EM Special 4: Palliative Care 2 (Lecture by Dr Tanghal) Flashcards
based on Palliative care module by Dr Tanghal
Criteria for ED end-of-life (EOL) management
1) actively dying patient or high likelihood of mortality within hours to a few days
2) patient is not for CPR/intubation/ICU transfer
3) the goals of care are provision of comfort, symptom relief, and dignity
Describe Karnofsky performance scale
describes overall physical quality of life
lower the Karnofsky score, the worse the likelihood of survival
Category C + cancer –> 3-month medial survival
Describe “Surprise Questions”
1) Would I be surprised if my patient dies during the hospitalization?
No
2) Is my patient’s chance of dying higher than surviving this hospitalization?
Yes
- consider EOL care
- inform family that patient is critically ill and likely to demise
- allow family presence
nonpharmacologic palliative management of dyspnea
- provide sensation of moving air onto face (e.g., fan)
- reposition patient for comfort (e.g., elevate head of bed, allow patient to lean forward)
- draw back the curtains if patient feels claustrophobic
pharmacologic palliative management for dyspnea
opioids (mainstay)
benzodiazepines
steroids
bronchodilators
oxygen
Morphine dosing for dyspnea
PO mist morphine 2.5 mg 4-6 hourly prn
IV/SC 1-2 mg 4-6 hourly prn
IV/SC 0.2-0.5 mg/hour continuous infusion
Fentanyl dosing for dyspnea
IV/SC 10-20 mcg bolus 2-3 hourly prn
IV/SC 5-15 mcg/hour continuous infusion
morphine dosing for dyspneic crisis
dilute an ampule of injection morphine with normal saline to 1 mg/mL strength
If opioid-naive (<60 mg morphine/day), give 1 mg every 3-5 mins until symptom is relieved or patient feels drowsy
If opioid tolerant (≥60 mg morphine/day for 7 days), then give 2 mg every 3-5 mins
fentanyl dosing for dyspneic crisis
dilute to 100 mcg to 10 mL, and give 10-20 mcg boluses
Equianalgesic dosing for PO morphine 30 mg
PO morphine 30 mg/day
is equivalent to
SC/IV Morphine 10 mg/day (/3)
TD/SC/IV Fentanyl 12 mcg/hour
or 300 mcg/day
or 0.3 mg/day (/100)
PO oxycodone 15 mg/day (/2)
PO tramadol 150 mg/day (x5)
Case: patient currently has a dyspneic crisis. he is currently with a 12 mcg/hour fentanyl patch. How to address the dyspneic crisis?
12 mcg/hour fentanyl patch
= PO morphine 30 mg/day
<60 mg morphine/day –> opioid-naive
we can give rapid opioid titration with small IV boluses of 1 mg morphine or 10 mcg fentanyl
classification of pain
A. Nociceptive
1) somatic
(tumor invasion of bone, muscle, CT)
2) visceral
(e.g., bowel obstruction or compression of vital organs)
B. Neuropathic
(e.g., tumor compression of a nerve)
Remarks on WHO ladder of pain manangement
WHO ladder is to be used in patients with serious life limiting illness only, not for chronic pain
start at appropriate step based on pain intensity
maximize therapy at that step before moving up
what to give for mild pain
pain scale 1 to 3
non-opioid
+/- adjuvant
what to give for moderate pain
pain scale 4 to 6
weak opioid
+ non-opioid
+/- adjuvant
weak opioids:
tramadol
codeine
