Exam 4 - Palliative & Hospice Care

Question 1

what is palliative/hospice care?

Answer 1

compassionate care for the dying that is focused on caring for (treating symptoms) & not curing the patient that often occurs at home

Question 2

what is the goal of palliative/hospice care?

Answer 2

provide a good end of life experience for the patient & their family

Question 3

what are some examples of treatments that wouldn’t be allowed for palliative/hospice care?

Answer 3

nothing to prolong their life - no feeding tubes, IVF (would still treat concurrent conditions like a UTI that was making them feel worse)

Question 4

does hospice/palliative care preclude euthanasia?

Answer 4

nope

Question 5

what is important for client education/communication for pets in palliative/hospice care?

Answer 5

they must actively participate for it to work

clients need to be educated about hospice & understand that we aren’t treating the underlying disease

they need to know how to keep the patient as pain free & sanitary as possible (urine scald, fecal scald, bed sores, etc)

Question 6

what are the 4 key features of hospice/palliative care?

Answer 6

1. vets should have contact with the patient on a regular basis (weekly to daily visits)
2. staff tending to them should have appropriate insurance to cover travel/liability coverage
3. care should always be available & euthanasia should be available at any time when the client is ready
4. confirmation of death by vet may be needed by the owner in the event of a home death

Question 7

how is concurrent illness approached for patients receiving hospice/palliative care?

Answer 7

concurrent disease doesn’t disqualify the patient from receiving anti-cancer therapy

diagnosis of cancer doesn’t mean that concurrent disease should no longer be managed!!!!

Question 8

how do cancer patients have a weakened immune system?

Answer 8

they have high levels of tregs, IL-8, IL-10, etc - affects animals immune system & affects them systemically

chemo weakens their immune system

opportunistic infections such as UTIS, pyoderma, & demodex are common

Question 9

what is the chronic pain cycle we are trying to break for patients in hospice/palliative care?

Answer 9

chronic pain is difficult to break

pain -> muscle tension -> reduced blood flow -> muscle inflammation -> animal doesn’t want to move -> cycle repeats

Question 10

what are some examples of sources from pain from cancer that may be difficult for us to appreciate clinically?

Answer 10

stretching of organ capsules - reported to be very painful

intra-abdominal adhesions

tissue/bone invasion

nerve compression

Question 11

what are some behaviors seen in hospice/palliative care patients that indicate pain?

Answer 11

decreased activity/reluctance to do specific things

decreased appetite

attitude changes - aggressiveness, clinginess, increased dependance

lower head carriage, squinting (cats), & tragic facial expression

decreased grooming - cats

self-induced injuries - seen in dogs, over-grooming the painful area & causing traumatic wounds

aversion behaviors in certain areas associated with pain - not wanting their heads touched

Question 12

when looking at COX inhibitors for hospice/palliative care patients, which ones may be better suited? what are some examples?

Answer 12

non-selective options for COX inhibitors are better for cancer cells

anti-cancer NSAIDS = aspirin, piroxicam (mostly COX-1 inhibitors which is the best anti-cancer option)

Question 13

what is acetaminophen beneficial for in hospice/palliative care?

Answer 13

best for treating fever - blocks IL-6

not for cats though!!!!

Question 14

what NSAIDS are good for pain control in hospice/palliative care patients?

Answer 14

COX-2 inhibitors - meloxicam, rimadyl, the coxibs

Question 15

what opioid receptor is targeted for reducing pain?

Answer 15

mu receptors are the most effective for decreasing pain

Question 16

how is codeine used for hospice/palliative care patients?

Answer 16

mu agonist that is weaker than morphine - often paired with acetaminophen

Question 17

how is tramadol used for hospice/palliative care patients?

Answer 17

derivative of codeine, variable efficacy - not too sure

Question 18

how is buprenorphine used for hospice/palliative care patients?

Answer 18

partial mu agonist that is a great option for cats because of transmucosal absorption

Question 19

what is the mechanism of action of amantadine? how is it used for hospice/palliative care patients?

Answer 19

NMDA antagonist - similar to ketamine - works best for chronic pain & in conjunction with NSAID!!!!

potentiates opioids

takes several days to reach effectiveness - need to give it at least 1 week before giving up

Question 20

how is ketamine used for hospice/palliative care patients? what is the risk associated with it?

