1255 End of life

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What are four fears about death?

1. pain
2. physical and financial burden
3. abandonment = by healthcare when nothing else can be done
4. family responsibilitys

what is a good death?

around family, no pain

What are six components of good death?

1. pain and symptom management
2. clear decision making = informed decisions
3. preparation for death
4. completion (ex. faith issues, life review, resolving conflicts, saying good bye)
5. contributing to others
6. affirmation of whole person

What are five barriers to quality care at the end of life?

1. failure to acnowledge limits of medicine = curative treatment that prolong dying (life support, medicines)
2. lack of training for healthcare providers (pain mgt)
3. poor understanding of hospice / palliative care
4. Rules & regulations = controlled substances (medical marijuana)
5. denial of death

What is Palliative care?
(Philosophy of care)

- taking care of the whole person, body/mind/spirit
- goal is to give patients w/life threatening illnesses the best quality of life they can have by the aggressive management of symptoms (absence of suffering)
- Not an insurance benefit, paid by fee-for-service or philanthropy or direct hospital support

- Interdisciplinary approach to identify and treat physical, psychological, spiritual and practical burdens of illness
- Can be used in any setting, with or without life prolonging treatment (surgery, radiation, etc)

What is Hospice?

- currently a service delivery system
- Provide palliative care for patients with limited life expectancy (prognosis of months usually 6 or less)
- Support patient and family through dying process
- Covered by Medicare, must sign off on Part A (hospital benefits) to switch to hospice benefits (can switch back)
- Originally a way station on journey to the Holy Land in the Middle Ages

What are nine Hospice benefits?

1. Interdisciplinary care = social worker/RN/MD
2. medical supplies = w/c, O2
3. drugs for pain and symptom relief
4. short term inpatient & respite care = let caregivers take a break
5. Homemaker/home health aide
6. Counseling
7. Spiritual care
8. Volunteer services
9. Bereavement services

Quality Care at the end of life addresses what four dimensions?


physical dimension (7)
(as it pertains to care/quality of life at end of life)

1. Functional Ability ↓
2. Strength/Fatigue ↓
3. Sleep & Rest
4. Nausea ↑
5. Appetite ↓ (things shutting down)
6. Constipation (pain meds)
7. Pain

psychological dimension (7)
(as it pertains to care/quality of life at end of life)

1. Anxiety
2. Depression (fear of dying)
3. Enjoyment/Leisure
4. Pain Distress
5. Happiness (quality of life)
6. Fear
7. Cognition/Attention

social dimension (5)
(as it pertains to care/quality drive at end of life)

1. Financial Burden
2. Caregiver Burden
3. Roles and Relationships
4. Affection/Sexual Function ↓
5. Appearance ↓

spiritual dimension (5)
(as it pertains to care at end of life)

1. Hope
2. Suffering
3. Meaning of Pain = whatever person says it is
4. Religiosity
5. Transcendence

What is current status of pain (7)

1. Cancer patients at EOL - 54% have pain
2. AIDS with prognosis < 6 months - intense pain
3. Less research conducted than in other chronic illnesses
4. Inadequate pain relief hastens death
5. pain relief is essential at EOL
6. 1/3 of cancer patients have pain
7. if pain is not under control then ↓ quality of life or will to live

What are three Barriers to Pain Relief

1. Professionals
2. Health care systems
3. Patients/families

What are six Barriers to Pain Relief by professionals?

1. inadequate knowledge
2. poor assessment skills
3. concern about controlled substance regulation/abuse
4. fear of patient addiction
5. concern about adverse effects of drugs
6. concern about patient tolerance

What are two Barriers to Pain Relief by health care systems?

1. inadequate reimbursement (cannot afford it)
2. difficulty obtaining needed medication (high crime areas)

What are four Barriers to Pain Relief by Patients/families?

