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PHM 704- Geriatrics > Palliative Care/Hospice Care > Flashcards

Palliative Care/Hospice Care Flashcards

(48 cards)

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1
Q

Palliative care definition

A

active total care of patients whose disease isn’t responsive to curative treatment

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2
Q

What does palliative care focus on?

A

Focuses on pain control, other symptoms, and psychological, social, and spiritual problems

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3
Q

What should be done with palliative care?

A

Should be provided in conjunction with curative care at the time of diagnosis of a potentially terminal illness

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4
Q

When is palliative care indicated?

A

Palliative care alone may be indicated when attempts at a cure are judged to be futile

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5
Q

What is hospice care?

A

philosophy and program that delivers palliative care

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6
Q

Hospice care team

A

Interdisciplinary team which provides expert medical care, pain management, and emotional and spiritual support expressly tailored to the patient’s wishes (pharmacists are included too!!)

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7
Q

Medicare benefit with hospice

A

terminal illness with a prognosis of ≤6 months as certified by an attending physician and hospice medical director

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8
Q

Hospice care is provided under what types of mayors?

A

Part A
Private/public/government health insurance
Medicaid
Foundations if there is no payor

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9
Q

Palliative care vs. hospice care

A

Palliative care is improving the QoL for those with serious illness; it doesn’t require a terminal diagnosis and doesn’t have to forego curative treatment

Hospice is a subset of palliative care with a timeline (≤6 months or less), it’s more comfort care and you’re not really curing any diseases anymore vs. giving life-sustaining treatment

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10
Q

Fatigue, weakness is manifested by…

A

Decreasing function, hygiene
Inability to move around bed
Inability to lift head off pillow

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11
Q

Cutaneous ischemia is manifested by…

A

Erythema over bony prominences
Skin breakdown, wounds

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12
Q

Decreasing appetite/food intake, wasting is manifested by…

A

Anorexia
Poor intake
Weight loss, muscle and fat, notable in temples

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13
Q

Cardiac dysfunction, renal failure is manifested by…

A

Tachycardia
Hypertension followed by hypotension
Peripheral cooling
Peripheral and central cyanosis (bluish color of extremities)
Mottling of the skin (livedo reticularis)
Venous pooling along dependent skin surfaces
Dark urine
Oliguria, anuria

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14
Q

Decreasing level of consciousness is manifested by…

A

Increasing drowsiness
Difficulty awakening
Unresponsive to verbal or tactile stimuli

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15
Q

Decreasing ability to communicate is manifested by…

A

Difficulty finding words
Monosyllabic words, short sentences
Delayed or inappropriate responses
Verbally unresponsive

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16
Q

Terminal delirium is manifested by…

A

Day-night reversal
Confusion
Agitation, restlessness
Purposeless, repetitious movements
Moaning, groaning

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17
Q

Respiratory dysfunction is manifested by…

A

Change in respiratory rate—increasing first, then slowing
Decreasing tidal volume
Abnormal breathing patterns—apnea, Cheyne-Stokes respirations, agonal breaths

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18
Q

Loss of ability to swallow is manifested by…

A

Dysphagia
Coughing, choking, aspiration
Loss of gag reflex
Buildup of oral and tracheal secretions
Gurgling (“death rattle”)

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19
Q

Loss of sphincter control is manifested by…

A

Incontinence of urine or bowels
Maceration of skin
Perineal candidiasis

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20
Q

Pain is manifested by…

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A

Facial grimacing
Moaning
Tension in forehead, between eyebrows

21
Q

Loss of ability to close eyes is manifested by…

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A

Eyelids not closed
Whites of eyes showing (with or without pupils visible)

22
Q

Rare, unexpected events

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A

Bursts of energy just before death occurs, the “golden glow”
Aspiration, asphyxiation

23
Q

Portmanteau properties

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A

Multiple therapeutic effects
Minimal DDIs
Multiple routes of administration
Wide therapeutic window
Cost-effective
Convenient dosing schedule
Dose response and favorable ceiling effect

24
Q

Intensol products are what?

