Palliative Care

Question 1

Define palliative care

Answer 1

Patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering

Addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information, and choice

Question 2

What is the difference between hospice and palliative care?

Answer 2

Hospice is usually reserved for life expectancy less than 6 months, you’re not seeking curative treatment

Palliative care has no time restrictions and can occur at any stage of illness (ie Upon diagnosis of CHF/cancer/CKD, etc) and you can still seek curative treatment.

Both focus on pain and symptom management

Question 3

How is the old approach different from the new approach?

Answer 3

Old approach: Did life prolonging care, then at 6 months life expectancy, switched to hospice, then the pt died.

New approach: Have palliative care IN ADDITION TO life prolonging care, switch to hospice at 6 months life expectancy, and then after death also provide bereavement services (check on family members, see how they’re doing/suggest grief groups, etc)

Question 4

Describe medicare hospice benefit

Answer 4

Payment is calculated per patient per day; all therapies are covered under the daily reimbursement (including medications)

Cost-effective symptom management is a must, and pharmacy costs are #2 expense for hospices, they are also the largest yearly increase for hospices

Question 5

Blood and blood-forming agents: What medications fall under this class? When do we consider them to have limited benefit? Explain

Answer 5

Apirin

Consideration: They’re for primary prevention only

Explanation: They have little short or intermediate term risk of stopping. Drugs for primary prevention generally have no place in end-of-life pts since the time-to-benefit usually exceeds life expectancy

Question 6

Dyslipidemia agents: What medications fall under this class? When do we consider them to have limited benefit? Explain

Answer 6

Statins, fibrates, ezetimibe

Considerations for limited benefit: All indications

Explanation: Little short or intermediate term risk of stopping

Question 7

Anti-HTN agents: What medications fall under this class? When do we consider them to have limited benefit? Explain

Answer 7

ACEi, BB’s, CCB’s, Sartans, Thiazide diuretics

Considerations: If sole use is to reduce mild-mod HTN for secondary prveention of CV events or as management of stable CAD

Explanation: Ongoing therapy unnecessary in most shorted life expectancy

Question 8

Musculoskeletal system: What medications fall under this class? When do we consider them to have limited benefit? Explain

Answer 8

Osteoporosis, Bisphosphonates, Raloxifene, Strontium, Denosumab

Considerations: Except if used for treatment of hypercalcemia secondary to bone metasteses

Explanation: Little short or intermediate term risk of stopping

Question 9

Alimentary tract and metabolism: What medications fall under this class? When do we consider them to have limited benefit? Explain

Answer 9

Peptic ulcer prophylaxis: PPI’s, H2RA’s

Considerations: Lack of any medical history of GI bleeding, peptic ulcer, gastritis, GERD, or concomitant anti-inflammatory agents

Explanation: Ongoing therapy unnecessary in most shortened life expectancy

Question 10

Hypolycemics: What medications fall under this class? When do we consider them to have limited benefit? Explain

Answer 10

Medications: Oral meds (metformin, sulfonylureas, etc)

Conditions: If sole use is to reduce mild hyperglycemia for secondary prevention of diabetic associated events

Explanation: Potential short term complications outweigh the benefits

Question 11

Vitamins/Minerals: What medications fall under this class? When do we consider them to have limited benefit? Explain

Answer 11

Medications: Various agents

Considerations: If not indicated to treat low plasma concentration

Explanation: No evidence for effectiveness

Question 12

What are the advantages of IV administration? Cautions?

Answer 12

Advantages: Widely used and accepted by clinicians/patients. Excellent choice for those with permanent IV access, generalized edema, coagulation disorders

Cautions: Limited availability in home/nursing home settings, generally requires a higher level of nursing involvement/training/education, and there’s risk of infection

Question 13

What are the advantages of enteral administration? Cautions?

Answer 13

Advantages: Many drugs compatible with this route

Cautions: Frequent medication efforts (crushing long acting formulations, for example), failure to flush before and after administering medication (can clog tube). Can only use IR products, with some exceptions.

Note: She said she doesn’t like this option

Question 14

What are the advantages of transdermal administration? Cautions?

Answer 14

Advantages: Ease of admin, extended duration of action, good patient compliance

Caution: Local irritation

Notes: Fentanyl patch should only be used in those with stable pain, and patch adhesiveness is key for effectiveness

Question 15

What are the advantages of sublingual administration? Cautions?