1. some of the same myths as HCP, fear addiction, death
2. unhappy with side effects (feel loopy, fuzzy thinking, constipation)
3. don't want to complain because good patients get better care
4. fear it won't help in the future when they really need it = fear of tolerance

Pain History acronym PAINE

P place = assess area
A amount = 0-10, faces
I intensifiers = what makes it worse? (movement, etc.)
N nullifiers = what makes it better? (alt therapy, drug)
E effects = impact on life

PLACE includes what information
(regards to pain history)

-location, always examine the area: trauma, breakdown,structure changes, palpate for tenderness,ausculate for abnormal breath or bowel sounds,percuss for fluid or gas
-"all over" frequently suggests existential distress (depression, fear, anxiety, hopelessness)

AMOUNT includes what information
(regards to pain history)

scale of 0 to 10 or mild, moderate, severe

INTENSIFIERS includes what information
(regards to pain history)

what makes the pain worse

NULLIFIERS includes what information
(regards to pain history)

what makes the pain feel better

EFFECTS includes what information
(regards to pain history)

impact on life
meaning of pain (eg. punishment)
cultural beliefs

reassess for pain includes? (5)

1. patient should report any changes in pain
2. how much relief and how long
3. look for visible changes: routine part of assessment, the fifth vital sign
4. pain diary may help with chronic pain management
5. HR, BP, RR

Two Common Syndromes at the End of Life

1. Somatic: arthritis, bone metastasis, oral mucosal infections, skin lesions
2. Visceral: tumors in pancreas or spleen, end stage cardiac or liver disease, ascites, abdominal cramping from AIDS associated diarrhea

what is Nociceptive?

adj. for nociceptor :A free nerve ending that is a receptor for painful stimuli
- pain related to the skin, musculoskeletal structures, or body organs

Common Syndromes at the End of Life

-post herpeticneuropathy
-AIDS associated peripheral neuropathy
-chemo associated peripheral neuropathy
-spinal cord injury
-stroke in thalamus
-Pain is frequently chronic with episodes of acute/breakthrough pain

what is neuropathy?

1. Any disease of the nerves.
2 ↓ sensation, tingling, burning, ↓ fine motor skills

What are Five Chronic Pain Management components?

1. Oral preferred
2. ATC dosing
3. Adjust according to patient response
4. Breakthrough pain (Use immediate release form of drug)
5. Add adjuvants and non-pharmacological approaches (ex. tylenol/motrin)

Opioids work by

- Blocking the neurotransmitters that process the pain
- the different drugs work on different pain receptors

What are seven examples of opioids?


All people do not have the same pain receptors therefore some drugs do not work for some people
(They do not have a receptor)


this medication helps with post operative shivers

meperidine (Demerol)

these three opioids are not used for chronic pain?

meperidine (Demerol)
propoxyphene (Darvocet)
mixed agonist-antagonists (Stadol, Talwin, Nubain)

What are six Adverse Effects of opioids?

1. Respiratory depression = rare, 6-8 RR, unarousable
2. Constipation = ↓ peristalsis, ↑ H20 reabsorption
3. Sedation = usually initially, maybe from exhaustion
4. Urinary retention
5. Nausea/vomiting = tx with antienemitics
6. Pruritus

What are s/s of respiratory depression caused by opioids?

actually rare
RR 6-8 AND low PO2

What is the treatment of respiratory depression caused by opioids?

small doses of naloxone (0.4mg in 10 ml give 1ml,repeat as needed)

What is the cause of constipation from opioids?

decreased peristalsis and increased water resorption
slow moving dry feces

What is the treatment of constipation from opioids?

laxative/softener combo (senna)

Sedation caused from opioids occurs usually just initially, frequently due to exhaustion


Urinary retention caused from opioids occurs in opioid naïve individuals,disappears in a few days


What is the treatment of nausea and vomiting caused by opioids? (3)

administer antiemetic
switch drugs
patient tolerance will develop

How is pruritis caused by opioids & what is the treatment?

-from spinal delivery method
-tx with antihistamines

What are adjuvants?

Drugs that enhance the effect of opioids &/or decrease the side effects of opioids

What are five types of adjuvants used with opioids?

1. Antidepressants (↑ dose if for depression, ↓ if adjuvant)
2. Anticonvulsants = older agents have significant adverse effects) - they attach to pain receptor
3. Corticosteroids
4. Local Anesthetics
5. Cancer Therapies

What are three types antidepressants used as adjuvants

1. Tricyclics
2. Atypicals
3. SSRIs

What are Tricyclics for opioid adjuvants used for & what are the s/e? (4)

1. useful in neuropathic pain
2. pain dose lower than depression dose
3. give at night can sedate
4. SE: dry mouth and constipation

examples of tricyclics (antidepressants)

nortriptyline (Pamelor)

What are atypicals for opioid adjuvants used for?

useful in low level neuropathic pain and fibromyalgia

What are two examples of atypicals (antidepressants)?

