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

Module 1: Palliative Care Flashcards

(75 cards)

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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
end stage criteria?
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
26
Physical ADLS?
DEATH dress eat ambulate/transfer toileting/continenece hygiene - bathing/grooming
27
how do you measure progressive decline in palliative patients?
PPS - palliative performance scale it's a valid reliable funcitonal assessment tool that is based on the Karnofsky Performance Scale
28
how is the PPS physical performance measured?
10% incremental levels from fully ambulatory 100% to death 0%
29
how is PPS differentiated further?
degree of ambulation ability to do activities/extent of disease ability to do self care food/fluid intake level of consciousness
30
additional end stage criteria?
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)
31
what are some hospice diagnoses?
terminal illnesses cancer, dementia, ESLD, COPD, ESRD, HIV/AIDS, CVA/coma, chronic neurodegenerative disease, failure to thrive, heart disease,
32
who gets hospice?
10% non white - african americans have stronger preference to continue treatment 51% women 71% with cancer
33
diagnoses of those in hospice
43% cancer 57%: dementia, esrd, chf, copd, als
34
who is most likely to refer for hospice?
medical generalist, geritrician & family practitioner
35
hospice outcomes?
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
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37
barriers to hospice
late referrals culture/racial preferences low income & educational level distrust of system need for primary care provider to agree to prognosis
38
opportunities in ICU for palliative care
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
what are some simple communication interventions?
"get to know me" poster identification of surrogate decision maker advanced directive status give printed materials for family infomation breavement brochure
40
impact of family meetings & printed materials?
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
what does proactive communication give you?
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
what beneftis are there with increased family satisfaction w/ clinical statements?
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
what are issues with professional burnout/moral distress
* 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
key points of palliative care?
* 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
points for code status and goals of care discussion
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
palliative care methods for pain & conspitaion?
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
paliative care methods for nausea & vomiting
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
anorexa & cachexia
almost universal issue treat dry mouth w/ saliva substitues liberalize diet appetite stimulants (Megesterol acetate)
49
how to deal with dyspnea
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
how to help w/ cough
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
how to deal with diarrhea
rare 7-10% rule out excessive laxative use check for fecal impaction
52
how to deal with bowel obstruction
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
how to deal with delirium
distressing to patient and family search for cause non-sedating vs sedating antipsychotic avoid benzodiazepines
54
how to deal with depression
underrecognized and treated insomnia, anorexia, loss of interest, anhedonia, suicidal ideation treatment antidepressats, address other symptoms, talk therapy, PMH consult
55
nausea & vomiting
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
example of motility agent
metoclopromide
57
example of serotonin antagonist
odansetron, granisetron
58
example of antihistamines
promethazine, hydroxyzine, meclizine, dimenhydrinate
59
causes and treatments of vestibular apparatus nausea & vomiting
causes: drugs (opioids), labryinthitis, acoutic & other tumors treatments: scopolamine, meclizine, hydrobromide
60
cerebral cortex causes & treatments for N/V
causes: increased ICP, CNS malignancy treatment: Dexamethasone, 8 mg PO/IV/SubQ
61
type & order for surrogate?
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
what does molst do for us? (Medical Orders for Life Sustaining Treatment)
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
when must a MOLST form be completed?
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
NP who signs MOLST order form is responsible for ....
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
when can a surrogate authority withhold life sustaining treatment
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
when are MOLST orders reviewed
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
when might you withdrawal life support
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
how do you go about withdrawal of life support?
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
can you use neuromusclar blockade during withdrawal?
no...it's prohibitied should be stopped and appropriate reveral implemented prior to withdrawal
70
can you remove tubes/drains if there is going to be an autopsy?
no
71
72
what is definition of death
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
conditions that can mimic death
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
how do you pronounce death
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
post mortem examination sequence?
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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