Palliative Care

Front 1

True or False: palliative care seeks to eliminate or cure a condtions

Back 1

false

Front 2

Which (palliative care / hospice) allows for more liberal use and why?

Back 2

Palliative- because hospice is a medicare benefit and has limitations

Front 3

How does hospice and palliative care differ for the following?

- Life expectancy

- DNR/advanced directives

-beyond point of active therapies

Back 3

- hospice = less than 6 months; palliative = no time limits

- hospice= DNR required; palliative = advanced directives encouraged

-hospice = chemo/radiation/dialysis/surgery; Palliatve = may include active therapies

Front 4

"On Death and Dying" Identified 5 stages of emotion that affect dying patients- what are they?

Back 4

Denial, Anger, Bargaining, Depression, Acceptance

"DABDA"

Can start at any one of these and change between stages at anytime.

Front 5

True or False: Palliative care generally relies on cutting edge, experimental drug treatment regimens?

Back 5

False: relies on evidence-based medicine!

Front 6

SubQ opioids are placed in the _____ region, anterior ____ wall, or ___ wall

- Change site every __ to __ days

- Rate of admin: __ to __ ml/hr with max of ___ ml/hr

- which meds are generally used

Back 6

- subclavicular; anterior chest wall; abdominal wall

- change every 3-7 days

-1-2 ml/hr with max of 10ml/hr

- use: morphine, hydromorphone, or fentanyl

Front 7

Sublingual Opioids:
- morphine concentration: ___ mg/mL
- oxycodone concentration: ___ mg/mL

- administer how?

Back 7

- morphine 20 mg/mL
- oxycodone 20 mg/mL

- give a few drops at a time to allow for absorption

Front 8

Transdermal Opioids:

- only ____ agent not give PO

- may cause less ___ and ___ compared to PO morphine

Back 8

- only long acting not give PO

- less constipation and sedation

Front 9

Rectal Opioids:

-Suppositories use:

- CR tablets: can use ___ or ___ and have to place in ____

Back 9

- use morphine, hydromorphone, APAP; can compound others

- use morphine CR or oxycodone CR; place in gel capsule

Front 10

Vomit Center receives input from:

- GI tract: which neurotransmitters?

- Chemoreceptor Trigger Zone : which NTs?

- Vestibular apparatus: Which NTs?

- Cerebral Cortex

Back 10

- GI: 5HT, ACh, Histamine, Substance P

- CTZ: dopamine, 5HT

- Vestibular: Histamine, ACh

Front 11

Hypercalcemia can be a common cause of ___ and ____ and is a complication of ___?

Back 11

- nausea and vomiting

- bone metastases

Front 12

Meds used for N/V: name the adverse effects of each:

- Promethazine (phenergan)

- Ondansetron (Zofran)

- Metoclopramide (Reglan)

- Lorazepam (Ativan)

- Dexamethasone (Decadron)

Back 12

- promethazine: Sedation, dry mouth, blurred vision, dizziness

- ondansetron: HA, fatigue, constipation, drowsiness

- metoclopramide: drowsiness, fatigue, diarrhea

- Lorazepam: sedation, respiratory depression, dizziness

- DXM: nausea, HTN, fluid retention, hyperglycemia

Front 13

Definitions:

- Anorexia:

- Cachexia:

- Asthenia:

- Consider ____ for pts unable to swallow

Back 13

Anorexia: diminished appetite

Cachexia: physical wasting, weight loss (not just result of reduced food intake)

- Asthenia: weakness and fatigue

- consider feeding tube

Front 14

Treatment for anorexia/cachexia:

- _____ has no overall weight gain and not for long term use

- ____: can use longer than steroids but can increase risk of VTE

- ____: causes drowsiness, fatigue, diarrhea

- ____: inhibits endorphins

- ____: can cause somnolence, dry mouth, constipation but can lead to 7% or more weight gain

Back 14

- Dexamethasone

- Megestrol

- Metoclopramide

- Dronabinol

- Mirtazipine

Front 15

True or false: fluid replacement is a large part of the dying process

Fluids can be given via which route if needed?

- Can add ____ to the infusion at a rate of ____ and works by ___

Back 15

False!

