True or false
Withdrawing life-sustaining treatments and euthanasia or assisted suicide is the same thing and is illegal
False
- withdrawing life-sustaining treatments and euthanasia or assisted suicide are two different thing and they are both legal in some states
A patient that is asking for euthanasia or assisted suicide needs what type of evaluation?
- Prompt a palliative care evaluation by mental health professional
True or false
No moral, legal, or ethical difference between withdrawing life-sustaining treatments and having never started them
True
Easier to withhold than to withdraw
What is the goal of palliative sedation?
-To alleviate symptoms that can't be managed any other way
-to administer sedative medication at the minimum dosage necessary to decrease consciousness and relieve pain
**
May unintentionally hasten death due to side effects
**- document patient/surrogate
What medications are often use for palliative sedation?
Benzodiazepines or anesthetic agents
Is the use of Palliative sedation ethical? who should you consult before performing this procedure?
- Ethically + legally acceptable (main intent: relieve suffering)
-Consult with palliative care team, anesthesia pain service
Documentation is very important for Palliative sedation. What should the NP write regarding this procedure?
-Documentation: Should be congruent with symptoms. The dose should be documented as to why. NO question in court why you did the dose you did. It was congruent with the symptom.
When should the np have a discussion about palliative care with a patient and family?
Clinicians should introduce palliative care options long before the patient becomes terminally ill.
What is services does palliative care offers?
-Fee for service - specialty visit
-Addresses goals of care + QOL, family support, symptom management
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Includes ongoing curative or disease-directed therapies
***
-Can begin with symptom onset from life-limiting disease
-Assists with symptoms, hard con
In what kind of setting is palliative care is provided?
-Often provided in hospitals or an outpatient clinic setting
Which patient are candidates for Palliative care?
-No surprise if patient died within 12 months
-Frequent admissions for same condition within several months
-Complex, difficult symptoms or psychological need
-Functional dependence for complex home support needed
-Decline in functional status, weight, or
How does Palliative care gets paid?
-Fee for service model similar to other services and specialties
What services does Hospice offers?
_Hospice takes over EVERYTHING. They DO everything.
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Specific type of palliative care: recognizing End-of-Life (EOL) trajectory
***
-Insurance coverage will end services for life-prolonging treatment (prognosis must be ?6 months)
-Medicare usually dic
In what type of setting- Hospice care is provided?
- Team based support services in home or institution
(it should not be a death bed referal
How does hospice gets pay for services?
- Geographically prorated per diem payment system
-Hospices receive amount (?$150/day)
- Rate must cover all medication, equipment, specialty services required for comfort and QOL
- cost is often a barrier for expensive interventions
What tool is used find out the prognosis of a patient to be admitted to hospice?
- Karnofsky Performance score (K score)
***
K score less or equal than 70 makes the patient a candidate to hospice
*
What tool can the NP use to determine the days, weeks, or months the patient has left to live?
Palliative Performance Score (PPS)
What staging tool can the NP use to score HF?
-NYHA CHF staging
-Seattle heart Failure score
A patient has Alzheimers. What staging tool can the NP use to stage the patient based on his disease progression?
- Reisberg Functional Assessment Staging (FAST)
A patient with Alzheimer's disease usually meet criteria for hospice care at which stage of disease proration based on Reisberg Functional Assessment Staging (FAST)?
-Stage 7
Experiencing profound levels of difficulty communicating and moving independently, but this isn't always the case
A patient comes to the clinic with cancer needing hemodyalisis and chemotherapy. Patient and family wants to continue treatment. What kind of end of life this patient needs?
Palliative care
A patient with AIDS comes to the clinic with family members. He was told he had less than 6 months to live. What type of care should this patient be referred to?
Hospice
A patient comes to the clinic with pain of 3/10 what type of pain she has and what should the treatment be?
- Mild paint (1-3)
- Nonopioid treatments, including aspirin, acetaminophen, or nonsteroidal anti-inflammatory drugs (NSAIDs)
A patient comes to the clinic with pain of 6/10 what type of pain she has and what should the treatment be?
Moderate (4-6)
-Combination opioids + nonnarcotic pain relievers (such as oxycodone and acetaminophen).
Count mg of acetaminophen to avoid overdosing: acetaminophen dose < 4, (recommended limit of 2 g for patients with liver disease)
A patient comes to the clinic with pain of 9/10 what type of pain she has and what should the treatment be?
Severe (7-10)
-Use opioids, preferably oral: Transdermal opioid patches(chronic pain), Codeine, tramadol, and morphine (caution with renal function)
-Also topical options:+ NSAIDs, corticosteroids, antiepileptics (Depakote), antidepressants
What pain medication are useful for chronic pain?
-Long-acting opioids, such as extended-release morphine, extended-release oxycodone, and transdermal fentanyl patches, can be used to ensure basal pain relief throughout the day.
-Short-acting opioids alone are often insufficient to manage chronic pain.
Which opioids should be avoided for chronic pain?
- Meperidine: variable oral bioavailability can cause tremors, twitching, and nervousness.
-Partial opioid-receptor agonists and agonist-antagonist agents, such as buprenorphine, dezocine, nalbuphine, pentazocine, and butorphanol, may cause delirium and p
How can a np treat sedation secondary to opioids?
- Dose reduction if significant
- it dictates as tolerance develops in 1-2 days
How can the Np treat constipation secondary to opioids?
- First: Osmotic laxative or stimulant: docusate + senna or bisacodyl.
