not require terminal dx
- does not forgo curative therapy
- hospice: focuses primarily on comfort care
- may be life sustaining but NOT curative
- pt prognosis < 6 months
desirable proeprites in medications used in end of lfe care
portmantaeu drugs
- multiple tpx effects
- minimal adr
- multiple roa
- wide tpx window
- cost effective
- conienent dosing
- dose response and favorable ceiling effect
portmanteau drugs examples
- morphine liqd
- metahdoe liqd
- hydromorphone liqd
- oxy liqd
- lorazepam concentrate
- alprazolam liqd (lil expensive tho)
- haloperidol
- atropine gtts
- dexamethasone liqd
- ondansetron odt (lil expensive tho)
- metoclopramide ODT (lil expensive tho)
- metoclopramide liqd
intensol
concentrated liqd (like morphine liqd, lorazepam concentrate)
gut wall n/v end of lfie causes and treatment
gastrtis, chemo, intestinal distention
1. H2RA or PPI
2. metoclopramide
3. zofran
med induced N/V (area postrema) end of life treatment
- haloperidol or metoclopramide
- || + dexamethasone
- zofran + dexamethasone
cerebral cortex (fear/anx, hyponatremia) N/V end of life treatment
- dexamethasone
- amitriptyline or haloperidol or lorazepam
- limit free water +/- 3% saline +/- haloperidol
- esp if hyponatremia
vertigo end of life treatment
- diphenhydramine or dimenhydrinate
- meclizine or cyclizine
- glycopyrrolate or scopolamine
dyspnea end of life treatment
- targeted therapy
- duoneb +/- dexamethasone
- morphine (or any opioid) +/- dexamethasone
- morphine + (chlorpromazine or diazepam or midazolam)
dyspnea: targeted treatment - tumor
radiotherapy
dyspnea: targeted treatment - carcinomatous lymmphangitis
steroids
dyspnea: targeted treatment - bronchospasm
bronchodilators
dyspnea: targeted treatment - cardiac falure
diuretcis
dyspnea: targeted treatment - chest infection
abx +/- physoitherapy
dyspnea: targeted treatment - pleural effusions
aspiration
dyspnea: targeted treatment - ascites
paracenteiss and maybe diuretcs
dyspnea: targeted treatment - anemia
transfusion
s/s of bowel obstruction
- early satiety
- constpation
- bloating
- ileus with n/v (intractable)
cough end of life treatment
- treat underlying cause
- prmote production (neb saline and/or mucinex)
- supress cough (morphine, hydrocodone, dextromethorphan)
- dexamethasone or glycopyrroltae/atropine; NAC
- nebulized lidocaine, gabapentin, others
if using neb NAC, give bronchodilator prior (duoneb)
anx end of life treatment
- non-pharm
- short term (lorazepam, alprazolam, amitriptyline)
- longterm (buspar, ssri, mirtazepine)
end of life = bad organ -> increased half life and [ ] -> short actiing better (lorazepam)
delirium end of life treatmet
- haloperidol
- haloperidol + lorazepam (sedaton)
- haloparidol + (midazolam or chlorporamie) for agitatio in terminal stages
depresson end of lfie treatment
- > 4 weeks survival: (lexapro or zoloft) +/- methylphendiate (until SSRI effective)
- > 4 weeks survival with other s/s: (amitriptyline or nortriptyline) +/- methylphenidate
- < 4 weeks: methylphendiate (maybe ketamine)
constipatio prevention end of life treatment
- if opioid: senna or bisacodyl +/- docusate +/- metoclopramide
- if aging or disease induced: fiber, fluids, docsate
- sorbitol, lactulose, PEG
- MOM, mag citrate, bisacodyl supp
acute constipation end of lfie treamtnet
- stimulant laxative (bisacodyl or senna)
- double dose
- osmotic laxtive (sorbitol)
- MOM
- bisacodyl suppository then enema in 2H (repeat QD for 3 day)
- pheripheral acting mu opoid reeptor antag, naloxegol, methylnaltrexone
- nuclear enema
underlying causes of anorexia-cachexia
- anx
- depression
- n/v
- stomatitis
- constiaptin
- dysphagia
- pain
bowel obstruction end of life treatment
- metoclopramide +/- dexamethasone IF it is NOT a complete obstrution because it will try to push poo through
- glycopyrrolate +/- morphine +/- haloperidol
- octreotide +/- above
- PEG tube or stent
bowel obstruction: too much secretion into bowels that cant excrete -> vomit it up (octreotide reduces these secretios)
anorexia-cachexia end of life treatment
- treat underlying cause
- early saity, dysmotility, gastroparesis: metoclopramide
- appetite loss, wt loss
- survival < 3 months: dexamethasone
- surivival > 3 months: mirtazepine or megestrol
- dronabinol
insomnia end of lfie treatment
- ftreat underlying cause
- cause dependent
- difficult iniating sleep
- trazadone or melatonin (esp in sundowning or dementia)
- temazepam or zolpidem (bed ound)
- difficulty staying asleep (disturbing dreams): haloperidol
- conmitat depression: mirtazapine or amitriptyline
- difficult iniating sleep
- increase doses, try combos
- substitue midazolam or high dose lorazepam (NOT to exceed 7 days)
xerostomia end of life treatment
- ice chips, gum, lemon drops
- saliva substitite
- pilocarpine
terminal secretions treatment
atrpine 2-3 sl gtts q2h prn (used for death rattle - normal saliva production but not draining)
- scopolomine patch
- glycopyrrolate
palliative sedation agents
- opioids
- benzos
- neuroletptic
- barbitutes
- anesthetics
or combo of above