- SubQ

- hyaluronidase; 60 ml/hr; breaks down barrier btw tissue and skin to allow more fluids to be given

Front 16

For constipation, what type of laxative should be avoided and why?

Back 16

Fiber- can cause fecal impaction and obstruction

- especially in patients with inadequate fluid intake/dehydration

Front 17

True or false: both hypercalcemia and hyperkalemia cause constipation

Back 17

False; hypercalcemia does but hypOkalemia does, not hyperK

Front 18

Constipation Treatment
- if no opioids: _____ PO BID
- if opioids: _____ PO BID

- add ____ or ____ if no BM >24 hrs

- add ___ or ___ if no BM in next 12 hrs

-If opioids induced: ______ weight based dose ____ PRN

Back 18

- no opioids: Docusate sodium 100 mg PO BID
- opioids: Docusate sodium/sennosides PO BID

- no BM: MOM 30-60 ml PO daily OR bisacodyl 10 mg PO/PR daily

- Mag Citrate 8oz PO or Fleet enema

- opioid induced: methylnaltrexone dosed QOD prn

Front 19

Causes of delirium:

D:
E:
L:
I:
R:
U:
M:

Back 19

D: drugs
E: electrolyte or glucose abnormalities
L: liver failure (NH3 build up)
I: Ischemia
R: Renal failure
I: impaction of stool
U: urinary tract or other infection
M: metastasis to brain

Front 20

Name some treatment for Agitation/Delirium:

- ____ until sx resolve; dose ever __ to __ hrs

- Risperidone q ___ hrs

- _____ qd

- Qeietapine q___hrs

- can add ___ to above but never given alone

Back 20

- halperidol q 6-8 h

- risperidone q 12h

- olanzapine QD

- quetiapine Q 12h

- benzodiazepine

Front 21

Anxiety Tx:

- Short acting Benzos

- Longer acting Benzos

- Non-sedating neuroleptic

Back 21

- Short: alprazolam, lorazepam (can be given SL)

- Longer: clonazepam, diazepam

- Neuroleptic: haloperidol

Front 22

Complaints of dyspnea:

- trial of oxygen __ - __ L/min, reassess q__hrs

-Opioids: ___ given IV, PO, SQ

- No relief?

Back 22

- 2-6 L/min; Q2hrs

-morphine: IV/SQ = 3mg; PO = 10 mg

- lorazepam 0.5 mg PO/SL/IV q4h PRN

Front 23

Dyspnea: Bronchospasm treatment

- ___ MDI or nebulized

- if no relief?

- no relief with that?

Back 23

- albuterol

- no relief: Ipratropium MDI or nebulized

- opioids

Front 24

Dyspnea: treatment for Mild CHF with respiratory distress:

- give ____ and monitor for imporvement

- opioids

Back 24

- furosemide or bumetanide

- monitor for diuresis, 02 sat, dyspnea

Front 25

Nonpharm treatment for dyspnea:

Back 25

- pursed-lip breathing
- fan
- repositioning

Front 26

Nebulized Opioids:

- FDA approved?

- major benefit compared to other routes?

- what types of formulations should be used?

- place opioid in ___

- can use which ones?

Back 26

- Nope!

- Nope!

- preservative free injectable solution

- 2 mL NS

- Morphine, hydromorphone, fentanyl

Front 27

Xerostomia treatment

1.
2.
3.

Back 27

1. mouth swabbing
2. sialogogues
3. artificial saliva

Front 28

Secretions Treatment:

- position patient on ___ or ___

- is suction always effective?

- reduce ___

Back 28

- side or semi-prone

- nope, can be disturbing to pt

- fluid intake

Front 29

Secretion Treatment:

Drugs:
1.
2.
3.
4.

Back 29

1. Scoplamine
2. hyosyamine
3. glycopyrrolate
4. atropine

"SHAG"

When you SHAG there's secretions

Front 30

Advance Directives: legal documents that allow patients to make ____ wishes know if unable to ____

- take effect only when:

Back 30

- end of life; communicate

- only when patient cannot communicate and not able to consciously make medical decisions
(if they're not end stage they don't apply)

Front 31

Last sense to be lost during the dying process?

Back 31

Hearing