medical- FOCUS: palliative Flashcards
(72 cards)
1
Q
how do we support the patient and family of a palliative pt?
A
- physical
- emotional
- spiritual
- INTERPROFESSIONAL collaboration
2
Q
how is interprofessional collab distinguished from multidisciplinary care?
A
-it focuses on communication and cooperation among the various professionals involved.
-with each member of the team contributing to a SINGLE careplan!!
no mobility vs. medical care plan. working together to make one care plan that is patient centered!!
3
Q
specific approaches for the palliative patient?
A
- use approaches and language that are inclusive of gender identity, sexual orientation, chosen family community caregivers and culture
- assess and address physical symptoms, mental, spiritual distress concurrently
- encourage ppl to identify their strengths and areas of wellness
- openness, active listening, silence, and a therpaeutic presence are interventions within the scope of any clinician
- if beyond nurses scope of practice, refer to palliaitve social workers, counsellors, and spiritual health practitioners
- when a person expresses a wish to hasten their death, explore their experience before taking any action
- work together with families to support children when someone they love is dying
4
Q
communication at palliative care?
A
- active listening
- providing information (multiple times through the process)
- therapeutic
- open-ended questions
- how can you support your patients and families?
- -> when they receive bad news
- -> when they ask difficult questions
5
Q
culturally competent care–> what does this mean
A
we document that we do this to ensure the families needs and wishes are known, so not bombarded with these questions over and over again
- if pt does not speak english, interpreter is necessary, able to ask questions, and receive answers
- speak to their beliefs around death and dying
- written material in their language!!
6
Q
physiological changes near end of life?
A
- Weakness/Fatigue
- Decreasing Appetite/Food Intake, Wasting
- Decreasing Fluid Intake, Dehydration
- Decreasing Blood Perfusion, Renal Failure
- Neurological Dysfunction:
o Decreasing Level of Consciousness
o Terminal Delirium
o Changes in Respiration
o Loss of Ability to Swallow - Loss of Sphincter Control
o Big source of shame for someone… - Loss of Ability to Close Eyes
o Close them for them or eye drops - Changes in Medication Needs
7
Q
principles of symptom relief?
A
o Constant pain or other symptoms requires ongoing assessment and treatment (discomfort / anguish / pain) provide interventions and reassess respond with appropriate urgency
8
Q
respond with appropriate urgency, meaning…
A
o Do thorough Assessment o Consider Etiology o Remember “Total” Pain/Symptom o Consult whenever you need to (OT, PT, chaplain) o Educate all involved Document
9
Q
pain, what is TOTAL pain?
A
- physical
- psychological
- social, cultural, spiritual
- how do these types of pain interact?? all areas in our live!!
10
Q
what are the 7 Ps of total pain??
A
Physical pain (anticipate, treat)
o we’ve all felt it… sometimes hard to keep under control.
o Family can have a hard time
Intellectual pain
o Unfinished business, trying to finish things, understand what is happening
Emotional pain
o Broken heart or sadness or lost someone
o Some people have physical sensation
Interpersonal pain
o Relationships, fluctuating
Financial pain
o Provider for family
o ANGER!!! Caustic and challenging to deal with.
o Peel back the source of the anger, it was fear, leaving them behind and the finances etc.
o Have financial planner come to hospital
Spiritual pain
o Why me god etc.
o Final gifts book.
o Chaplain, spiritual leader come in.
o Think outside the box
Bureaucratic pain
o So many forms to fill out
o So many barriers, insurmountable for families, social work!
- *pain is not just a physical sensation, it might be a consequence of loneliness and spiritual distress, inappropriate diet or tumor growth careful listening is the important skill in determining best way to reduce discomfort
11
Q
incidence of pain in cancer care?
A
70 % of cancer patients in the advanced stage experience pain of moderate to severe degree
o 75% caused by cancer
o 10% caused by anti-cancer therapy
o 10% related to cancer but not directly caused
- 5% unrelated to either cancer or it’s treatment
- Between 25 – 75% of people die without good pain control
- One of the biggest fears with cancer is the pain
- Family members feel powerless
12
Q
pain syndromes–> direct tumor involvement?
A
space that it shouldnt usually take up!
