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37 Cards in this Set
- Front
- Back
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< __% of deaths in the USA are sudden and unexpected.
> __% of deaths occur after one or more long debilitating illnesses |
< 10% of deaths in the USA are sudden and unexpected.
> 90% of deaths occur after one or more long debilitating illnesses |
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Where we die:
Hospitals - ~__% Nursing Homes - ~__% Home - ~__% The street - ~5% |
Where we die:
Hospitals - ~50% Nursing Homes - ~25% Home - ~20% The street - ~5% |
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In 2006 __% of deaths attended by hospice
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In 2006 36% of deaths attended by hospice
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The usual signs of imminent death:
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Decreased responsiveness
Decreased oral intake Cold hands and feet Mottling Periodic respirations with apnea Low BP, low UOP, bradycardia |
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What BP does it take to perfuse the carotid artery
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60mmHg
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What BP does it take to perfuse the radial artery
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90mmHg
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What advance Directives are recognized Ga law?
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The Georgia Advance Directive for Healthcare:
Appoint an agent for HC decisions Specify limits to life sustaining treatment Nominate a Guardian if court needs one Replaced Living Wills and Durable Power of Attorney on July 1, 2007 Ga may recognize ADs from other states |
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Define Palliative Medicine:
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Study and management of patients with active, progressive, advanced disease for whom the focus of care is quality of life. Palliative care focuses on the relief of suffering.
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Define Hospice Care:
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Interdisciplinary palliative care to terminally ill patients, centering on the patient and his or her family, addressing the physical, social, spiritual and emotional dimensions of illness and death
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If a patient in Hospice care gets better, then Medicare won't pay anymore. What percent of Hospice pt "graduate" and get let loose?
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5%
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True or false
pts with metastatic cancer often surviv codes and go home doing well |
False
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T or F
Pts with alzheimer's who cannot swallow do better with artificial tube feeding |
False
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Name the 3 criteria predicting a futile code
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unwitnessed arrest
Initial rhythm NOT V tach or V fib No response for > 10 minutes; |
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name the 3 subtypes of pain defined by quality characteristics
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somatic
visceral neuropathic |
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How do pts describe neuropathic pain?
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burning, shooting, electricity in nerve distribution
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Tx of neuropathic pain
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Opiates
Snticonvulsants - carbamazapine TCA Steroids |
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How do you treat opioid initiation nausea?
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meclazine (sea sickness pill OTC)
metoclopramide (Reglan) |
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Name the one side effect of opioids that does not impromve with continued use
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constipation
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Suffering is different from pain- comment
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suffering results as the whole person reacts to their illness and its complications in the context of their family and community
One can have nocioception without suffering One can suffer without physical injury |
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Step 1 of breaking bad news
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Create a conducive environment
SIT IF AT ALL POSSIBLE Allow adequate time Get the right people there Plan what you will say FIRE A WARNING SHOT confirm medical facts Prioritize |
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Step 2 of breaking bad news
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What does the patient know?
Establish what the patient knows Assess ability to comprehend Reschedule if unprepared |
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Step 3 of breaking bad news
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How much does the patient want to know?
People handle information differently race, ethnicity, culture, religion, socioeconomic status developmental level? cognitive limitations? planners versus worriers |
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Step 4 of breaking bad news
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Sharing the information :
Say it, then stop promote dialogue avoid jargon, euphemisms pause frequently check for understanding use silence, body language Provide hope but do not minimize |
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Step 5 of breaking bad news
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Responding to feelings :
Be prepared for broad range of reactions outburst of strong emotion Have tissues ready Give time to react Do not drop the bomb and run Listen quietly, attentively Acknowledge the Affect Ask patient to verbalize Observe and Verify Use nonverbal communication |
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Step 6 of breaking bad news
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Planning, follow-up :
Plan for the next steps additional information, tests treat symptoms referrals as needed Discuss potential sources of support Give contact information, set next appointment Before leaving, assess: safety of the patient supports at home Repeat news at future visits |
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Why does pt ask the following:
TWO FOLD QUESTION: HOW LONG? WHAT IS THE NATURAL HX OF THIS DISEASE AS MODIFIED BY PC/HC? |
Some patients want to plan
Others are seeking reassurance Ask the pt what they have been told already- what do they know so far- Inquire about reasons for asking “What are you expecting to happen?” “How specific do you want me to be?” “What experiences have you had with: others with same illness? others who have died?” Avoid precise answers hours to days … months to years Average and range Discuss limitations of prognostication and typical patterns of disease Docs over-estimate prognosis (5X) Reassure availability, whatever happens |
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Questions for Clarifying Goals
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WHAT IS YOUR UNDERSTANDING OF THE ILLNESS?
