End of Life Care (Exam 3 Cut Off) Flashcards Preview

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Flashcards in End of Life Care (Exam 3 Cut Off) Deck (33)
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1
Q

Palliative Care

A
  • Specialized medical care for people with serious illness that focuses on relief form pain, symptoms, and distress due to illness
  • Can be provided at the same time as curative care
  • Any age or stage of illness
2
Q

Hospice

A
  • Type of care and a philosophy or care that focuses on palliation of a terminally ill patient’s symptoms
  • All is palliative care but not vice versa
3
Q

Terminal Illness

A

Estimate survival of 6 months or less

4
Q

Supportive Care

A
  • Extra layer of support
  • Focuses on intensive family meetings and patient/family counseling
  • Resolves questions and conflicts between family/patients and physicians on achievable goals of care
  • Expertise in pain and symptom management
5
Q

Medicare Hospice Benefit

A
  • Passed by Congress in 1982
  • 4 criteria patients must meet to enroll
  • Certification periods: eligible for two 90-day periods initially, re-certification every 60 days thereafter with terminally ill certification from physician
6
Q

Hospice Benefit Criteria

A
  • Eligible for Medicare Part A
  • Medicare approved hospice program
  • Signed statement by patient choosing hospice care instead of “regular” Medicare
  • Certification by physicians and hospice medical director of terminal illness
7
Q

Symptom Management Principles

A
  • Frequent, standard assessment
  • Oral meds when possible and altering routes when needed
  • Assess for SE and anticipate/treat them as needed
  • D/C meds no longer contributing to symptom control
  • Address possible reversible contributing causes
8
Q

Approach to Symptom Management

A
  • Identify potential causes of symptom
  • May require history, physical exam, labs, etc.
  • Treat underlying cause and symptom if possible
  • Re-evaluate frequently
9
Q

N/V Assessment/Approach

A
  • Self-report is gold standard for nausea
  • Documentation of vomiting/retching and associated symptoms, triggers, durations, severity
  • Monitor food intake, hydration status, and bowel movements
  • Documentation of relief from medications
10
Q

Opioid-Induced Constipation

A

First Line Options

  • Stimulant laxatives (Senna or Bisacodyl)
  • Osmotic laxatives (Polyethylene glycol or Lactulose)

Additional PRN Agents

  • Bisacodyl suppository
  • Magnesium
  • Evaluation for ileus
  • Low/high impaction

NOT DOCUSATE - no proven benefit

11
Q

Malignant Bowel Obstruction

A
  • Common with abdominal cancers

- Symptoms: N/V, pain, distention, constipation or liquid stools

12
Q

Malignant Bowel Obstruction Treatment

A

Treatment Goal: eliminate need for NG tube/IV hydration
-Palliative surgery

Medications

  • Opioids and antiemetics for pain and N/V
  • Anticholinergics/antimuscarinics for colic pain (glycopyrrolate or hyoscyamine)
  • Octreotide
  • Corticosteroids (dexamethasone)
13
Q

Dyspnea

A
  • Discomfort in breathing - common symptom in advanced cancer or illnesses
  • Evaluated by subjective responses
  • Could be physical, chemical, or neurological in causation
14
Q

Dyspnea Non-Pharm Treatment

A
  • Re-positioning
  • Maintaining cool room temperatures
  • Relaxation exercises
  • Acupuncture
  • Minimal exertion
15
Q

Dyspnea Pharm Treatment

A
  • Oxygen for documented hypoxia
  • Opioids - first line, morphine is most commonly used and nebulized route not shown to be superior, no optimal agent
  • Anxiolytics: Benzos reserved for breakthrough or refractory dyspnea affected by anxiety or unable to titrate opioids
16
Q

Anorexia/Cachexia

A
  • Anorexia: loss of appetite or inability to eat
  • Cachexia: wasting regardless of calories intake
  • Could be due to inflammation, constipation, late illnesses (cancer/HIV), or other causes
  • Assess for possible contributing factors like pain, infection, nausea, depression, GI conditions, meds, etc
17
Q

Anorexia/Cachexia Non-Pharm

A
  • Reassurance that syndrome is normal at end-of-life
  • Diet modification for easier to swallow food and for frequent/smaller meals
  • Artificial nutrition doesn’t prolong life and increases costs/morbidities (N/V, aspiration, congestion)
18
Q