- invasion of bone
- involvement of nerves (radiation can help)
- -> brachial plexus, lumbosacral plexus, epidural spinal cord compression
13
Q
pain syndrome–> involvement of viscera and ducts?
A
- obstruction (bowel, biliary duct)
- abdomen (big tumours in soft tissues)
- viscera
14
Q
pain syndrome–> involvement of blood vessels?
A
vascular tumor or lodges around vascular area–> discomfort
15
Q
pain syndrome–> related to cancer therapy?
A
post surgical pain
post chemo pain: peripheral neuropathy, mucositis, aseptic necrosis of bone
post radiation therapy pain (skin burns, thrush, cellulitis, worst before better-> inflammation!!)
16
Q
pain syndrome–> related to cancer induced debility?
A
- constipation
- decubitus ulcer
- gastric distension
- bladder spasm
17
Q
pain unrelated to cancer?
A
arthritis, angina, osteoporosis, migraine, etc
18
Q
pain assessment strategies?
A
-self-report!! search for potential causes!! -observe patient behaviors! symptom assessment tool... -surrogate reporting -attempt analgesic trial -PQRSTUV!! -referred pain picture...
19
Q
principles of symptom relief? for pain
A
- Constant symptom requires constant TX
- Do thorough assessment
- Consider etiology (Cause)
- Remember Total Pain concept – emotional can mnfts as physical!!!!
- Avoid unnecessary delay
- Educate all involved
- Individualize care (does Q2 work??)
- Consider adjuvants at all stages
- Use oral route when possible (oral lasts longer)
- Evaluate frequently (titrate as necessary)
- Remain in communication with patient and family (it should work in 5-10 minutes, I will come back, reassure)
- Treat other symptoms (nausea, vasovagal)
- Be flexible
20
Q
analgesic ladder… what is the steps?
A
PAIN
step 1. non opioid for mild pain (+/- adjuvant)
step 2. opioid for mild to moderate pain (+/- non-opioid, +/- adjuvant)
step 3. opioid for moderate to severe pain (+/- non-opioid, +/- adjvant)
21
Q
step 1 of WHO ladder?
A
non-opioid–> tylenol, ibuprofen
-may give an adjuvant (cold washcloth, turn lights off, calm music)
22
Q
step 2 of WHO ladder?
A
pain is persisting!!
- reassessment
- opioid withor without a non-opioid and adjuvant
- non-opioid (ketorolac)
- adjuvant, warm blanket, adjust bed, moving,
23
Q
step 3 of WHO latter?
A
pain persisting–> reassess!! how can we enhance the opioid? CBD?
-collab with other nurses, may have to call doctor, pain clinic, oncologist may help
24
Q
what is the WHO pain management principles???
A
ORAL is the route of choice
- by the clock–> analgesics on a fixed dose schedule not PRN (chronic pain is better on fixed dose!!)
- by the ladder: follow the WHO latter
- for the individual: dose must be tirtrated against particular pts pain
- use of adjuvants: when we are alexious, contributes to pain!
- attention to detail: know the pts believes and fears and things that can relieve it!
25
long acting opioids for pain management--> sustained release?
- Meslon, OxyContin, Hydro morph Contin, Fentanyl patch
o Always determine 24-hour dose by titration with short acting preparation
In 24 hours, the physician will come in and say ok, pt. is getting 4mg every 6 hours regularly so 24 mg. Breakthrough, 2mg ever 2 hours. 36mg in 24 hours is used to convert medication to the continuous long acting
o Oral forms and patches take 24 hours to reach steady state
(patch not fully effective for at least 24 hours can take up to 72 hours)
In meantime, give 4mg etc. until window is up. And then giving breakthrough
If pain after that, call doctor
o Give BTDs (break through dose) in first 12 hours if necessary
o Always look for a short acting form of same drug if possible for BTP
o If pain not controlled, revert to short acting and re-titrate
o Oral forms cannot be crushed or chewed
o Meslon can be opened and sprinkled on food but cannot be put down NG tubes
26
pain control with opioids--> break through doses?
o Use immediate release
o ½ of the q4h dose
o offer more after peak reached
o If <3 BTDs per day no change in regular dose
o If >3 BTDs per day then increase regular dose by the BTD amount
- Add up the total amount given in past 24 hours including regular and BTDs
- Divide total by 6 and give next regular dose by that amount (we don’t do this.. the doctor orders it)
27
switching between PO and sc?
o SC dose is ½ of PO dose based on the immediate release form of the drug
o We are not allowed to switch from PO to Subcut or subcut to PO unless we have orders
28
switching between immediate to sustained?
conversion is based on total daily dose of immediate release and divided accordingly
29
respiratory depression and pain control?
pain is a potent stimulus to breath!
