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End of Life Care Flashcards

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1
Q

What is MAID not the same as?

A

palliative care
palliative sedation
-ongoing sedation until natural death
-use of medications to reduce consciousness
withholding or withdrawing life-sustaining or life-prolonging treatment

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2
Q

How are MAID requests handled in Saskatchewan?

A

through the provincial MAID program
-prescriptions for MAID are filled by hospital pharmacies

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3
Q

Can a pharmacist decline to participate in MAID?

A

yes
-a pharmacist or tech may decline to participate in MAID for reasons of conscience or religion
-express objection to MD or NP instead of patient
-if not able to assists, must provide an effective referral

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4
Q

What are the limitations of the scope of the pharmacist in MAID?

A

no participation in MAID unless contacted by MD or NP
we can provide education about MAID but must not imply leading the process
-refer to someone who can
we do not assess a patient for eligibility
we do not collect consent for MAID
we do not prescribe or administer drugs for MAID
we do not prescribe drugs for “office use”

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5
Q

What is the role of a pharmacy technician in MAID?

A

activities performed by the pharmacy technician as part of the dispensing process must be done with a pharmacist present
-legal risk: the amendments needed to protect everyone involved are extensive and they be could be open to prosecution

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6
Q

Describe a good process to take with MAID prescriptions.

A

MAID or non-MAID? if unsure, call MAID program
-if the purpose is for MAID it must be written
-if for MAID, you cannot dispense from a community pharmacy
-if not, (i.e. ondansetron for nausea), you can dispense from a community pharmacy

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7
Q

Where are MAID prescriptions dispensed?

A

hospital pharmacy
-can only dispense to MD or NP (NOT the patient)

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8
Q

How does palliative care address patient needs?

A

addresses the patients needs in the physical, psychological, social, and spiritual domains via:
-communication around goals of care
-symptom management
-practical support for patient and family needs

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9
Q

What are the elements of good palliative care?

A

patient and family-centered
strives for the best possible QoL
an active approach to symptom management
affirms life and regards dying as part of the normal process of living
does not attempt to hasten nor postpone death
uses a team approach to address the needs of the patient and their families
offers a support system to help the family cope
is offered early in course of illness, in conjunction with therapies intended to prolong life

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10
Q

Who is palliative care not exclusively meant for?

A

is NOT meant exclusively for individuals who are imminently dying and not exclusively for cancer patients

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11
Q

Who is palliative care appropriate for?

A

any patient with a chronic, life-limiting illness who is experiencing symptoms related to their illness or treatment
-e.g. renal dialysis, oxygen therapy, cancer chemotherapy
-includes patients still receiving treatment intended to prolong life
unfortunately access to specialized palliative care teams and services may be reserved for individuals with advanced terminal illness

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12
Q

What are some examples of palliative conditions?

A

cancer
progressive/advanced organ failure (ex: HF, COPD, ESRD)
advanced neurodegenerative disease (ex: dementia, Parkinsons)
sudden onset of a serious medical condition (ex: serious infection, MI/stroke, bowel obstruction)

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13
Q

What do individuals recieving palliative care report?

A

greater satisfaction with symptom management and care received

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14
Q

Where would most Canadians prefer to die?

A

at home

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15
Q

What is the goal of palliative care?

A

limit physical and emotional suffering by adequately managing pain and other symptoms
support the ability to enjoy remaining life while avoiding inappropriate prolongation of death

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16
Q

What does the goal of palliative care look like from a pharmacist perspective?

A

stopping non-essential drugs
ensure ongoing administration of essential drugs
-management of symptoms
-appropriate route of admin

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17
Q

What plays a big role in symptom control at the end of life?

A

drug therapy

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18
Q

Who is palliative drug coverage an option for in SK?

A

individuals with a life expectancy measured in months, for whom curative or life-prolonging treatment is not an option
-form must be completed by physician and submitted to SPDP
-100% coverage for Rx and adjunctive OTC
-may also cover dietary supplements as required

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19
Q

What are the most commonly used drugs in the last year of life in the palliative setting?

A

opioids
corticosteroids
reflux drugs
propulsives
anxiolytics

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20
Q

What is the goal of palliative pain management?

A

comfort

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21
Q

Which types of pain are most common in the palliative setting?

A

nociceptive & neuropathic

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22
Q

How is palliative pain primarily managed?

A

opioids

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23
Q

How are opioids scheduled in the palliative pain setting?

A

around the clock plus breakthrough

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24
Q

Which route of admin is preferred for pain management in the palliative setting?