Answer 15

Advantages: Simplicity, rapid onset for highly lipophilic drugs

Disadvantages: Hydrophilic drugs poorly absorbed, bitter taste and burning sensation possible

Question 16

What are the advantages of buccal administration? Cautions?

Answer 16

Advantages: Simplicity, rapid onset for highly lipophilic drugs, formulations well studied/safety data readily available

Caution: Current fentanyl buccal products intended for breakthrough cancer patients and in opioid tolerant patients, high cost

Question 17

What are the advantages of rectal administration? Cautions?

Answer 17

Advantages: Simplicity, useful in pts with n/v/Gi abstruction/malabsorption

Caution: Avoid in pts with impaction, constipation, diarrhea; avoid in pts with hemorrhoids, fissures, or lesions of anus/rectum; avoid in pts with neutropenia or thrombocytopenia; not useful in pts or caregivers unwilling to accept or administer

Question 18

What are the advantages of subq administration? Cautions?

Answer 18

Advantages: Relative potency is equal to IV route; availability of SC route is virtually unlimited; less frequent and less severe infections compared to IV; infusion needle can remain in place for up to one week; eliminates need for multiple injections

Cautions: Local complications rare but can occur; infusion rates are a limiting factor (max 5ml/hr)

Note: This is her fav

Question 19

What route of admin do we not use for medications in palliative care? Why?

Answer 19

IM bc it’s painful and they’re already in pain, absorption is variable

Question 20

Which route of admin is the standard of care for sx management of oral/rectal route not viable and frequent dosing is anticipated?

Why?

Answer 20

SubQ

All 4 horsemen can be given via SubQ route

Question 21

Describe subQ administration

Answer 21

25 or 27 gauge butterfly needle
Upper arm, shoulder, abdomin, thigh
(Deltois)

Question 22

What are the 4 essential drugs needed for quality of care in the dying?

Answer 22

An opioid
A bdz
A neuroleptic
An anti-muscarinic

Question 23

What are the four horsemen of palliative care? What are they used for?

Answer 23

Lorazepam (anxiety, agitation, n/v, dyspnea, insomina, seizures)

Haloperidol (agitation, anxiety, refractory n/v, delirium, hiccups)

Dexamethasone (pain, decreased appetite, fatigue, n/v, dyspnea)

Opioid analgesic (pain, dyspnea, cough)

Question 24

What are the indications for lorazepam? Starting dose? PO:IV:SC conversion? Admin schedule?

Answer 24

Indications: anxiety, insomnia, dyspnea, seizures, refractory n/v

Typical PO dose: 0.5-1 mg/dose (lower dose for elderly - 0.25 mg) (Seizures: 2-4 mg IVP/SQ q10 min prn)

1:1:1

q4h prn (often reduced as terminal symptoms approach, if needed: q1-2hr prn)

Question 25

What side effects/concerns are there with lorazepam?

Answer 25

``` Somnolence Paradoxical reactions (especially in elderly) ```

Question 26

Why is Lorazepam the preferred BDZ?

Answer 26

- Other BDZs not routinely used subQ | - Does not require renal/hepatic adjustment (unless IV formulation contains propylene glycol)

Question 27

What are the indications for haloperidol? Typical PO starting dose? PO:IV:SC conversion? Typical admin schedule?

Answer 27

Indications: Agitation, sun-downing, terminal delirium, hiccups Dose: 0.5-1 mg/dose (typically inc in 0.5 mg increments prn based on effects) PO:IV:SC is 1:1:1 (some sources say 2:1:1) q3-4h prn (schedule in evening for sundowning)

Question 28

Side effects/concerns with Haloperidol?

Answer 28

Risk of movement disorders and cardiac side effects at high doses (incidence is very low with appropriate dosing) Somnolence

Question 29

Why is Haloperidol different from the other 3 horsemen?

Answer 29

It has to have its own site IV/SC or given separately with adequate line flush; it is incompatible with the other 3 horsemen

Question 30

What are the indications, dosing, conversion, and admin schedule for Dexamethasone?

Answer 30

Indications: Bone pain and metastases, Brain mets, low appetite, low energy; nausea/vomiting, spinal cord compression Po dosing varies: General pain/mood/appetite: 2-8 mg/day Spinal cord compression, brain metastases: 12-16 mg/day divided 1:1:1 1-2x per day for daily doses of 4-8 mg q6h for higher doses

Question 31

What are the side effects/concerns with Dexamethasone?

Answer 31

``` Insomnia (avoid PRN dosing if possible) Increased blood sugar Steroid rage (rare) ```

Question 32

What other notes were included for dexamethasone?