- loss of consciousness precedes resp depression
- if pain is gone--> can lose consciousness--> naloxone, wake up with no narcotic in system--> full pain crisis
30
opioid/non-opioids used for pain?
fentanyl patch, dilaudid- po, sc
morphine, po sc
methadone po
sufentanil sl
31
antispasmodic and opioid?
belladonna and opium (B& supp)
32
anesthetic agents?
- ketamine (sc injection/infusion)
- bupivacaine (intrathecal)
- lidocaine (topical)
33
non opioid analgesics?
acetaminophen, ibuprofen
34
adjuncts?
ALWAYS GIVEN W OPIOID/NONOPIOID!! we dont rely on these aloneo Tetrahydrocannabinoids:
Nabilone, Mirjana, CBD oil
Tricyclic antidepressant:
Amitriptyline – po
Neuroleptics:
Chlorpromazing – po, Methotrimeprazine – po/sc, Haloperidol – po, sc, Gabapentin – po, Quetiapine – po,
steroid – Decadron
Benzodiazepines:
Lorazepam – sl, Midazolam – sc/iv
Adrenergic:
Clonidine – po
Anticholinergics:
Buscopan
35
pain control- nonpharm
ice/hot packs
- massage
- reposition
- meditation
- distraction (TV)
- soft music
- tub bath hot shower
- personal care
- compassion
36
3 COMMON side effects for opioid naive patient?
COGNITIVE change- confusion or sedation
NAUSEA
CONSTIPATION
37
teaching with pain??
o To be able to contact if pain or side effects worsen! So, they don’t have to suffer
o Encourage to report pain
o Inform they have right to receive adequate pain management
o Assure reported pain will be acted on
o If pt./ family disagree, explore understanding & come to agreement!
o If someone is worried about addiction…
o Accurate & reliable information should be given regarding opioid tx.
o Pay attention and correct false beliefs can affect adherence effective or ineffective
o Pt. safety, more is not necessarily better!!!!
o Explanation for the cause of each kind of pain
o Reassurance that pain can be well controlled
o GOOD NIGHTS SLEEP
o Difference between hope and despair is often a good night’s sleep
o Pain when at rest or when ambulatory !!! take ahead of time
o Do not try to chase and get on top of it
o 3 common side effects for opioid naïve pt.:
Cognitive change – confusion or sedation
Nausea
Constipation
o Explain that cognitive & nausea commonly improve and disappear in 3-7 days if cannot wake up, not a good sign
o Tease out patient willingness to tolerate side effect during titration phase… Sedation until under control but not everyone is willing to do that
o Constipation is ongoing. Laxaday. Lactulose. Prune juice change diet.
o Taught how to use pain assessment tool
o Pain diary
o Tracking sheets to make sure under control.
38
bone pain- symptom?
o Constant, worse with movement
o Mets, compression or pathologic fractures
o Prostaglandins from inflammation, mets
o Rule out cord compression – emergency radiation shrink tumour
39
management of bone pain?
```
o Opioids
o NSAIDs
o Corticosteroids
o Bisphosphonates
o Calcitonin
o Radiation
o External bracing (bone cancer – so may need support, back brace)
```
40
dyspnea--> how common is it?
o 60% of patients with terminal cancer, ALS, or end stage lung and heart disease will experience some degree of dyspnea, especially during last 6 weeks of life.
o How would you assess for dyspnea?
Terrifying to the patient!!