-bupropion (Welbutrin)
-duloxetine (Cymbalta)

SSRI's for opioid adjuvants will?

give a feeling of well being

what are two examples of SSRI's (antidepressants)?

fluoxetine (Prozac)
sertraline (Zoloft)

What are five Anticonvulsants used as adjuvants?

Gabapentin (Neurontin)
Pregabalin (Lyrica)

What is Gabapentin (Neurontin) dose? (3)

-100 mg po TID and titrate gradually
-900 to 3600mg per day
-start low, patient may show sedation and fatigue at first

What is the Pregabalin (Lyrica) dose? (3)

-50 mg TID x 1 wk then 100 mg TID
-can titrate faster
-more expensive so some insurances require failure on other pain control methods first

Corticosteroid adjuvants are used for two things?

- Neuropathic, bone and visceral pain
- used as short term treatment, bridge to other therapy and end of life treatment

Corticosteroid adjuvants will? (2)

- Reduce edema surrounding many types of tissues
- Increases energy and appetite

Corticosteroid adjuvants side effects (5)

- Long term side effect muscle wasting and psychosis
- mineral corticoid effect changes in Na and K excretion
- Dexamethasone has least mineral corticoid effect
- easily bruise
- ↑ BS

Corticosteroid adjuvants have a Long half life therefore should be given in the morning to prevent loss of sleep


Local Anesthetics adjuvants are used for? (3)

- neuropathic pain
- great with nasogastric tubes
- catheters for men

Local Anesthetics adjuvants work by

Inhibiting transmission of pain along the sensory nerve

Three examples of local anesthetics used as adjuvants?

1. Topical = Lidocaine gel, EMLA & Lidoderm
2. Intravenous
3. Spinal

Five Cancer Therapies used to Relieve Pain?

1. Radiation
2. Surgery = ↓ tumor size
3. Chemotherapy = ↓ reduce tumor size
4. Hormonal therapy = relieve bone mets pain
5. Other

Radiation, surgery and chemo work as adjuvants to opioids how? (3)

-decrease tumor size
-reduce bleeding
- remove obstruction

What are five Non-Pharmacologic Techniques used as adjuvants to opioids?

-Support groups
-Pastoral counseling

opioid patches require how long for initial benefit?

12-14 hours

opioid patches must be placed?

on nonedematous, non-hairy skin with good capillary flow

example of opioid patch

Fentanyl patch

What are four common symptoms categories at EOL?

1. Respiratory = Dyspnea, cough
2. GI = Anorexia, constipation, diarrhea, nausea/vomiting
3. General/Systemic = Fatigue/weakness
4. Psychological = Depression, anxiety, delirium/agitation/confusion

Two common EOL respiratory symptoms?


What is dyspnea & how often does it occur at EOL?

distressing SOB occurs in 50 to 85% of patients at EOL

dyspnea is most commonly associated with what six diseases (EOL)?

lung disease
heart disease
end stage renal disease

Subjective report by patient is the only reliable indicator of dypsnea


What are five components of an assessment exam for dypsnea?

1. history: new or ongoing problem, what makes better or worse
2. Resp: breath sounds, Pulse Ox, RR and depth, use of accessory muscles, pain with respiratory movement
3. CV: HR, BP, chest pain, JVD, pulses
4. functional status: ability to sleep, dress, talk, eat, etc
5. Diagnostic tests = chest X-ray, pulse ox

all opioids help dypsnea


What are three Pharmacologic treatments of dypsnea?

1. Opioids = ↑ pulse ox as much as 10%, ↓ RR
2. Bronchodilators
3. Diuretics

What are six Nonpharmacologic treatment of dypsnea?

1. Oxygen
2. Counseling
3. Pursed lip breathing
4. Energy conservation
5. Fans, elevation
6. Other (thoracentesis)

how does purse lip breathing help dypsnea

- decreases small airway collapse
- helps reverse collapsed airway

how does a fan help dypsnea

If pulse ox 98% and O2 helps then try a fan directed to the face
(O2 flow to the face stimulates the trigeminal nerve, to decrease the perception of breathlessness, so will fan)

a cough at EOL is most common in & causes what?