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A

Concentrated liquid formulations of drugs

25
Examples of Intensol products
Roxanol (morphine liquid) Atropine 1% Haloperidol 2mg/ml Lorazepam liquid 2mg/ml
26
N/V treatment: gut wall
Step 1: H2RA (Cimetidine, Famotidine, Nizatidine, Ranitidine), PPI (Omeprazole, Esomeprazole, Pantoprazole, Lansoprazole) Step 2: metoclopramide Step 3: ondansetron
27
N/V treatment: area postrema
Step 1: haloperidol, metoclopramide Step 2: step 1 meds + dexamethasone Pamidronate for hypercalcemia Step 3: ondansetron + dexamethasone
28
N/V treatment: cerebral cortex
Step 1: dexamethasone Step 2: amitriptyline, haloperidol, lorazepam Step 3: limited free water +/- 3% saline +/- haloperidol
29
N/V treatment: vestibular nuclei
Step 1: diphenhydramine, dimenhydrinate Step 2: meclizine, cyclizine Step 3: glycopyrrolate, scopolamine
30
Dyspnea treatment: step 1
Treat underlying cause Obstruction by tumor: radiotherapy, steroids Carcinomatous lymphangitis: steroids Bronchospasm: bronchodilators Cardiac failure: diuretics, etc. Chest infections: ABX +/- physiotherapy Pleural effusions: Pleural aspiration Gross ascites: Abd paracentesis (diuretics) Anemia: Transfusion (Hg < 8g/dl)
31
Dyspnea treatment: step 2
DuoNeb +/- dexamethasone Dyspnea, DuoNeb- both start with D
32
Dyspnea treatment: step 3
morphine/any opioid +/- dexamethasone
33
Dyspnea treatment: step 4
morphine AND chlorpromazine, diazepam, OR midazolam
34
Cough treatment
Step 1: treat underlying causes Step 2: promote production → nebulized saline and/or guaifenesin Step 3: suppress cough → morphine, hydrocodone, dextromethorphan Step 4: dexamethasone or glycopyrrolate/atropine, NAC Step 5: nebulized lidocaine, gabapentin, others
35
Anxiety treatment
Step 1: non-pharm care Step 2: short-term care: lorazepam, alprazolam, amitriptyline with depression Step 3: long-term care: buspirone, SSRI (escitalopram, sertraline), mirtazapine with depression/insomnia/anorexia
36
Delirium treatment
Step 1: haloperidol Step 2: haloperidol +/- lorazepam (sedation required) Step 3: haloperidol + midazolam (Versed) or chlorpromazine (Thorazine), agitation in terminal stages
37
Constipation prevention
Step 1: opioid induced → senna or bisacodyl +/- docusate +/- metoclopramide Aging or disease-induced → fiber, fluids, docusate Step 2: sorbitol, lactulose, MiraLax Step 3: MOM, magnesium citrate, bisacodyl suppository, peripherally-acting mu-opioid receptor antagonists
38
Acute constipation treatment
Stimulant laxative: bisacodyl or senna Double dose Osmotic laxative → sorbitol MOM Bisacodyl suppository, then enema in 2 hours; repeat QD X3 days Peripherally-acting mu-opioid receptor antagonists Naloxegol, methylnaltrexone Nuclear enema
39
Bowel obstruction treatment
Step 1: metoclopramide +/- dexamethasone; not used if complete obstruction Step 2: glycopyrrolate +/- morphine +/- haloperidol Step 3: octreotide +/- the above agents Step 4: PEG-tube or stent
40
Asthenia treatment
Step 1: energy conserving measures Step 2: methylphenidate or dexamethasone
41
Depression treatment
Step 1 (>4 weeks survival): escitalopram, sertraline, +/- methylphenidate until the SSRI becomes effective Step 2 (>4 weeks survival c/ other signs/symptoms): amitriptyline or nortriptyline +/- methylphenidate until the TCA becomes effective Step 3: methylphenidate (<4 weeks survival), ketamine
42
Anorexia-cachexia treatment
Step 1: treat underlying causes Anxiety, depression, N/V, stomatitis, constipation, dysphagia, PAIN Step 2: early satiety, dysmotility, gastroparesis → metoclopramide Step 3: appetite loss, weight loss Survival <3 months: dexamethasone Survival >3 months: mirtazapine, megestrol Step 4: dronabinol
43
Insomnia treatment: step 1
Step 1: treat underlying causes Wakeful stimuli, daytime sleep, normal aging (you sleep less when you get older) Anxiety, depression, fear of dying Pain, dyspnea, N/V, incontinence, diarrhea, pruritus, restless legs Diuretics, steroids, caffeine, sympathomimetics, night sedative withdrawal, BZDs, alcohol
44
Insomnia treatment: step 2
Difficulty initiating sleep: trazodone, melatonin (sundowning/dementia), temazepam or zolpidem (bed-bound) Difficulty staying asleep (disturbing dreams): haloperidol, mirtazapine or amitriptyline in concomitant depression
45
Insomnia treatment: step 3
Titrate doses of meds in step 2, combinations of the drugs in step 2, midazolam/Versed for <7 days or high-dose lorazepam
46
Xerostomia treatment
Step 1: ice chips, gum, lemon drops Step 2: saliva substitute Step 3: pilocarpine 5mg PO BID
47
Terminal secretions treatment
SL atropine 1% eye drops q2-3h PRN!!
48
Palliative sedation treatment
opioids, BZDs, neuroleptics, barbiturates, anesthetics, or a combination of these agents

PHM 704- Geriatrics (15 decks)

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