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L 68: End of Life Care
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Terms in this set (22)
Palliative Care definition. When does it end?
Relieving or soothing the symptoms of a disease or disorder without effecting a cure. Care does not end until the family have been supported with their grief reactions
Pain control: WHO 3-step ladder
Mild pain= 1-3 on pain scale
Moderate pain= 4-6 on pain scale
Severe pain= 7-10
Breakthrough dosing
a) Breakthrough pain definition
b) DOC
a) Transitory flares of pain in chronic conditions
b) Immediate-release prep of same opioid used for routine dosing (or fentanyl)
Opioid
a) No ceiling effect
b) AE
c) Clearance
d) Which opioids are not recommended
a) Seen in pure opioids in which there is no maximum dose that can be given in which there is no further increase in anesthesia
b) Nausea, sedation, constipation, respiratory depression
c) 90-95% excreted renally (conjugated into glucuronides)
d) Meperidine (normeperidine AE)
-Mixd opioid-antagonists should not be used with pure opioid because it lowers the ceiling
Tolerance definition
Requirement of a higher dose to produce same effect
Physiologic/Pharmacologic dependence
A normal physiological phenomenon in which a withdrawal syndrome occurs when an opioid is abruptly discontinued or an opioid antagonist is administered
Psychological dependence and addiction
A pattern of drug use characterized by a continued craving for an opioid which is manifest in compulsive drug-seeking behaviour leading to an overwhelming involvement in the use and procurement of the drug
Pain control adjuvants
a) Opioid induce constipation
b) Opioid induces nausea/vomiting
a) Detergent stool softener (docusate) plus a stool stimulant (ex. castor oil)
b) Antiemetics (e.g. metoclopramide). Tolerance usually develops within a few days
Neuropathic pain management
a) Burning tingling pain
b) Shooting stabbing pain
c) Complex pain
a) TCA's (amitriptyline, imipramine), gabapentin
b) Gabapentin, carbamazepine, valproate
c) Combination may be required (NMDA receptor antagonist, corticosteroid, antiarrhythmics... etc)
Bone pain management
Opioids= mainstay of treatment
-Second-line drugs: NSAIDs, corticosteroids, calcitonin
Corticosteroids use in advanced illness
• acute nerve compression
• increased intracranial pressure
• bone pain
• visceral pain
• anorexia
• nausea
• depressed mood
Anorexia/cachexia management
-Non-pharmacological
-Corticosteroids (e.g. dexamethasone)
-Cannabinoids (e.g. dronabinol)
End of life confusion
a) causes
a) Drugs, hypoxia, intrinsic CNS disorders
Constipation management
• stimulant laxatives (eg, casanthranol, senna)
• osmotic laxatives (e.g. lactulose, sorbitol)
• detergent laxatives (stool softeners eg, docusate)
• prokinetic agents
• lubricant stimulants
• large-volume enemas
Depression management
• psychologic support
• antidepressants for persistent, clinically sig.
depression
• anxiety & insomnia (sedating TCA)
• withdrawn, vegetative signs (methylphenidate)
Diarrhea management
a) Transient/mild
b) Persistent/bothersome (slow peristalsis)
c) Persistent, severe secretory
a) Bismuth salts
b) Loperamide, diphenoxylate/atropine, tincture of opium
c) Octreotide, parenteral fluid support
Dyspnea (difficult/laboured breathing) management
-Oxygen
-Opioids (morphine DOC)
-Anxiolytics
fatigue/weakness management
• discontinue medications that are no longer
appropriate and may make fatigue worse
(eg, antihypertensives, diuretics)
• optimize fluid & electrolyte intake
• not easy to treat pharmacologically
Fluid/edema management
At end of life no amount of IV fluids or salt will return intravascular volume to normal
Insomnia managment
• avoid caffeine
• avoid staying in bed when awake
• excess alcohol use
• avoid overstimulation before sleep
pharmacological interventions include:
• antihistamines (eg, diphenhydramine)
• benzodiazepines (eg, lorazepam)
• neuroleptics (eg, chlorpromazine)
Pressure ulcers management
• hygiene
• protection (thin hydrocolloid dressings)
• supports
• avoid iodine-containing products
• charcoal-impregnated dressings
• superficial infections (topical metronidazole or
silver sulfadiazine)
Grief steps
-Normal process that usually begins before an anticipated death
1) Denial
2) Fears about loss of control
3) Suffering
4) An uncertain future
5) Loss of self
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