EM Special 2: Palliative Care

Question 1

the goal of palliative care

Answer 1

to relieve the suffering of patients with serious illness

regardless of the patient’s prognosis, relief of suffering should be a primary goal for both emergency medicine and palliative care

Question 2

remarks on hospice care

Answer 2

a branch of palliative care

a comprehensive program of palliative treatment that is appropriate when patients with chronic, progressive, and eventually fatal illness are determined to have a life expectancy of 6 months or less

Question 3

remarks on palliative care

Answer 3

patient centered rather than disease centered

palliative care is guided by the axiom that distressing symptoms should be treated.
*it thus provides expert assessment and treatment of symptoms, including pain, dyspnea, and vomiting

Question 4

most common reason for seeking care in the ED

Answer 4

pain
Unfortunately, only 60% of patients reporting pain receive pain medications

Question 5

remarks on assisting surrogates in making EOL care choices for patients who lack decision-making capacity

Answer 5

assist them to make EOL care choices based on the patient’s own preference, values, and goals

Question 6

describe a patient with decisional capacity

Answer 6

one who has the mental ability to
1) grasp and retain information about his or her condition,
2) weight risks and benefits
3) and demonstrate these abilities by verbalizing a medical decision

Question 7

most common targets of symptom management

Answer 7

pain control
dyspnea
nausea/vomiting
constipation
agitation

Question 8

the biggest obstacle to aggressive pain management with opiates

Answer 8

fear of respiratory depression

respiratory depression is not a sudden occurrence, but instead is part of a progression that starts with sedation, somnolence, and then respiratory depression

Question 9

remarks on IV opiates

Answer 9

IV opiates reach maximum therapeutic levels and have peak effects or side effects at 6-10 minutes

Therefore, IV pain medications can be safely redosed every 15 minutes until relief is reached if potential adverse effects are monitored

Question 10

how to manage dyspnea

Answer 10

When treating breathlessness/dyspnea in an opioid-naive patient,start with morphine at a dose of 0.05 mg/kg IV, and monitor for sedation and hypoventilation

This is half of the starting dose of morphine when it is used to treat pain.

Use a goal of maintaining a RR of at least 10-12 breaths/min.

Although opioids have traditionally been withheld due to concerns about respiratory depression, opioids are beneficial in treating the agitation and anxiety provoked by dyspnea

Question 11

can be used to treat chemotherapy-induced N/V

Answer 11

ondansetron
steroids (dexamethasone)

Question 12

can be used to treat N/V from increased intracranial pressure and bowel obstruction from cancer

Answer 12

steroids

Question 13

can be used for refractory nausea in the palliative care setting

Answer 13

dopamine antagonists such as
haloperidol
droperidol

Question 14

indications of metoclopramide

Answer 14

symptoms of diabetic gastroparesis
compression of the stomach due to tumor or ascites

Question 15

medications that are indicated for agitation in palliative care

Answer 15

antipsychotics such as haloperidol
anxiolytics such as midazolam
opiates such as morphine

There is no evidence that these palliative interventions hasten death.

The causes of agitation in patients with terminal illness are multifactorial, including pain, effects of the terminal illness, anxiety, terminal restlessness, breathlessness, and mental anguish

Question 16

opioids in the opioid-naive patient

Answer 16

a 2-mg dose of IV morphine or a 0.5- to 1-mg dose of hydromorphone is a reasonable starting dose

This should be administered every 15 minutes until the pain is relieved by approximately 50%

Question 17

opioids in the opioid-tolerant patient

Answer 17

the average 4-hourly dose of opioids already prescribed should be doubled for severe pain and increased by 50% for moderate pain (pain scale score of 4 to 6)

Question 18

smaller doses of opioids are required in

Answer 18

elderly patients
lower BMI
unstable VS
with baseline severe cardiorespiratory compromise (e.g. COPD)
because such patients are at risk for hypoventilation

Question 19

N/V etiologies where steroids (dexamethasone) are indicated

Answer 19

Chemotherapy-induced
Increased intracranial pressure
or Bowel obstruction from Cancer