- if unsuccessful: Osmotic laxatives (magnesium citrate, lactulose, and polyethylene glycol ( well tolerated)
**
stool softener by itself is not effective
**
How can the NP treat pruritus secondary to opioids?
-Try another opioid or combine with a non-sedating antihistamine (Acrivastine, Bilastine., Cetirizine., Desloratadine., Fexofenadine., Levocetirizine., Loratadine., Mizolastine)
How can the NP treat Nausea secondary to opioids?
-Usually dissipates as tolerance develops in 3-5 days
-Use anti-dopaminergic anti-emetics (rmetoclopramide or prochlorperazine)
-If refractory: try corticosteroids or ondansetron - -Maintain constant levels: reduce dosing interval for immediate-release pr
Opioid induce nausea responds better to what type of medications?
- Dopaminergic signaling: metoclopramide (reglan) and prochlorperazine (Compro)
A patient with chemotherapy induced nausea will get better relieve if they take which antiemetic medication?
-Seretonin antagonists (ondasentron, granisetron) with corticosteroids as adjuvants if needed
How can nausea secondary to intracranial pressure cause by brain tumor be relieve?
- Corticosteroids: decahedron
A patient in palliative care is complaining of dull, colicky, and poorly localized pain. Patient has pancreatic cancer. Due to the mobility and opioids patient develop a blockade of celiac plexus, sympathetic plexus, or splanchnic nerves if refractory to
-Palliative surgery for bowel obstruction
How can incomplete mechanical bowl obstruction be treated for a patient under palliative care?
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octreotide + dexamethasone + metoclopramide
***
-for higher grade obstructions: venting gastrostomy tubes + octreotide
A patient in palliative care has reduce motility due to immobility and recent surgery. How can we help this patient increase paristalsis?
- Metoclopramide (reglan)
A patient on palliative care is experiencing dizziness and nausea. What should the NP order?
anti-choligernic antihistamines (e.g., scopolamine, meclizine, and diphenhydramine)
A patient in a palliative care complains of numbness, tingly, electricity, burning secondary to DM and cancer. How can a NP control the patient's neuropathic pain?
dexamethasone 2-4mg starting dose then increase (Corticosteroids): reduce tumor swelling and edema, may reduce obstruction pain + improve mood, and energy.
A patient in palliative care is complaining of burning, tingling, stabbing, or shooting on lower extremities. How can the NP control the patient's peripheral neuropathic pain?
-opiods.
- Tricyclic antidepressants (amitriptyline), venlafaxine, and duloxetine (cymbals) may be especially useful in patients with both neuropathic pain and depression.
-Gabapentin and pregabalin are also effective for neuropathic pain.
-Initial trial:
A patient was recently dx with bone metastases. Pt is complaining of deep awful pain. how can the NP treat this pain?
Consider radiation (to reduce tumor size and symptoms not to treat the tumor), corticosteroids, bisphosphonates (risedronic acid (Actonel, Atelva), alendronate (Binosto, Fosamax), and ibandronate acid (Boniva), interventional procedures
What is the gold standard to treat dyspnea in a patient under palliative care?
- low dose of Morphin 10 - 20 mg/ day
How can we treat dyspnea worsened by anxiety in a patient under palliative care?
- Bezodiazepines: (e.g. alprazolam [Xanax�], diazepam [Valium�], lorazepam [Ativan�]chlordiazepoxide [Librium], clonazepam [Klonopin])
Supplemental oxygen is used on palliative care on patient with what conditions?
-Dyspnea and hypoxemia
A patient on palliative care has increase recreations and is making a noise call "death rattle". What intervention can we take to help that patient?
- Sublingual atropine
A patient has hyperactivity or apathy and withdrawal; moaning or grunting; use of accessory muscle for breathing; or tachypnea, tachycardia, or diaphoresis. Before the NP diagnose the patient with delirium, she should evaluate for what?
-Psychoactive drugs (e.g., benzodiazepines)
-Untreated pain
-Urinary obstruction or bowel impaction
-Sensory deprivation (missing eye glasses, ear wax) - give them their hearing aids and glasses
A patient has hyperactivity or apathy and withdrawal; moaning or grunting; use of accessory muscle for breathing; or tachypnea, tachycardia, or diaphoresis. A NP confirmed that is delirium. What would be the first line of tx for this patient?
-Treat with haloperidol in small doses
**
If ineffective, try more sedating chlorpromazine 10-20 mg po or SQ.
**
How can a np help reduce or prevent distressing tracheal secretions "death rattle" on a dying patient?
- prophylactic anticholinergics: (e.g., scopolamine,meclizine, and diphenhydramine)
A patient on hospice has persistent symptoms of depression for several weeks. What would be the treatment?
1-SSRIs:Fluoxetine (Prozac), Sertraline (Zoloft)
Paroxetine (Paxil), Escitalopram (Lexapro), Citalopram (Celexa) (might have drug-drug interactions)
*****2-Psychostimulants: methylphenidate (safe)
3-Mirtazapine ( for pt with insomnia y anorexia)
4-Tricycl
How can a np help a cancer patient with uncertain prognosis without an imminent death increase their appetite and improve anorexia and cachexia?
- First line: progestins: megestrol 400-800 mg/day
- of death is imminent: educate patients and caregivers and disease process
What is the role of the surrogate in relation to end of life care?
- to represent the patient's expressed wishes when he/she can no longer do so.