Working to breath – indrawing in upper chest, abdominal muscles being used
wanting to sit up, panicky, not being able to speak in full sentences
41
what patient and family teaching is important for dyspnea?
o They have to be able to breath & feel comfortable first!
o Make sure they are using their inhalers and correctly – and not compliant with oxygen
o Constipation! Bearing down… make sure they don’t strain
o Fresh air, fan, repositioning, diary is a good thing, are they happening at bedtime, first thing in morning etc.
o Cultural practices with smoke? Respect decision to continue these practices.
o Encourage smoking cessation
o Can be lessened even after lung cancer diagnosis
o How to use meds properly
42
prevention of dyspnea?
o No perfumes-
o Avoid triggers such as smoke, smells, memories, anxiety
o Limit number of people in the room
o Encourage fresh air with an open window or fan
43
treatment of dyspnea?
```
Treat the cause if possible
• Obstruction: Radiation/Chemotherapy/Meds
• Pleural effusion: Thoracentesis
• Ascites: Abdominal paracentesis
• Antibiotics: Pneumonia
• Anemia: Transfusion
```
44
pharmacological treatment of dyspnea?
```
o Opioids
o Bronchodilators (for bronchospasm)
o Diuretics – furosemide
o Steroids – hydrocortisone
o Benzodiazepines – Lorazepam, midazolam (anxiety)
o Neuroleptics, esp. if dying CPZ, Methotrimeprazine
o Anticholinergics – Glycopyrrolate
o Cough suppressants
o Oxygen
```
45
non-pharmacological treatment for dyspnea?
```
o Comfort during acute episodes
o Positioning
o Elevate HOB
o Recliner
o Pillows under arms to expand chest
o Leaning on side table with pillows
o Loosen clothing
o Fan on
o Open windows
o Calm environment
o Touch, support, information
```
46
nausea and vomiting... how often?
- Occurs intermittently in 60% of terminally ill cancer patients
- 40% in patients during last week of life
- Occur in up to 60% of patients receiving opioids, particularly at the initiation of therapy
47
common causes of nausea?
o Chemical
o Cortical
o Cranial
o Vestibular
o Visceral or serosal
o Gastric Stasis (impaired gastric emptying)
o Often multi-faceted – ongoing assessment critical
o Patients have expressed that the ongoing experience of nausea is worse than pain
o Ongoing assessment and trial of drugs – if it is not working change the regime
o Please tell me you can do more than Gravol!!
48
non-pharmacological treatment for nausea and vomiting?
o Environmental modification – eliminate strong smells and sights and use air deodorizers or fresheners, open windows, fan
o Cold compress to forehead and back of neck
o Maintain good oral hygiene, especially after episodes of vomiting.
o Acupuncture or acupressure point have been found to have limited benefit.
o Visualization or hypnosis.
o Distraction
o Consult with Social Worker, Spiritual Practitioner, Physiotherapist, Occupational Therapist, Counselors for psychosocial care, anxiety reduction.
49
nausea education?
o Cut out intolerant foods.
o Restrict intake when gastric distension is a factor.
o Start with sips, ice chips or popsicles,
o after nausea settled; gradually increase from fluids to semi-solid to full food. If nausea recurs, step back until nausea resolves.
o Avoid spicy, fatty and salty foods, or ones with strong odors
o Avoid mixing liquids and solids.
o Use small frequent, bland meals when hungry.
o Drinking cool, fizzy drinks.
o Avoid lying flat after eating.
o Take antinausea medication regularly
o Explain to the patient / family what is understood about the multiple triggers of nausea and / or vomiting and that it may take many strategies together to make a difference.
o Consult with a Clinical Dietician and provide dietary advice.
50
constipation--> assess and treat causes... prevention is key!!! what are some causes?
```
o Medications (opioids)
o Lack of mobility
o Decrease fluid intake
o Decrease nutritional intake
o Tumors
o Pain
o Stress (irritable bowel)
o Can you think of anymore causes?