WHAT DO YOU EXPECT TO HAPPEN? THE BEST THE WORST HOW ARE YOU COPING WITH THIS ILLNESS? DO YOU HAVE ANY ADVANCE DIRECTIVES? HAVE OTHER FAMILY MEMBERS DELT WITH A SIMILAR PROBLEM? DO YOU NEED GUIDANCE? Family Pastor/Chaplain Ethics Consult DO YOU THINK ____ IS SUFFERING? IF SO, HOW? IF SHE COULD TELL US RIGHT NOW, WHAT WOULD YOUR MOTHER WANT? |
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Language with unintended consequences
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Do you want us to do everything possible?
Will you agree to discontinue care? It’s time we talk about pulling back I think we should stop aggressive therapy I’m going to make it so he won’t suffer |
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Language to describe the goals of care . . .
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We will focus our efforts on treating your symptoms
Let’s discuss what we can do to fulfill your wish to stay at home We will concentrate on improving the quality of your mother’s life We will focus our efforts on treating your symptoms Let’s discuss what we can do to fulfill your wish to stay at home We will concentrate on improving the quality of your mother’s life |
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Management of neuropathic pain
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Opioids –methadone may have advantages
ACDs – Carbamazepine most effective list TCAs – amitriptyline has the most data Steroids – dexamethasone works well. |
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DOSING FOR CONSTANT PAIN
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Balance analgesic versus adverse effects
Put patient in control as much as possible Opioids: Long acting preparation for baseline Short acting drug for breakthrough Seldom worried about addiction in PC pts |
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TREATING ADVERSE EFFECTS of pain meds
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Opioid nausea is best treated with metoclopramide (reglan)
Sedation gets better with time on steady doses Constipation will continue Docusate alone ineffective Stimulants (Senna) Osmotics (PGE) |
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Why is meperidine not recommended for pain
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poor oral absorption
normeperidine is a toxic metabolite longer half-life (6 hours), no analgesia psychotomimetic adverse effects, myoclonus, seizures if dosing q 3 h for analgesia, normeperidine builds up accumulates with renal failure |
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Why is propoxyphene (Darvocet) not recommend for pain
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no better than placebo
low efficacy at commercially available doses toxic metabolite at high doses |
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The Medicare Hospice benefit requires that two physicians state the pt has ___ months or less to live.
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The Medicare Hospice benefit requires that two physicians state the pt has six months or less to live.
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Georgia has one AD in three parts
NEVER SAY THERES NOTHING LEFT TO DO FIRE THE WARNING SHOT before breaking bad news Acknowledge AFFECT AVOID MEPERIDINE & PROPOXYPHENE |
Georgia has one AD in three parts
NEVER SAY THERES NOTHING LEFT TO DO FIRE THE WARNING SHOT before breaking bad news Acknowledge AFFECT AVOID MEPERIDINE & PROPOXYPHENE |
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Metoclopramide is a great drug for opioid induced nausea
Constipation is a constant side effect of opioids Neuropathic pain must be recognized and treated differently from nocioceptive pain Constant pain requires baseline and breakthrough opioid dosing |
Metoclopramide is a great drug for opioid induced nausea
Constipation is a constant side effect of opioids Neuropathic pain must be recognized and treated differently from nocioceptive pain Constant pain requires baseline and breakthrough opioid dosing |