A

oral route when possible

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25
What is the preferred parenteral route of administration in the palliative setting?
subcutaneous
26
What is the onset of subcutaneous analgesics?
15-30 minutes
27
What are the advantages of the subcutaneous route?
less equipment vs IV may be administered by patient or family member absorption is slower than IV, but complete
28
What are the disadvantages of the subcutaneous route?
potential discomfort local tissue irritation limited volume for injection (5 mL maximum) requires one subcut line per medication
29
What is the role of the WHO analgesic ladder in the palliative setting?
often ignored and we start with opioids
30
What is often the preferred analgesic in the palliative setting?
hydromorphone -higher potency vs morphine (5:1) -no active metabolite -low induction of histamine release vs morphine
31
Which opioid is quite high in potency?
fentanyl
32
What is the role of injectable fentanyl?
SC or buccally for relief of incident pain
33
What is the onset and duration of injectable fentanyl?
onset ~ 10 min lasts ~ 1 hour
34
What is the role of the fentanyl patch?
stable, chronic pain not suitable for patients requiring opioid titration
35
What are the side effects we should be ready to manage with opioids?
nausea and vomiting constipation sedation delirium/confusion/hallucinations pruritis dry mouth urinary retention respiratory depression myoclonus hyperalgesia & allodynia
36
Describe how to manage sedation induced by opioids.
tolerance develops ~ 2-4 days may occur when initiating or increasing dose if persistent, decrease dose or switch to another opioid palliative care: can use psychostimulant (MPH)
37
Describe how to manage delirium/confusion/hallucinations induced by opioids.
usually resolves within 3-4 days management: -avoid increasing opioid until resolved -rule out other causes -palliative care: haloperidol po/subcut
38
Describe how to manage pruritis induced by opioids.
if persistent, reduce dose, switch to another opioid or pre-treat with anithistamine -DPH po/subcut 15-30 min before opioid -2nd gen antihistamine if can administer orally to avoid droswiness
39
What causes pruritis in the context of an opioid?
secondary to histamine release (not a true allergy)
40
Describe how to manage dry mouth induced by opioids.
may be exacerbated by other drugs mouth care, ice chips, frequent sips palliative care: pilocarpine (can use eye drops orally)
41
Describe how to manage urinary retention induced by opioids.
usually improves within one week catheter in the meantime if complete retention
42
Which serious side effect of opioids is rare in the palliative setting?
respiratory depression
43
Describe how to manage respiratory depression induced by opioids.
if mild ( > 8 breaths/min): -monitor patient closely -hold further doses of opioids, BZD until resolved - then review/reduce if severe ( < 8 breaths/min): -naloxone -monitor closely (opioids have a longer duration of action than naloxone)
44
What is myoclonus?
spontaneous jerking movement
45
Describe how to manage myoclonus induced by opioids.
if pain is controlled, reduce opioid dose switch to another opioid add a BZD
46
Differentiate hyperalgesia and allodynia.
hyperalgesia: exaggerated pain response allodynia: pain evoked by a non-painful stimulus
47
Describe how to manage hyperalgesia & allodynia induced by opioids.
significantly reduce dose and/or switch to another opioid -methadone palliative care: may add a NMDA antagonist (ketamine) if severe
48
What are some adjuvant agents for pain?
anticonvulsants antidepressant dexamethasone
49
What is the role of dexamethasone for pain management in the palliative setting?
e.g. metastatic bone pain, neuropathic pain -less mineralocorticoid activity
50
What are the causes of nausea and vomiting in palliative care?
often multifactorial: -constipation -medications (e.g. opioids, NSAIDs) -reduced GI motility -metastatic disease/obstruction -metabolic changes (e.g. hypercalcemia, hyponatremia, uremia) -increased intracranial pressure -uncontrolled pain -anxiety -candidiasis
51
Describe the approach taken to NV in palliative care.
identify and correct likely cause(s) optimize non-pharm strategies select an antiemetic based on cause and appropriate route, reassess q2-3 days -if patient vomits oral dose within 30 min, repeat the dose -titrate the dose up or down as needed -scheduled vs prn vs scheduled + prn if nausea persists after 48h, add another agent with different MOA anticipate need for antinauseants proactively assess for and manage AE
52
Describe the non-pharm management of NV in the palliative setting.
cold food may be associated with less nausea separating solid and liquid foods may decrease early satiety offer preferred foods and textures, allow eating at own pace dont pressure a person to eat or drink against their will peppermint oil or ginger tea if patient finds soothing cold, lightly carbonated beverages
53
What are the 1st line anti-nauseants in palliative care?
haloperidol -fast onset, mild sedation metoclopramide -fast onset, prokinetic, mild sedation
54
What are the 2nd line anti-nauseants in palliative care?
