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Acute Care II - Summer 2017 > Module 1: Palliative Care > Flashcards

Module 1: Palliative Care Flashcards

1
Q

leading causes of death today?

A
  1. heart disease
  2. cancer
  3. stroke/cvd
  4. chronic lung disease
  5. trauma
  6. alzheimer’s
  7. diabetes
  8. influenza/pneumona
  9. kidney disease
  10. speticemia
    11.
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2
Q

examples of steady decline?

A

20% of population

major cancer

age 60’s

hospice was developed for this group < 6 months to live

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3
Q

information on hospice

A

only medicare program tailored to EOL

requires prognosis < 6 months

15% of community dwelling die w/ hospice services

>50% cancer patients get hospice

average length of stay: 26 days

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4
Q

health care system issues w/ steady decline patients

A

hospice isn’t for everyone

very fragmented health care system that lacks continuity - everyone is just treating their organ/speciality leading to multiple specialists and no one feels responsible

great innacuracy with prognosis, & it limits ability to make best use of limited time

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5
Q

examples of slow decline with crises

A

25% of population

declining function w/ interspersed exacerbations, then unexpected death

progressive organ failure

age in 70s

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6
Q

health care system issues w/ slow decline

A

system is set up for crises by not slow decline

prognosis is unclear so hospice is not offered

continuity of care is interrupted by fragmented system & multiple hospitalizations

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7
Q

examples of prolonged dwindling?

A
  • dementia & frailty
    • >75 y/o
    • afflicted w/ physical & mental disabilities
    • interfere w/ ability to independently perform ADLs
    • increase risk for further decline
  • age 80s
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8
Q

aggressive care is associated with?

A

lower QOL & increased complications

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9
Q

barriers to quality care at EOL

A

poorly managed symptoms

lack of training for professionals

delayed access to hospice/palliatve care

poorly informed patients & families

lacke of appropriately prepared providers

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10
Q

palliative care information

A

can have palliative care while in ICU

based on need: for people with serious and complex illness, regardless of prognosis

can be provided together w/ approrpiate restorative or life sustaining treatment includig intensive care therapy

no limitation on CPR status/life support required.

provided by ICU team and/or palliative care consultant to primary team

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11
Q

hospice care information

A

based on prognosis for people expected to live < 6 months

strongly encourages the patient to forego restorative treatment and have concurrent care limitations such as DNR and no transfer to ICU

hospice team assumes primrary care responsibility

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12
Q

barriers to better integration of palliative care and critical care

A

unrealistic expectations for intensive care therapies on the part of patients/families/clinicians

misperception of palliative care and critical care as mutually exclusive/sequential rathr than complementary and concurrent approaches

conflation of palliative care w/ EOL or hospice care

concern tht incorporation of palliative care will hasten death, studies show it prolongs life & QOL

insufficient training of clinicians in communication and other necessary skills to provide high-quality palliative care

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13
Q

other barriers to better integration of palliative care and critical care

A

competing demands on ICU clinial effort w/o adequate reward for palliative care excellence

failure to apply effective approaches for system/culuture change to improve palliative care

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14
Q

consultative model vs. integrative model of palliative care

A
  1. expert palliative care through a palliative care consultation service - this is available at majority of US hospitals
  2. palliative care principles and process are incorporated as part of routine practice in ICU - less common

studies have shown that success can be reached in each model

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15
Q

principles of palliative care

A

interdisciplinary team

patient & family = unit of care: education & support, across illnesses & settings, berveavement support

attention to physical, social, psychological, spiritual

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16
Q

symptoms addressed in palliative care

A

pain

constipation

nausea & vomiting

diarrhea

bowel obstruction

anorexia & cachexia

delirium

depression

dyspnea

cough

loud respiration

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17
Q

hospice?

A

emphasis on QOL

need 6 months or less prognosis

have to forego additional curative care

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18
Q

physical factors affecting quality of life

A

functional ability

strength/fatigue

sleep & rest

nausea

appetite

constipation

pain

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19
Q

psychological factors for quality of life

A

anxiety

depression

enjoyment/leisure

pain distress

happiness

fear

cognition/attention

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20
Q

social factors for quality of life

A

financial burden

caregiver burder

roles and relationships

affection/sexual function

appearance

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21
Q

spiritual factors for quality of life

A

hope

suffering

meaning of pain

religiosity

transcendence

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22
Q

what does hospice include?