```
51
what patient teaching is important for constipation?
o Explain normal bowel function varies from person to person
o Daily bowel movement not necessary as long as soft & easy to pass 2-3 days okay
o Never ignore the urge to have a bowel movement
o Try 30-60 minute after a meal when the gastrocolic reflux is occurring
o Avoid excess straining harmful (cardiac esp.)
o Sitting position with use of raised toilet seat, stool or bedside commode
o Privacy in toileting, reduce anxiety & aids relaxation
o Advanced pain control improve comfort & mobility
o Teach how to differentiate between oozing stool and diarrhea – sometimes we depend on pt. to report what they are doing? Are they bypassing? Are they oozing?
o Teach constipation prevent increase fluids, fibre, mobility! – take time to work!
o Nutritional liquids milkshakes, cream sounds, fruit juices more energy
o Fruit laxative with prunes, raisons, dates
o When oral appetite & mobility are reduced, avoid extra fibre
o Laxative may be needed
o With opioids they will need a stimulant laxative from the beginning to prevent ongoing constipated effects cenacot. Prune juice, something every day, cut back if stools get loose
o Body continues to produce 1-2 ounces of stool a day even if there is no oral intake, laxative may still be required in advanced disease but can be stopped in last few days of life.
52
pharmacological treatment for constipation..?
- osmotic laxative--> lactulose, polyethylene glycol (PEG)
- stimulant laxative--> sennosides
- hyperosmotic laxative--> glycerin supps
53
no pharm treatment for constipation?
```
o Increase fluids
o Increase fiber
o Warm bath
o Warm blanket on abdomen
o Reposition frequently
o Stop oral laxatives in the last few days of life when patients are no longer able to receive medication and their level of consciousness diminishes.
o Cup of hot water or coffee
o Can you name more?
```
54
fluids and nutrition at end of life? causes of changes..
o Fluid deficits in terminally ill patients are frequently multifactorial.
o End result is total body water depletion and decreased renal function.
o There are 2 broad categories of fluid deficit disorders which may present separately or together: DEHYDRATION & HYPOVOLEMIA
Dehydration, which results from total body water depletion.
Hypovolemia or volume depletion, which results from loss of both salt and water, mainly from the extracellular (intravascular) space.
- Hunger – not a common sensation at EOL
- Thirst – more common – not related to dehydration and unrelieved by artificial hydration (AH) IV FLUIDS
- Dry mucous membranes -? Thrush
o Good mouth care so important
- Delirium – very common and distressing symptom
- 90% of patients experience it to some degree in the final weeks of life
- Most common physical reasons for initiating AH are to treat delirium caused by opioid toxicity and hypercalcemia- may start IV
- Anorexia and cachexia – caused by metabolic disturbance of Ca – loss of protein
55
2 broad categories of fluid deficit disorders that may present separately or together in end of life?
DEHYDRATION AND HYPOVOLEMIA
56
three psychosocial processes families engage in?
-Fighting back
The knowledge that reduced intake is normal for someone who is dying is in direct conflict with a family’s desperate attempt to prevent
-Letting nature take its course
Understand that no amount of nutrition of fluids with prevent the patient from dying
-Waffling
Go between accepting approaching death and wanting to keep fighting
Some care givers fit in here as well
57
benefits of dehydration at EOL?
o Natural anesthetic effect, reduction in resp secretions, decreased GI fluid, reduced urine output
58
risks of over hydration at EOL?
-edema, ascites, resp cogestion, distress, diarrhea, nausea and pain
59
depression at EOL?
- Depression and Delirium share symptoms that can hide their true etiology.
- Depression should not be an accepted response to dying
- Should not be mistaken for sadness and anticipatory grieving (normal response to impending death)
- Cancer patients with advance disease are vulnerable to depression, suicidal ideation and severe anxiety
- Assess for underlying causes (i.e. uncontrolled pain….)
- Management of physical symptoms (i.e. fatigue, nausea, anxiety….)
- Ensure rest
- Attention to emotional and spiritual distress team members
- -> pharmacologic interventions: psychostimulants, SSRIs, tricyclic antidepressants
60
delerium and EOL?
three sub-types:o Hyperactive – 30% restless and agitated; hallucinations more common
May appear to be in pain and giving more opioids can increase delirium
o Hypoactive – 48% drowsy and withdrawn most prevalent
Can be mistaken for fatigue, depression or dying
o Mixed subtypes – 22% patient fluctuates between hyperactive and hypoactive
-DELERIUM= common in palliative care! occurs in 20-8% of cancer patients.
-often occurs 24-48 hours before death BUT IT IS NOT A NORMAL PART OF DYING!!
