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704 Geriatrics > Palliative Care > Flashcards

Palliative Care Flashcards

(42 cards)

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1
Q

How should curative care be switched to palliative?

A

Gradual increase in palliative and decrease in curative

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2
Q

When should full palliative care be iniated?

A

Attempts at a cure are futile

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3
Q

What is the prognosis for Medicare benefit?

A

Terminal illness with prognosis <6 months by attending physician and hospice medical director

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4
Q

What is hospice care?

A

Subset of palliative care initiated in last 6 months

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5
Q

What symptoms can be seen in the last 1-3 months of life?

A
  • Withdrawal from world and people
  • Decreased food intake
  • Increase in sleep
  • Going inside self
  • Less communication
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6
Q

What mental changes can be seen in the last 1-2 weeks of life?

A
  • Disorientation
  • Agitation
  • Talking with the unseen
  • Confusion
  • Picking at clothes
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7
Q

What physical changes can be seen in the last 1-2 weeks of life?

A
  • Low BP
  • Paler/bluish
  • Respiratory irregularities
  • Sleeping but responding
  • Not eating, taking little fluids
  • Hot or cold temperature
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8
Q

What can be seen in the last days to hours?

A

A sudden burst in energy

Intensification of previous symptoms

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9
Q

What are symptoms of the last minutes of life?

A

“Fish out of water” breathing
Cannot be awakened

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10
Q

What cardiac/renal changes are seen while dying?

A
  • Tachycardia
  • HTN -> hypotension
  • Cyanosis
  • Mottling of skin (livedo reticularis)*
  • Venous pooling
  • Dark urine, decreased/no output
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11
Q

What are the 3 stages of cognitive decline while dying?

A
  1. Decreasing level of consciousness
  2. Decreasing ability to communicate
  3. Terminal delirium
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12
Q

T/F: Eyes usually become closed while dying

A

FALSE: loss of ability to close eyes

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13
Q

What are rare, unexpected events during death?

A
  • “Golden glow”
  • Aspiration
  • Asphyxiation
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14
Q

What are the properties of portmanteau medications?

A
  • Multiple therapeutic effects
  • Minimum interactions
  • Multiple routes
  • Wide therapeutic window
  • Cost effective
  • Convenient dosing schedule
  • Dose response and favorable ceiling effect
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15
Q

Which drugs do we use for palliative care?

A
  • Morphine
  • Methadone, hydromorphone, oxycodone
  • Lorazepam, alprazolam (has ODT)
  • Haloperidol
  • Atropine drops
  • Dexamethasone
  • Ondansetron ODT
  • Metoclopramide
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16
Q

What is an “intensol”?

A

Highly concentrated liquid form

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17
Q

What treatments do we use for gut wall N/V?

Study These Flashcards
A
  1. H2 antagonist/PPI
  2. Metoclopramide
  3. Ondansetron
18
Q

What are causes of gut wall N/V?

Study These Flashcards
A
  • Gastric irritants
  • Abdominal radiotherapy
  • Intestinal distention
  • Cytotoxic chemo
19
Q

What are causes of area postrema N/V?

Study These Flashcards
A
  • Morphine, digoxin
  • Hypercalcemia/uremia
  • Clonidine
  • Cytotoxic chemo
20
Q

How can we treat area postrema N/V?

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A
  1. Haloperidol, metoclopramide
  2. Step 1 + dexamethasone
    Pamidronate for hypercalcemia
  3. Ondansetron + dexamethasone
21
Q

What are causes of cerebral cortex N/V?

Study These Flashcards
A
  • Fear/anxiety
  • Raised intracranial pressure
  • Hyponatremia
22
Q

How can we treat cerebral cortex N/V?

Study These Flashcards
A
  1. Dexamethasone
  2. Amitriptyline, haloperidol, lorazepam
  3. Limited free water, saline, haloperidol
23
Q

What are causes of vestibular nuclei N/V?

Study These Flashcards
A
  • Movement
  • Vertigo
24
Q

How can we treat vestibular nuclei N/V?

Study These Flashcards
A
  • Diphenhydramine
  • Dimenhydrinate
  • Meclizine or cyclizine
  • Glycopyrrolate
  • Scopolamine
25
What should we give if we hear wheezing?
Ipratropium/Albuterol +/- dexamethasone
26
T/F: Morphine or other opioids should be avoided with dyspnea
FALSE: they can be used in low doses to treat it - reduces shortness of breath
27
How do you treat cough in end of life?
1. Treat underlying cause 2. Promote production (saline +/- mucinex) 3. Suppress cough (morphine, hydrocodone, DXM) 4. Dexamethasone or glycopyrrolate/atropine, NAC with bronchodilator 5. Nebulized lidocaine, gabapentin
28
What are symptoms of EOL anxiety?
- Worry - Tense - Unable to relax
29
What are symptoms of EOL delirium?
- Disorientation - Hallucinating - Aggressive
30
How can we treat anxiety in EOL?
- Non-pharm - Lorazepam, Alprazolam - Buspirone/SSRI (long-term)
31
What can we use to treat delirium in EOL?
- Haloperidol - Haloperidol + Lorazepam - Haloperidol + Midazolam
32
How can we treat constipation in EOL opioid use?
- Senna or bisacodyl + docusate + metoclopramide - Double the dose - Fiber, fluids, docusate if aging or disease induced - Sorbitol, lactulose, PEG - MOM, citrate of mag, bisacodyl sup - Naloxegol - Nuclear enema
33
How can we treat bowel obstruction
- Metoclopramide +/- dexamethasone (if incomplete obstruction) - Glycopyrrolate + morphine + haloperidol - Octreotide + above - PEG tube or stent
34
What should we use if a depressed patient has >4 weeks left?
- Escitalopram - Sertraline - +/- methylphenidate - Amitriptyline or nortriptyline - +/- methylphenidate
35
What should we use if a depressed patient has <2 weeks left?
- Methylphenidate - Ketamine
36
How should we treat anorexia/cachexia in EOL?
1. Treat underlying cause 2. Metoclopramide 3. Dexamethasone <3 months left 4. Mirtazapine/megestrol >3 months left 5. Dronabinol
37
How should we treat insomnia in EOL?
1. Treat underlying cause 2. Trazodone or melatonin 3. Temazepam or zolpidem 4. Haloperidol 5. Mirtazapine or amitriptyline (w/ depression) 6. Increase doses of above 7. Substitute midazolam or high dose lorazepam <7 days
38
How can we treat xerostomia in EOL?
1. Ice chips, gum, lemon drops 2. Saliva substitute 3. Pilocarpine
39
How do we treat death rattle gurgling?
Atropine 1% eye drops Not earlier than end stage terminal time Also glycopyrrolate or scopolamine patch
40
What should we use if intolerable symptoms are causing suffering and we should induce unconsciousness?
- Opioids - Benzodiazepines - Neuroleptics - Barbiturates - Anesthetics - A combination of these agents
41
What are signs that death occurred?
- Heart stops - Breathing stops - Pupils fixed and dilated - Body color pale - Body temperature low - Muscles and sphincters relax until rigor mortis (4-6 hours later) - Urine and stool released - Eyes may remain open - Jaw can fall open - Trickling of fluids may be audible
42
What is a "good death"
- Treated as individual with dignity and respect - Without pain or other symptoms - Familiar surroundings - Company of close family/friends

704 Geriatrics (8 decks)

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