A

nursing care

PT/OT/SLP

medical social services

home health aid

homemaker services

medical supplies & appliance

MD services

short term inpatient care (respite, procedures)

counseling to patient and family

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23
Q

hospice criteria?

A
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24
Q

hospice criteria?

A

2 MDs estimate prognosis of < 6 months

recertify every 90 days x 2, then every 60 days

NP can be ‘attending’

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25
Q

end stage criteria?

A

decline in functional status

decrease tolerance physical activity

decrease cognitive ability

palliative performance scale < 50

dependent in 3 of 6 ADLs

symptoms at rest that significantly interfere w/ QOL

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26
Q

Physical ADLS?

A

DEATH

dress

eat

ambulate/transfer

toileting/continenece

hygiene - bathing/grooming

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27
Q

how do you measure progressive decline in palliative patients?

A

PPS - palliative performance scale

it’s a valid reliable funcitonal assessment tool that is based on the Karnofsky Performance Scale

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28
Q

how is the PPS physical performance measured?

A

10% incremental levels from fully ambulatory 100% to death 0%

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29
Q

how is PPS differentiated further?

A

degree of ambulation

ability to do activities/extent of disease

ability to do self care

food/fluid intake

level of consciousness

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30
Q

additional end stage criteria?

A

frequent >2 ER visits or hospital admissions

issues with nutrition

loss >10% body weight over 4-6 months = poor prognostic sign

terminal diagnosis (prognosis < 6 months)

diagnosis specific criteria (by system)

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31
Q

what are some hospice diagnoses?

A

terminal illnesses

cancer, dementia, ESLD, COPD, ESRD, HIV/AIDS, CVA/coma, chronic neurodegenerative disease, failure to thrive, heart disease,

32
Q

who gets hospice?

A

10% non white - african americans have stronger preference to continue treatment

51% women

71% with cancer

33
Q

diagnoses of those in hospice

A

43% cancer

57%: dementia, esrd, chf, copd, als

34
Q

who is most likely to refer for hospice?

A

medical generalist, geritrician & family practitioner

35
Q

hospice outcomes?

A

longer survival: CHF, lung cancer, pancreatic cancer

lower costs without shorter life

lower use of acute care at EOL

late enrollment is associated with poor patient QOL, depression/mortality in bereaved.

36
Q

r

A
37
Q

barriers to hospice

A

late referrals

culture/racial preferences

low income & educational level

distrust of system

need for primary care provider to agree to prognosis

38
Q

opportunities in ICU for palliative care

A

untreated pain and symptoms

failure to address other needs

poor communication - comprised decision making –> worse experience

gap between patient preferences & treatment, delayed start of appropriate care plans

use of therapies with burdens greater than benefits.

39
Q

what are some simple communication interventions?

A

“get to know me” poster

identification of surrogate decision maker

advanced directive status

give printed materials for family infomation

breavement brochure

40
Q

impact of family meetings & printed materials?

A

element: proactive, protocalized family meetings with distribution of printed informational materials

90 day follow up showed lower prevalence & severity of PTSD related symptoms

prevalence & severity of anxity & depression

41
Q

what does proactive communication give you?

A

greater family satisfaction & comprehension

earlier implementaiton of appropriate care plans

reduced use non-beneficial treatments (ICU, LOS & conflict re care goals)

efficiences & other benefits w/o increased ICU mortality

42
Q

what beneftis are there with increased family satisfaction w/ clinical statements?

A
  1. assure patient will not be abandoned before death
  2. assure patient will be comfortable and will not suffer
  3. support for family decisions about end of life care, including decision to withdraw or continue life support
43
Q

what are issues with professional burnout/moral distress

A
  • 40% critical care nurses feel they’ve acted against their conscience caring for dying patients
  • assocaited with increased prevalence of PTSD symptoms in critical care nurses
  • high level of burnout in intensivitis, prevalance & associated factors
44
Q

key points of palliative care?