61
top priority with delerium???
identify anad treat the cause if it is within the goals of care!!
-this is very distressing to family, a quiet peaceful death doesnt always happen!!
62
causes of delirium at EOL?
```
o Pain
o Drugs
o Metabolic
o Dehydration
o Infection
o Constipation
o Sleep deprivation
```
63
family teaching regarding delirium?- how would you support the family with a patient experiencing delirium at home or in the hospital?
Anticipatory guidance about what to expect!
Helps understand that loved one isn’t being difficult, response to body stress.
Guidance how to interact, don’t argue, calm voice
Symptoms due to illness, it’s a process
Less reversable near end of life
64
what non-pharmacologic techniques could you teach the family for delirium?
Calm, reorienting environment, clocks and calendars
Familiar objects
Encourage stimulating activity & mobility
Hearing aids & glasses available or in place &functioning
Small amounts of food & fluid frequently
Sleep warm drinks, relaxing music, massage, do not wake in night
Night light
Comfort & reorientation
Educate family teach to watch for sundowning can be a first sign
65
palliative sedation therapy? what is it
- The monitored use of pharmacological agent(s) to intentionally reduce consciousness to treat refractory, intractable and intolerable symptoms for a patient* at end of life with advanced life limiting, progressive illness.
- It is considered a last resort and is only used when other treatments have failed.
- The level of sedation must be in proportion to symptom severity, using the lowest dose to achieve comfort.
- The intent of PST is to provide symptom relief. When used appropriately, it does not hasten death
- PST almost always continues until natural death from the illness occurs
- Sedation as a side effect of treatment (i.e., consequential sedation) is not PST.
- Decreased level of consciousness is expected in the natural dying process regardless of PST
- Eg.
o For severe COPD – dyspnea & ongoing anxiety! That exacerbates cycle
o Use pump or drug such as midazolam
66
palliative sedation therapy vs MAID...
BOTH: suffering is unberable for patient
- PST= does not hasten death, intent is to provide symptom management and relief of suffering, natural death from illness is imminent, does not require that the pt be competent to provide consent, subsitute decision maker can do it...
- MAID= needs pts competent consent, natural death from illness is forseeable
67
goals of care conversations at EOL?
pts goals of care must be to allow natural dying with a focus on comfort an dsymptom management
68
assessment for use of PST?
- determining that the criteria for PST are met requires knowledge of pt and diagnosis, as well as symptom management expertise
- indications for PST: intractable physical symptoms, ex. dyspnea, pain, nausea, delirium, seziures
69
decision-making for PST?
• The decision must be made in consultation with the patient (when capable), family and/or their SDM, and interprofessional team members.
• Whenever possible, these discussions should happen in anticipation of refractory symptoms, before a crisis begins or escalates.
=
70
family education and support with PST?
* Before initiating PST, support the patient and family to do what is important to them such as rituals or saying goodbye as the patient will likely not awaken before natural death occurs.
* Continue ongoing, frequent check-ins and emotional support with family members throughout the process from assessment, decision-making, initiation, during sedation, and following death.
* Discuss the usual signs and symptoms of impending death that may be misinterpreted as being caused by PST (e.g., altered respirations) (chenye stoking is part of end of life process)
71
pharmacological interventions with PST?
o Most common medication classes used for PST are benzodiazepines, neuroleptics, barbiturates, or general anesthetics
o Opioids are not appropriate to induce PST
o Consider discontinuing previous benzodiazepines or neuroleptics if the same class will be used for PST purposes
o Discontinue non-necessary medications in keeping with goals of care
o DO NOT stop current medications for symptom relief as they will still be needed for optimal comfort.
o As consciousness is lowered, change all necessary medications to non-oral routes (may possibly use sublingual or buccal).
o Titrate only to the level of sedation that is required for symptom control using the lowest dose to achieve comfort
72
non-pharmacological interventions with PST?
o Ongoing assessment of patient comfort through facial expression or body language
o Use the RASS-PAL scale to monitor sedation level and titrate up or down to maintain goal level of sedation.
o Monitor frequency as per medication table .
o Provide the same care as for an unresponsive patient (such as mouth care and position changes)
