Witches and Wizards: Palliative Care

Question 1

hospice qualifiaton

Answer 1

• 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

Question 2

hospice vs palliative care

Answer 2

• 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

Question 3

desirable proeprites in medications used in end of lfe care

portmantaeu drugs

Answer 3

1. multiple tpx effects
2. minimal adr
3. multiple roa
4. wide tpx window
5. cost effective
6. conienent dosing
7. dose response and favorable ceiling effect

Question 4

portmanteau drugs examples

Answer 4

• 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

Question 5

intensol

Answer 5

concentrated liqd (like morphine liqd, lorazepam concentrate)

Question 6

gut wall n/v end of lfie causes and treatment

Answer 6

gastrtis, chemo, intestinal distention
1. H2RA or PPI
2. metoclopramide
3. zofran

Question 7

med induced N/V (area postrema) end of life treatment

Answer 7

1. haloperidol or metoclopramide
2. || + dexamethasone
3. zofran + dexamethasone

Question 8

cerebral cortex (fear/anx, hyponatremia) N/V end of life treatment

Answer 8

1. dexamethasone
2. amitriptyline or haloperidol or lorazepam
3. limit free water +/- 3% saline +/- haloperidol
   - esp if hyponatremia

Question 9

vertigo end of life treatment

Answer 9

1. diphenhydramine or dimenhydrinate
2. meclizine or cyclizine
3. glycopyrrolate or scopolamine

Question 10

dyspnea end of life treatment

Answer 10

1. targeted therapy
2. duoneb +/- dexamethasone
3. morphine (or any opioid) +/- dexamethasone
4. morphine + (chlorpromazine or diazepam or midazolam)

Question 11

dyspnea: targeted treatment - tumor

Answer 11

radiotherapy

Question 12

dyspnea: targeted treatment - carcinomatous lymmphangitis

Answer 12

steroids

Question 13

dyspnea: targeted treatment - bronchospasm

Answer 13

bronchodilators

Question 14

dyspnea: targeted treatment - cardiac falure

Answer 14

diuretcis

Question 15

dyspnea: targeted treatment - chest infection

Answer 15

abx +/- physoitherapy

Question 16

dyspnea: targeted treatment - pleural effusions

Answer 16

aspiration

Question 17

dyspnea: targeted treatment - ascites

Answer 17

paracenteiss and maybe diuretcs

Question 18

dyspnea: targeted treatment - anemia

Answer 18

transfusion

Question 19

s/s of bowel obstruction

Answer 19

• early satiety
• constpation
• bloating
• ileus with n/v (intractable)

Question 20

cough end of life treatment

Answer 20

1. treat underlying cause
2. prmote production (neb saline and/or mucinex)
3. supress cough (morphine, hydrocodone, dextromethorphan)
4. dexamethasone or glycopyrroltae/atropine; NAC
5. nebulized lidocaine, gabapentin, others

if using neb NAC, give bronchodilator prior (duoneb)

Question 21

anx end of life treatment

Answer 21

1. non-pharm
2. short term (lorazepam, alprazolam, amitriptyline)
3. longterm (buspar, ssri, mirtazepine)

end of life = bad organ -> increased half life and [ ] -> short actiing better (lorazepam)

Question 22

delirium end of life treatmet

Answer 22

1. haloperidol
2. haloperidol + lorazepam (sedaton)
3. haloparidol + (midazolam or chlorporamie) for agitatio in terminal stages

Question 23

depresson end of lfie treatment

Answer 23

• > 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)

Question 24

constipatio prevention end of life treatment

Answer 24

1. if opioid: senna or bisacodyl +/- docusate +/- metoclopramide
   
   1. if aging or disease induced: fiber, fluids, docsate
2. sorbitol, lactulose, PEG
3. MOM, mag citrate, bisacodyl supp

Question 25

acute constipation end of lfie treamtnet

Answer 25

1. stimulant laxative (bisacodyl or senna) 2. double dose 3. osmotic laxtive (sorbitol) 4. MOM 5. bisacodyl suppository then enema in 2H (repeat QD for 3 day) 6. pheripheral acting mu opoid reeptor antag, naloxegol, methylnaltrexone 7. nuclear enema

Question 26

underlying causes of anorexia-cachexia

Answer 26

- anx - depression - n/v - stomatitis - constiaptin - dysphagia - pain

Question 27

bowel obstruction end of life treatment

Answer 27

1. metoclopramide +/- dexamethasone IF it is NOT a complete obstrution because it will try to push poo through 2. glycopyrrolate +/- morphine +/- haloperidol 3. octreotide +/- above 4. PEG tube or stent ## Footnote bowel obstruction: too much secretion into bowels that cant excrete -> vomit it up (octreotide reduces these secretios)

Question 28

anorexia-cachexia end of life treatment

Answer 28

1. treat underlying cause 2. early saity, dysmotility, gastroparesis: metoclopramide 3. appetite loss, wt loss - survival < 3 months: dexamethasone - surivival > 3 months: mirtazepine or megestrol 4. dronabinol

Question 29

insomnia end of lfie treatment

Answer 29

1. ftreat underlying cause 2. 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 3. increase doses, try combos - substitue midazolam or high dose lorazepam (NOT to exceed 7 days)

Question 30

xerostomia end of life treatment

Answer 30

1. ice chips, gum, lemon drops 2. saliva substitite 3. pilocarpine

Question 31

terminal secretions treatment

Answer 31

atrpine 2-3 sl gtts q2h prn (used for death rattle - normal saliva production but not draining) - scopolomine patch - glycopyrrolate

Question 32

palliative sedation agents

Answer 32

- opioids - benzos - neuroletptic - barbitutes - anesthetics ## Footnote or combo of above