Palliative Care

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Author:
anhpham
ID:
276624
Filename:
Palliative Care
Updated:
2014-06-11 17:02:03
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Palliative Care
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Palliative Care
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  1. Symptoms Encountered in Palliative Care
    —Pain

    • —Nausea and Vomiting
    •      CINV
    •      Generalized N/V

    • —Bowel Issues
    •     Constipation & Bowel Obstruction
    •     Diarrhea

    —Anxiety

    —Depression

    —Delirium

    • —Oral Complications
    •     Xerostomia and Mucositis

    —Dyspnea

    —Death Rattle/Terminal Secretions

    —Insomnia

    —Anorexia/Cachexia
  2. What have we usually seen in last hours of life in palliative care?
    • Dyspnea
    • Secretion
  3. Potential causes of Dyspnea in last hours of life
    Muscle wasting

    Acid/Base disturbance

    Anxiety

    Obstruction
  4. Treatment for Dyspnea in last hours of life
    • Opioids
    •   Act by decreasing respiratory drive and       reducing sensation of breathlessness
    •   2.5-5 mg morphine po every 4 hours in opiate naïve patients

    Benzodiazepines

    Bronchodilator
  5. Treatment for Secretions ("Death Rattle") in last hours of life
    O2?

    Suction

    • Medications
    •    Hyoscyamine 0.125mg  po every 8 hours prn
    •    Scopolamine patch 1-3 patches every 3 days
    •    Glycopyrrolate 0.4mg subcutaneously  every 4-6h prn*
  6. What are 5 advanced directives?
    • —Capacity
    • Able to make sound decisions or not
    • —
    • Surrogate
    • Appointed by physician to make healthcare decisions

    • —MPOA
    • Appointed by patient
    • Gives someone else the authority to make medical decisions for the patient if they are unable to make them for themselves

    • —Living Will
    • Statement of decisions the patient made
  7. What are Neuropsychiatric complications?
    • Anxiety
    • Delirium
    • Depression
  8. Presentation of anxiety
    Agitation, insomnia, restlessness,

    Sweating, tachycardia, hyperventilation,

    Panic disorder, worry, tension
  9. What is anxiety?
    Fear, uncertainty about future
  10. What are 3 types of anxiety in terminal illness?
    • Situational
    • Psychiatric
    • Organic
  11. What are underlying etiologies  of anxiety?
    —Poor pain control

    —Medications

    —Metabolic

    —CV disease

    —CNS disease

    —Arthritis

    • —Thyroid disorders
    • —Co-morbid psychiatric disease

    —Paraneoplastic syndromes

    • —Active/Palliative Therapy
    • (Chemo/Rad)

    —Substance Withdrawal
  12. What are 3 medication induced anxiety?
    • Motor restlessness
    • Withdrawal
    • General
  13. Medication Induced Anxiety?
    Motor Restlessness
    —Drug-induced akathisia

    —Confused with anxiety

    • Drugs commonly implicated
    • Chlorpromazine,
    • haloperidol,
    • metoclopramide,
    • prochlorperazine

    —Management – stop offending drug
  14. Medication Induced Anxiety:
    Withdrawal
    —Medications with physical and/or psychological dependence

    • Common examples:
    • Opioids,
    • benzodizepines,
    • clonidine,
    • steroids,
    • nicotine,
    • sedative-hypnotics,
    • alcohol,
    • anticonvulsants 

    • —Management
    • Taper when appropriate
    • Continue use if not harmful
  15. Management of anxiety
    —Review potential underlying causes

    Counseling, supportive therapy

    • —Pharmacotherapy
    • Primary
    • Benzodiazepine (lorazepam or alprazolam)
    • Secondary for autonomic features
    • Beta-blocker (propanolol, cross BBB)
  16. Management of anxiety
    —Review potential underlying causes

    Counseling, supportive therapy

    • Pharmacotherapy
    • Primary
    • Benzodiazepine (lorazepam- only one studied in terminal illness or alprazolam-commonly used b/c it has a longer half-life)

    • Secondary for autonomic features
    • Beta-blocker (propanolol, cross BBB)
  17. What are some anxiolytics?
    • —Antidepressants
    • —Buspirone
    • Chlorpromazine
    • —Haloperidol
    • —Hydroxyzine
    • Thioridazine
  18. What is delirium?
    Global change in cognition, awareness, acute onset
  19. Presentation of delirium
    Fluctuating level of consciousness

    Cognitive impairment

    Distinguish from dementia, depression, anxiety

    Distinguish hypoactive vs. hyperactive (more common)
  20. What are subtypes of delirium?
    Hyperactive (more common) and hypoactive

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