- advanced diseases (lung & heart disease)
- Causes: pain, fatigue & insomnia

what are four Pharmacologic Interventions for Cough?

1. Suppressants/expectorants
2. Antibiotics
3. Steroids
4. Anticholinergics = helps dry up excessive secretions

steriods would be used for what type of cough

dry and irritated

Anticholinergic would be used for a cough with

excessive secretions

a scopalamine patch is used to

dry secreations

a scopalamine patch is placed

behind the ear

What are four Non-Pharmacologic Interventions for Cough?

1. Chest PT
2. Humidifier
3. Positioning
4. Other - caffeine dilates vessels

Chest PT does what for a cough

mobilize secretions

Cool humidifier does what for a cough

thins secretions

why would you Elevate HOB for a cough

for a more effective cough

Caffeinated beverages help a cough by

dilating pulmonary vessels

what is Cachexia?

lack of nutrition and wasting

What is Anorexia?

loss of appetite, usually with decreased intake

what are five causes of anorexia and/or cachexia?

oral infection
chronic N & V
constipation, diarrhea, bowel obstruction
radiation (chemo patients)

Goal for anorexia and/or cachexia

Eat for pleasure

What are five Treatments for Anorexia and Cachexia?

1. Dietary consultation = ex. small meals
2. Medications
3. Parenteral/enteral nutrition = flush, check residual
4. Odor control = separate cooking & eating area
5. Counseling = to ↓ stress

dietary treatment of Anorexia and Cachexia

High calorie, frequent meals

What are four medication treatments for Anorexia and Cachexia?

-megesterol acetate (megace), appetite stimulant
-metoclopramide (Reglan), prokinetic increases gastric emptying & ↑ peristalsis
-wine before meal

Parenteral/enteral nutrition appropriate when

if patient has an appetite but cannot swallow (eg. esophageal cancer)

what is Constipation? (3)

- Infrequent passage of stool
- frequent symptom in palliative care
- prevention is key (fluids, stool softener, ↑ mobility)

What are six Causes include of Constipation?

intestinal obstruction
hypercalcemia & hypokalemia
inactivity, pain, depression
drugs (opioids, antidepressants, chemo)

Six Treatments of Constipation?

1. Minimum goal: bowel movement every 72 hours
2. Meds:stimulant and softener combo (senna & docusate or bisacodyl)
3. suppository if oral ineffective
4. consider mineral oil enema if severe
5. Diet:drink fluids, support proven regimens
6. Other:massage may be useful

diet treatment of Diarrhea (2)

clear liquid
avoid: milk, proteins, fats, hot spices, gas forming foods

hydration treatment of Diarrhea (2)

sports drinks (watch out for DM)
IV fluids

medication treatment of Diarrhea (4)

loperamide (lomotil)

Five causes of Nausea and Vomiting in EOL

-vagal stimulation: constipation, obstruction, pancreatitis, ascites, cough, radiation
-metabolic: uremia, infection, hypercalcemia, drugs
-CNS: pain, IICP, drugs, tumors
-motion sickness

Five Pharmacologic Treatment of Nausea and Vomiting?

1. Anticholinergics
2. Antihistamines
3. Steroids = ST treatment
4. Prokinetic agents
5. Other (benzodiazapines)

Anticholinergics treat (n/v) (2)

motion sickness, SBO

Antihistamines treat (n/v) (3)

obstruction, IICP, motion sickness

Steroids treat (n/v) (2)

all causes, short term treatment

Prokinetics treat (n/v) (1)

gastric stasis

Benzodiazepines treat (n/v) (2)

anticipatory nausea, anxiety

5HT3 receptor blocker treat (n/v) (3)

-example ondansetron (Zofran)
- chemo and radiation induced

Four Non-Drug Treatment of Nausea and Vomiting?

Dietary (eg.room temp meals, no strong smells)
Small/slow feeding
Invasive therapies (eg. NGT, draining PEG, surgery)

Six Treatments for Fatigue?

Rest periods
Assistance with independence, housekeeping
Regular exercise can decrease severity
Transfusion if anemia

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