Answer 32

Max IV push was 4mg/dose at some facilities; higher doses must be given IVPB Blood glucose NOT routinely monitored in the palliative care setting (unless it's in the 400's or consistently above 300)

Question 33

What are some possible causes of dyspnea in end of life?

Answer 33

Fluid overload Urinary/fecal retention Oxygen detachment

Question 34

What are some non-pharm measures for dyspnea?

Answer 34

Sit pt up, increase air movement with fan/window, utilize relaxation techniques

Question 35

What are some pharm treatments for dyspnea in end of life?

Answer 35

Opioids are first line (usually responsive at low doses UNLESS pt is opioid tolerant; endo/exogenous opiods likely modulate perception of dyspnea) Oxygen: Often but not always helpful (NC better than mask); no reason to exceed 4-6 mL/min via NC in actively dying pt Nebulized agents: Opioids, lidocaine, furosemide Others: Antitussives, anticholinergics, anxiolytics

Question 36

How do you treat mild dyspnea?

Answer 36

Supplemental oxygen IF hypoxic/dyspneic Systemic opioids (oral or parenteral)

Question 37

How do you treat moderate dyspnea?

Answer 37

BDZs for anxiety If opioid naive: Morphine (or eq) 2.5-5 mg PO q3h prn; IVP/SC if po not reliable or available If on opioids already: Inc regular dose by 25%, breakthrough dose should be 10% of total regular dose; parenteral doses q1h prn

Question 38

How do you treat severe dyspnea?

Answer 38

Attend to meaning of symptoms (find out cause) Alternate BDZ and opioid Opioid naive: Give parenteral bolus morphine 2mg (or equiv); if tolerant, repeat every 3 hours. Monitor respiratory status CLOSELY. Start regular dose of an immediate release opioid, guided by bolus doses used Already on opioids: Sane as above but using IVP/SC bolus = 10% of the regular, 24 hr dose. Inc regular opioid dose, guided by bolus dosing.

Question 39

How to treat terminal secretions non-pharmacologically?

Answer 39

Position patient on their side/semi-prone position to facilitate postural drainage Oropharyngeal suctioning often disturbing to patient, family; fluids may often be beyond reach of catheter Reduce fluid intake (tube feeds, IV meds depending on indication, IV fluids)

Question 40

How to treat terminal secretions pharmacologically?

Answer 40

Standard of care is muscarinic receptor blockers (aka anticholinergic agents): Scopolamine patches (1 mg/72h); atropine 1% opthalmic drops given SL!!!, hyoscyamine available as IR, SA, ODT, po soln (preferred) All agents may cause variable degrees of blurred vision, sedation, confusion, delirium, restlessness, hallucinations, palpitations, constipation, urinary retention Side effects differ based on drug's ability to cross the blood brain barrier

Question 41

How is treating pain in palliative care different from non-terminally ill?

Answer 41

Terminally ill often need long acting and short acting combo (NTI usually only need short acting) Admin is usually q2-3h (NTI q4-6h) IV/SC push opioid dosing usually q1-2h (NTI q4h) Common admin route usually oral/IV but also subQ, rectal, etc. (NTI mostly oral/IV) PCA usually just continuous infusion (NTI can have regular PCA)

Question 42

What is her stance on fentanyl patches?

Answer 42

They're FINE on non-opoid tolerant patients as long as they're terminally ill...still wouldn't use them first line in non-cancer pts.

Question 43

JC is a 56 year old female with PMH of breast cancer with bone metastases (lumbar spine), chronic kidney disease, hypertension, coronary artery disease, and hypothyroidism who presents with complaints of reduced appetite, dysphagia, low energy, and worsening low back pain. JC is admitted to palliative care. Which of the following is the BEST non-opioid adjuvant to add for palliation of this patient’s pain syndrome and symptoms reported at admission? A: Ibuprofen 600 mg three times daily with meals for bone pain B: Naproxen 500 mg twice daily with meals for bone pain C: Morphine SA 15 mg every 12 hours for bone pain D: Dexamethasone 4 mg every morning with breakfast for bone pain

Answer 43

D: Dexamethasone 4 mg every morning with breakfast for bone pain