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PALLIATIVE CARE For End of life (for full explanation see GERI Pearls at geriatrics.unmc.edu) (Issues and Orders to cover) 1) Discuss & clarify with patient &/or family &/or DPOA-HC a) goals of care b) advance directives, (hospitalizations?) c) anticipated sx’s of dying & plan of management d) hospice referral 2) Involve & assure staff’s comfort with plan and orders 3) Document discussions and write orders, (anticipate problems to avoid delay in treatment using the following plan:) 4) AGGRESSIVE care (mnemonic) A NOREX-IA/ A GGITATION (mnemonic for correctable causes) A ches (see P ain) N ausea (see G astrointesitnal) O ral candidiasis R eactive depression E vacuation (see G astrointesitnal) X erostomia I atrogenic (radiation/chemotherapy) A cid (gastritis/PUD) b) offer food/fluids as able c) Appetite stimulants? ;(megestrol, remeron, trazadone) (marinol, dexamethasone) A GGITATION (Terminal Delirium) a) Correct “correctables” b) Haldol 0.5 mg po/sc q 30 min prn delirium G ASTROINTESTINAL -CONSTIPATION: (with opiates always start these) a) DSS 100-250mg q.d. to b.i.d or b) Senna 1-6 tabs q. d. -NAUSEA: Compazine or Haldol or TD Scopolamine or Reglan or Zofran G ENITOURINARY -BLADDER: discuss incontinence management catheter? If spasms? - > oxybutinin R ESPIRATORY DYSPNEA “B-R-E-A-T-H A-I-R” (for correctable causes) B ronchospasm R ales E ffusions A irway obstruction T hick secretions H emoglobin (low?) A nxiety I nterpersonal issues R eligious concerns (For unresponsive dyspnea, give immediate release opiates) M.S. (write prn pain or dyspnea) E MOTIONAL SUPPORT (Hospice? , counselor?) S PIRITUAL SUPPORT (pastoral support? Hospice?) S ECRETIONS If cough strong - moisten If cough weak - dry-up (with anticholinergics) -for Death Rattle: atropine qtts, glycopyrolate, TD scopalamine I NFLAMATION (FEVER) -acetaminophen &/or ASA scheduled dose (is best) or PRN V OLUME (review with family, dehydration has no pain) E MPATHY (secure your emotional support) PAIN (P-A-I-N) (Mnemonic for evaluation) P hysical A nxiety I interpersonal/social problems N on-acceptance/spiritual distress P hysical (Pain)- (make sure of diagnosis when you can) Drug Mech/ Inflm + + + + - Neuro pathic + +/+ Bone APAP* + NSAIDS + Decadron** + Opiates~ + Antidepressants Anti+ convulsants Radiation/ + chemo *Acetaminophen scheduled dose and add PRN narcotics (write p.o. or p.r.) **dexamethasone: 4 – 10 mg per day ~Opiates po/pr morphine 5-7.5 mg q 4h* ocycodone 2.5mg q 4h.* 15mg q 12 h* MS Contin sc/i v 2 mg q2 h* -- size liquid 15mg 10 & 20mg/5ml 100mg/5ml 5mg 5mg/5ml 15,30,60 -100,200 mg Oxycontin 10 mg q -10, 20, -12 h.* 40,80, 160 mg Duragesic 25 -25,50,75 -patches mcg/h. 100 q 3 d* mcg/h* *(these are starting doses – titrate to pain control and tolerance) (UPPER LIMIT determined by sedation) Antidepressants Nortryptyline Anticonvulsant Neurontin -- dose p.o. 10-50mg q.d. 100 mg q.d.– 400 mg t.i.d. size 10 &25 mg 100 & 300 mg (gabapentin) Tegretal 100mg t.i.d. 100 & 300 mg Abdominal pain (colicky) (r/o urinary retention or impaction) oxybutinin 5-10 mg t.i.d., or TD scopolamine (1.5 mg patch q 3 d.) Bowel obstruction - > M.S. + anticholinergics, if severe - > Octreotide A nxiety (pain) (counsel, reassurance, family, friends, pastor) medication hydroxyzine po/im size liquid 10-50mg q 10 & 25 10&25mg 4h mg /5ml Haldol 1-5 mg q 30 2mg/ml min.(no IV) lorazepam 0.5-2 mg 0.5, 1, 2 2mg/ml t.i.d mg (If unable p.o.) (Give sublingual: Dissolve lorazepam in water, give buccally q 1 hr.) I nterpersonal/spiritual-->counseling, family, friends, pastors, hospice. N on-acceptance---------> counseling, family, friends, pastors, hospice. Adapted form “Primer of Palliative Care” Porter Storey MD For full explanation see Geri Pearls at: geriatrics.unmc.edu evv 10-26-03