methotrimeprazine -broad spectrum receptor activity, more sedation olanzapine -if concurrent anxiety/mental distress
55
What are some "other" anti-nauseants seen in palliative care?
dexamethasone -broad-spectrum anti-nauseant, unknown MOA PPI -lansoprazole or pantoprazole, add-on therapy may help provide relief regardless of cause octreotide -nausea associated with malignant bowel obstruction
56
What is dyspnea?
subjective experience of difficulty breathing or unsatisfactory breath -may or may not be related to underlying pathology -one of the most feared aspects of dying
57
What is the non-pharm management for dyspnea in palliative care?
provide 'fresh air' - open a window or direct a fan to face oxygen if hypoxic nebulized saline reduce room temperature use a humidifier if air is dry plan rests around activities
58
What are the pharmacologic options for dyspnea in palliative care?
opioids - treatment of choice if respiratory panic attacks - BZDs if history of asthma or COPD - bronchodilators, steroids
59
What is the 1st line therapy for dyspnea in palliative care?
opioids
60
What is the MOA of opioids for dyspnea?
act on respiratory centre, reducing respiratory effort central sedative effect, attenuating the ventilatory response lower sensitivity to hypercapnia and hypoxemia reduce oxygen consumption diminish perception of dyspnea and anxiety
61
How are opioids dosed for dyspnea?
same principles as for palliative pain control -i.e. scheduled and rescue doses, dosage increases, manage side effects
62
Which route is preferred for opioids when used for dyspnea?
oral or SC most common
63
What is seen with regards to severity and occurrence of dyspnea in the last hours of life?
occurrence & severity increases in last 48 h of life actively dying patients can have altered breathing patterns -unresponsive does not equal dyspnea -reassure family that altered breathing is not distressing to the patient
64
What is a cognitive disturbance that is common at the end of life?
delirium
65
Which drug classes are used to treat delirium in palliative care?
antipsychotics and/or sedatives only as needed to calm agitation and relieve distress -do not speed recovery from delirium
66
How is delirium managed in the palliative care setting?
look for and address underlying cause(s) drug therapy if needed -haloperidol 1st line -if more sedation needed: methotrimeprazine, olanzapine, BZD
67
Which drugs warrant reassessment at the end of life?
hypoglycemics, diuretics, antihypertensives -advanced illness: malnourished, hypotensive, dizzy, dehydrated cardio-protective agents, vitamins/minerals, HRT, etc
68
Which drugs are considered essential at the end of life?
analgesics antiemetics anxiolytics antipsychotics sedatives
69
What is commonly seen in the last few days of life?
sleeping for longer and difficult to arouse eat and drink less difficulty swallowing become restless or confused --> terminal restlessness
70
What is the rally?
close to 'normal' functioning within hours --> days of end -1/3 patients seeing loved ones or pets who have passed, speaking childhood languages, talk of 'going home' -respect their reality
71
What is commonly seen in the last hours of life?
unresponsive to touch/voices develop wet or rattley-sounding breathing irregular pulse or heartbeat lose control of bladder or bowels cool limbs irregular or shallow breathing
72
Describe management of decreased appetite and fluid intake at the end of life.
key: natural part of dying process most people do not experience hunger or thirst as death approaches offer but do not force food or fluids providing nutrition or fluids artificially may actually increase some distressing symptoms, such as respiratory congestion or NV artificial hydration does not prevent thirst or relieve a dry mouth (mouth care more helpful)
73
What is respiratory congestion?
rattling, gurgling sound caused by accumulation of secretions in the airway may be due to increased secretion production, decreased swallowing, decreased mucociliary clearance or ineffective cough reflex
74
What is often a signal that death is near?
respiratory congestion -distressing to family; provide reassurance
75
Describe management of respiratory congestion at the end of life.
non-pharm: -reposition head or lie patient on their side -avoid/dc IV fluids pharm: -anticholinergics to dry up secretions -must be started at first sign of resp cong, will not dry up secretions already present -conscious: glycopyrrolate -unconscious: atropine, scopolamine
76
How is terminal restlessness managed?
assess for other causes/contributors meds may be necessary to relieve distress -haloperidol 1st line -if ineffective or more sedation needed, use BZD
77
What is palliative sedation?
use of sedating meds to relieve symptoms or reduce awareness when symptoms intractable to other measures and causing intolerable suffering -when all possible treatment has failed -may be appropriate in the final stage of illness
78
How does palliative sedation differ from MAID?
context very different from MAID -MAID: patient must be alert and competent to access -palliative sedation is usually implemented gradually and consent of substitute decision maker is sufficient

PHAR350 (17 decks)

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