A
  • communication is key
  • palliative care is a continuum
  • provide patients & family opportunities for informed autonomous decision making
  • death today is preceded by 2 years of disability and a prolonged process in the hospital.
    • a progressive deterioration with crises
    • mean hospice LOS is only 26 days
  • authority to send to hospice?
    • MD must certify for hospice and incapacity
    • NP may be attending for Hospice and do MOLST
45
Q

points for code status and goals of care discussion

A

establish setting - ensure comfort and privacy - introduce the subject

what does the patient understand

what does the patient expect?

listen carefully to the patient’s response

discuss a DNR order - never say do you want use to do ‘everything’ it’s unclear

respond to emotions

establish a plan

ask them what they know about CPR

46
Q

palliative care methods for pain & conspitaion?

A

pain: assess, multimodal approach, nonpharmacologic, pharmacologic (opioid, NSAID, neuromodulators), anticipate & manage side effects

Constipation: causes: opioids, immobility, poor fluid intake, prophylax, stool softner and laxative, stimulants (senna, bisocodyl) osmotic agents )sorbitol, lactulose, after 4 days enema or disimpaction

47
Q

paliative care methods for nausea & vomiting

A

D/t drugs & toxins: chemoreceptor trigger zone: vomiting center; teatments; dopamine antagonist (haloperidol - used a lot post op); prokinetic agent (metoclopromide); serotonergic antagonists (ondansetron, granisetron)

the gut: treatments, motility agents (metoclopromide); serotonin antagonists (ondansetron, granisetron); antihistamines (promethazine, hydroxyzine, meclizine, dimenhydrinate)

48
Q

anorexa & cachexia

A

almost universal issue

treat dry mouth w/ saliva substitues

liberalize diet

appetite stimulants (Megesterol acetate)

49
Q

how to deal with dyspnea

A

self report

treatment

O2 if sat is <90%

open window/fan

opioid to control respiratory drive

benzodiazepine to control anxiety

look for other causes

50
Q

how to help w/ cough

A

excess fluid production, irritation of airway receptors

look for cause

nebulized local anesthetic

opioid - codeine, hydrocodone, methadone for longer duration of action

dextromethorphan help w/ loud respirations

death rattle

family education

scopolamine, hyoscyamine

51
Q

how to deal with diarrhea

A

rare 7-10%

rule out excessive laxative use

check for fecal impaction

52
Q

how to deal with bowel obstruction

A

50% patients w/ ovarian or GI cancer

median survival 3 months

high symptom burden (N/V/colic, abdominal pain)

treatment

endoscopic stent if focal

combination therapy

opioid, antispasmodics, antiemetics, antisecretory agents, corticosteroids

53
Q

how to deal with delirium

A

distressing to patient and family

search for cause

non-sedating vs sedating antipsychotic

avoid benzodiazepines

54
Q

how to deal with depression

A

underrecognized and treated

insomnia, anorexia, loss of interest, anhedonia, suicidal ideation

treatment

antidepressats, address other symptoms, talk therapy, PMH consult

55
Q

nausea & vomiting

A

in 40-70% of patients w/ advanced cancer

causes: disease vs treatment

drugs (opioids)/toxins

gut: gastric irritation or distention, liver capsule stretch, stasis of bowel

biliary

GU, tumor, peritoneal irritation

other sites: vestibular apparatus, cerebral cortex)

treatment: scopolamine, meclizine, hydrobromide

in the cerebral cortex - increased ICP treatment is dexamethasone

56
Q

example of motility agent

A

metoclopromide

57
Q

example of serotonin antagonist

A

odansetron, granisetron

58
Q

example of antihistamines

A

promethazine, hydroxyzine, meclizine, dimenhydrinate

59
Q

causes and treatments of vestibular apparatus nausea & vomiting

A

causes: drugs (opioids), labryinthitis, acoutic & other tumors
treatments: scopolamine, meclizine, hydrobromide

60
Q

cerebral cortex causes & treatments for N/V

A

causes: increased ICP, CNS malignancy
treatment: Dexamethasone, 8 mg PO/IV/SubQ

61
Q

type & order for surrogate?