Anorexia/Cachexia Pharm Treatment

A

Unlikely to prolong life but could improve QoL

  • Megesterol - improves appetite (better in advanced cancer) but can cause VTEs and suppress the HPA axis
  • Corticosteroids: increase appetite/food intake but can effect GI and adrenal systems
  • Dronabinol (sativa): used for AIDS anorexia but can cause CNS effects
19
Q

CBD

A
  • Can improve appetite/food intake
  • Also has receptors that effect emotion, movement, mood, and pain perception
  • Approved use for several disease states in NM
20
Q

Delirium

A
  • Most common neuropsychiatric complication in advanced cancer patients
  • Disturbances in attention and awareness that aren’t explain by preexisting conditions
  • Can be medication induced, infections, impaction/retention/dehydration, metabolic disorders, brain tumors or disorders
21
Q

Delirium Symptoms

A
  • Agitation
  • Restlessness
  • Altered perception
  • Difficulty forming thoughts and incoherent speech
  • Disorientation to time, place, person
  • Sleep disturbances and nightmares
  • Sundowning
  • Changes in consciousness level
22
Q

Delirium Non-Pharm Treatment

A
  • Calm environment, music, aromatherapy, spiritual counselor

- Identify reversible causes (meds, constipation, etc.)

23
Q

Delirium Pharm Treatment

A
  • Antipsychotics are first line, most evidence for haloperidol and chlorpromazine (low doses PRN) - possible anticholinergic SE
  • Benzos are helpful for sedation when agitation is prominent and antipsychotics aren’t sufficient
24
Q

Anticholinergic Causing Drugs

A
  • Oxybutynin
  • Benztropine
  • Scopolamine
  • Diphenoxylate
  • Hyoscyamine
  • Atropine
  • Ipratropium
  • Diphenhydramine
  • TCA
  • Chlorpromazine
  • Prochlorperazine
  • Promethazine
  • Cyclobenzaprine
25
Q

Anticholinergic Management

A
  • Assess risk vs benefit before adding agent
  • Choose alternative med when possible
  • Consider non-drug therapy when possible
  • Use lowest, effective dose for the shortest duration
26
Q

Dysphagia

A
  • Can be associated with odynophagia or aspiration
  • Oral route fails in ~7-% of patients at end-of-life
  • Consider most appropriate non-oral route since IV isn’t practical for home hospice patients
27
Q

Secretions

A
  • Respiratory secretions common in last days of life esp with pulmonary malignancies and brain tumors
  • Repositioning could help with things like “death rattle”
  • Possible Contributors: IV hydration, tube feedings, diminished cough reflex or dysphagia, prolonged dying phase
28
Q

Secretion Types

A
  • Type I: mainly salivary secretions
  • Type II: bronchial secretions as part of normal mucous production or respiratory infections
  • Accumulates over days as cough reflex lessens
  • May be resistant to medication therapy
29
Q

Secretion Treatment

A

Not Near Death

  • Optimizing hydration
  • Nebulized NS +/- guaifenesin
  • Thinner secretions can use gentle suctioning and anticholinergics

Near Death
-Anticholinergics: Atropine eye drops, scopolamine, hyoscyamine, glycopyrrolate

30
Q

Terminal Restlessness

A
  • Could be included with delirium
  • Assess for contributing factors like med, kidney/liver failure, impaction/retention, pain

Signs/Symptoms

  • Skin mottling and cool extremities
  • Mouth breathing and hyperextended neck
  • Calling to dead family members/friends
  • Talking about going on a trip or packing bag
  • Deepening somnolence
  • Agitation
31
Q

Terminal Restlessness Treatment

A
  • Treat underlying cause
  • Non-pharm interventions as appropriate
  • Pharm: Benzos, preferably Lorazepam and can consider adding an antipsychotic, preferably haloperidol, if agitation is a contributor
32
Q

Palliative Sedation

A
  • Used to make patient unaware/unconscious due to extreme suffering causes by disease that will lead to death
  • Usually refractory option to conventional symptom treatment
  • Midazolam is most commonly used but propofol and phenobarbital can also be used
33
Q

End-Of-Life Expected Changes

A

Warn family/patient of expected changes ahead of time to lessen distress:

  • Progressive unresponsiveness
  • Purposeless movements and facial expressions
  • Noisy breathing
  • Unlikely periods of awareness right before death
  • Acute events and action plans