Answer 20

potent NMDA antagonist that has many potential routes for administration

potential for abuse - scheduled drug in the USA

Question 21

what is the mechanism of action of gabapentin/pregabalin? how is it used for hospice/palliative care patients?

Answer 21

blocks voltage gated Ca channels which modulates excitatory neurotransmitter release - which inhibits nociception (decreasing pain)

best for neurologic pain!!! brain tumor pressing on stuff!

Question 22

what is the mechanism of action of tricyclic antidepressants? how are they used for hospice/palliative care patients?

Answer 22

may interact with peripheral noradrenergic receptors - may inhibit reuptake of monoamines (noradrenaline)

controversial for pain control - it may just be improving mood/awareness instead of actually stopping pain, so best if used in combo with something else!!!

Question 23

what is the mechanism of bisphosphonates? how are they used for hospice/palliative care patients?

Answer 23

they inhibit osteoclast activity & promote osteoclast apoptosis - useful for bone pain! (osteosarcoma)

along with radiation therapy - super effective at controlling bone pain!

Question 24

how is radiation therapy used for hospice/palliative care patients as a non-drug pain management option?

Answer 24

radiation therapy is often used for bone pain, OA, oral tumors, large soft tissue sarcomas, & lymphoma - we use a high dose for a few treatments

good for primary & secondary bone lesions, decreases pleural & abdominal effusions, & decreases metastatic lesions in the lungs/lymph nodes that can cause symptomatic pain (swelling, coughing, etc)

Question 25

how is exercise used as a non-drug treatment for pain in hospice/palliative care patients?

Answer 25

exercise keeps them mobile which increases blood flow & helps to break the chronic pain cycle

if they are able to, do it!! let them set the pace!!

Question 26

how is acupuncture used as a non-drug treatment for pain control in hospice/palliative care patients?

Answer 26

relieves pain & nausea - historically effectice

Question 27

how is laser (cold) therapy used as a non-drug treatment for pain control in hospice/palliative care patients?

Answer 27

good for treating joint & bone pain

Question 28

T/F: for hospice/palliative care patients, eating is more important than not eating, and what they’re eating comes 2nd

Answer 28

true

Question 29

what is the ideal diet for hospice/palliative care dog patients? why?

Answer 29

high fat, high protein, low carbs (pretty much eating bacon, so highly palatable)

proteins are converted to glucose/glucose precursors - same amount of glucose to the tumor as normal diets

Question 30

what is the ideal diet for hospice/palliative care cat patients? why?

Answer 30

requires high protein diet regularly - variety of proteins should be tried

let them graze - not meal feed!!!

acute weight loss -> risk of hepatic lipidosis -> need to keep them eating

maintaining a healthy weight is important, but you don’t want acute weight loss!!!!!! leave the chubby babies alone!!

Question 31

why may polyunsaturated fats be beneficial for hospice/palliative care patients?

Answer 31

like those found in fish

improve palatability, energy dense, & helps to maintain a healthy BW

Question 32

what are the 2 most prevalent omega 3 fatty acids? which one is better for hospice/palliative care patients?

Answer 32

EPA & DHA

EPA (whitefish oils) - more likely to convert to inert eicosanoids which are anti-cancer!

Question 33

why start a hospice/palliative care patient on omega 3 fatty acids when they’re eating well? do you use these in cats?

Answer 33

if they are feeling good, and their body is not in a starvation state like it would be with anorexia, the omega 3s are going to convert to eicosanoids which are anti-cancer

if you start them when they are feeling bad, the fatty acids will convert to pro-inflammatory eicosanoids which promote cancer

cats are more sensitive & may have platelet dysfunction at high doses leading to bleeding problems - be careful

Question 34

T/F: vitamin D improves lifespan

Answer 34

true

Question 35

what cancers is vitamin d good for?

Answer 35

good for skin cancers - used topically as a retinoid

Question 36

why are b vitamins super important for cats with small cell gi lymphoma?

Answer 36

cobalamin = B12

clinical signs won’t improve until cobalamin is within normal range, so they need to be supplemented (continue to monitor these levels & supplement as needed)

banana bag when they need it - has all of the pick me ups

Question 37

what should be considered before making a decision for euthanasia for hospice/palliative care patients?

Answer 37

animal’s QOL

professional obligations/ethical commitments - if I don’t, will the owner try & kill it & it be more painful?

conflicts of duties between owners, patient, & public health (rabies)

best case scenario & how you achieve it

worst case scenario & how you avoid it

lethal injection is most common in USA