A

in Maryland..

written advanced directives (patient’s wishes or best interest)

guardian of the person

spouse or domestic partner

adult child

parent

adult brother or sister

friend or relative

62
Q

what does molst do for us? (Medical Orders for Life Sustaining Treatment)

A

standardized medical order form

coveres options for CPR & other life sustaining treatments

portable & enduring

valid in all health care ettings & in the community

helps increase the likelihood that patient’s wishes regarding life sustaining treatments are honored

63
Q

when must a MOLST form be completed?

A

a patient is admitted or transferred to

a nursing home

assisted living facility

home health agency

hospice

kidney dialysis center

hospital patients *not required for ER, observation, or short stay patients

64
Q

NP who signs MOLST order form is responsible for ….

A

discussing with & have patient / surrogate informed consent

if patient denies either then they become a full code with full life sustaining treatment

section 1, CPR status must be completed for everyone

ensure orders are consistent with patient’s wishes

give copy to patient/surroagte within 48 hours

revise orders at request of patient/surrogate

a copy accompanies patient if they are transferred

65
Q

when can a surrogate authority withhold life sustaining treatment

A
  1. must certify patient’s incapacity
  2. 2 MDs certify condition
  • terminal: incurable, no recovery, imminent death
  • end stage: advanced, irreversible, severe permanent deterioration
  • persistent vegetative state: no awareness self/surroundings, reflex activity only

3.or 2 MDs certify that treatment is medically ineffective for this patient - meaning it will not prevent or reduce deterioration (generally neurologist, neurosurgeon, specialist in cognitive function)

66
Q

when are MOLST orders reviewed

A

annually

patient transferred between health care facilities (receiving facility reviews)

patient is discharged

patient has substantial change in health status

patient loses capacity to make health care decisions

patient changes wishes

67
Q

when might you withdrawal life support

A

patient is experiencing irreversible terminal illness / life support is postponing an unavoidable death

anticipated outcome from continued care is state of health inconsistent with patient’s wishes via medical record, family or surrogate decision maker

68
Q

how do you go about withdrawal of life support?

A

discuss plan with multi D team, family and patient if they are consious and possess decision making capactiy

consider consulting palliative care, pastoral care and ethics if needed

prepare patient and family with what may occcur

comfort/sedation, help w/ respiratory effort,

discuss plan with all staff involved: respiratory therapy, nursing to make sure everyone is comfortable with the process

69
Q

can you use neuromusclar blockade during withdrawal?

A

no…it’s prohibitied

should be stopped and appropriate reveral implemented prior to withdrawal

70
Q

can you remove tubes/drains if there is going to be an autopsy?

A

no

71
Q
A
72
Q

what is definition of death

A

irreversible apnea & unconsciousness in absence of circulation

  • heart stops beating
  • breathing stops
  • pupiles fixed & dilated
  • pale and waxen color
  • temperature drops
  • muscles relax
    • jaw falls open
    • eyes remain open
    • urine & stool released
73
Q

conditions that can mimic death

A

hypothermia

prolonged immersion in cold water

alcohol or drugs - TCAs barbiturates, anesthetic agents

suddent cause of somatic death - airway obstruction, electric shock, lightening strike

coma - hypoglycemia/hyperosmolar state, myxedema, hepatic encephalopathy

74
Q

how do you pronounce death

A

observe for a minimum of 5 mintes

cardiac function for > 1 minute - absent heart sounds & central pulse (can look at ECG, arterial line, echo)

respiratory function for > 1 minute - absence of breath sounds & visible chest movement

neurological function > 1 minute - absent pupillary responses to light, corneal reflexxes, motor response to supra orbital pressure

75
Q

post mortem examination sequence?

A

inspection: dilated pupils, corneal reflex, corneal cloudines, fundi for segmentation of retinal blood colums, trunk for post mortem staining
palpation: major pules, muslce tone for rigor mortis (>3 hours after death), loss of eye tension, temperature < 35

ausculatate heart & lungs: x 1 minute & repeat at intervals

Acute Care II - Summer 2017 (10 decks)

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