Certified Hospice and Palliative Care RN Exam (Latest 2025/ 2026 Update) | 100% Correct | GRADED A.

Certified Hospice and Palliative Care RN Exam (Latest 2025/ 2026 Update) | 100% Correct | GRADED A. Minorities Monopolizing Hospice Care 1 in 5 Hospice pts is a member of a minority Hospice was conceived before 475 AD What year was the "Tax Equality and Fiscal Responsibility Act" and the Medicare Hospice Benefit therein? 1983 What year was Medicare Hospice Benefit made permanent by Congress? 1986 National Hospice and Palliative Care Organization (NHPCO) Model for quality, compassionate care for pt at EOL. Hospice involves team oriented approach, pt specific. Support to pt loved ones. Everyone has right to die pain-free, with dignity, and families receive report. In Hospice and Palliative Care, what is the "unit of care"? Pt and Family (as defined by pt) Volunteers in Hopsice To meet Medicare's conditions of participation, volunteers must provide day-to-day admin/direct pt care services in an amount that, at min = 5% of total pt care hours of all paid hospice employees and contract staff. Bereavement services A minimum of 1 year after pt death. Most Common Primary Diagnoses in Hospice Cancer - 36.5% Dementia - 15% Heart Disease - 13% Lung - 9 Unspecifified - 5 Stroke/coma - 5 ESRD - 3 Liver - 2 Etc. Consultative Members PRN basis, such as physicians, pharmacists, specialists (like for situations involving children involving a pediatric specialist/nurse). Multidisciplinary Team Team from other professional disciplines but also function on independent levels. Gen limited coordination/consultation between disciplines. Teams can be organized in a hierarchical manner, which can result in limited sharing of decisions and leadership Interdisciplinary Team (IDT) Collab approach Best practice Physician, nurse, medical social work, counselling (bereavement and spiritual). Other common team members: aides, volunteers, PT/OT, Speech Palliative Care Provides relief from pain and other sx Affirms life and regards dying as normal process Intends to neither hasten or postpone death Integrates psychological and spiritual aspects of pt care Offers support to pt/fam to live as actively as possible until death Offers support system to fam to cope during and after Team approach Enhance QOL Applicable early in cousre of illness and in conjunction with other tx IDT Meeting Frequency Regulations - Inpatient Meet to review/revise no less freq. than q 15 days. IDT Meeting Frequency Regulations - Outpatient and Hospital Based No regulations IDT Meeting Pt/Fam Encouraged to attend, but not mandatory. Even if not present, should be included in developing/updating POC. What are the four dimensions of "whole person suffering" by Dame Cicely Sanders? Physical, psychological, social, spiritual. All must be addressed to achieve comfort! Types of Clinician-Patient/Family Conflict Types of Clinician-pt/fam conflict: Parentalism - making decisions for pt and infringing on their rights to self-determination Deception - coercing or manipulating patients to do what care team wants (withholding information, lying, imposing beliefs on pt) Confidentiality - disclosing pt information without consent/to those not involved/specifically asked not to inform. Parentalism making decisions for pt and infringing on their rights to self-determination. Type of conflict between clinician-pt/fam Deception coercing or manipulating patients to do what care team wants (withholding information, lying, imposing beliefs on pt) Type of conflict between clinician-pt/fam Confidentiality disclosing pt information without consent/to those not involved/specifically asked not to inform. Type of conflict between clinician-pt/fam Balancing between family and patient Try to find a happy ground. If none, side with patient. Role model - passive method of supporting newer clinicians Mentor - - gen. Long-term relationship between mentor and mentee Precepting - direct supervising relationship When does burn out occur? What occurs when mismatch between work life in 1 or more of 6 areas: workload, control, reward, community, fairness, and values. What are the (3) components of burn out? Emotional exhaustion - over-extended or depleted Cynicism and depersonalization - negative, detached Ineffectiveness and lack of personal accomplishment - feeling incompetent/ineffective ... are the components of? What are the sx of "emotional exhaustion"? (burnout) - over-extended or depleted are sx of what r/t burnout? What are the sx of "Cynicism (depersonalization)"? (burn out) - negative and detached are sx of what r/t burnout? What are the sx of "Ineffectiveness and lack of personal accomplishment"? (burn out) - feeling incompetent/ineffective are sx of what r/t burnout? Compassion fatigue syndrome is...? What syndrome is almost identical to PTSD, except in that it is applying to emotionally affected by trauma? What are the (2) leading causes of death in the US? 1) heart disease 2) cancer What is "invasion" in cancer? ? Angiogenesis - generation of blood vessels, increase risk of mets Metastasis (mets) The spread of cancer cells to locations distant from their original site. Where are the common mets sites in BLADDER cancer? Bone, Liver, Lung Where are the common mets sites in BREAST cancer? Bone, Brain, Liver, Lung Where are the common mets sites in COLORECTAL cancer? Liver, Lung, Peritoneum Where are the common mets sites in KIDNEY cancer? Adrenal gland, Bone, Brain, Liver, Lung Where are the common mets sites in LUNG cancer? Adrenal gland, Bone, Brain, Liver, Other Lung Where are the common mets sites in MELANOMA cancer? Bone, Brain, Liver, Lung, Skin/Muscle Where are the common mets sites in OVARIAN cancer? Liver, Lung, Peritoneum Where are the common mets sites in PANCREATIC cancer? Liver, Lung, Peritoneum Where are the common mets sites in PROSTATE cancer? Adrenal gland, Bone, Liver, Lung Where are the common mets sites in STOMACH cancer? Liver, Lung, Peritoneum Where are the common mets sites in THYROID cancer? Bone, Liver, Lung Where are the common mets sites in UTERINE cancer? Bone, Liver, Lung, Peritoneum, Vagina What are the (4) different TYPES of treatment for cancer? Curative Adjuvant - used in addition/after primary therapy to minimize risk of return Neoadjuvant - given before primary therapy Palliative - intended to relieve/alleviate sx/burden and improve QOL, not cure Adjuvant - used in addition/after primary therapy to minimize risk of return Neoadjuvant - given before primary therapy Palliative - intended to relieve/alleviate sx/burden of tx and improve QOL, not cure Surgery in Cancer is used ... Frequently when turmor is localized Primary way of obtaining biopsy for diagnosing CAN BE PALLIATIVE Radiation in Cancer Approximately 60% of pts with cancer will receive radiation at some point in their tx Brachytherapy R/t radiation - when the source is placed inside or directly on the body What are the SE of radiation? Typical effects - skin reactions, fatigue, wt loss, myelosuppresion, alopecia, N/V, mucositis, xerostomia Acute - site-specific, short term (mucositis, GI distress, fatigue, ulceration), resolve at end of tx Subacute - appear within weeks/few months after treatment (pneumonitis, fractures, renal damage) What are the ACUTE SE seen in radiation? Acute - site-specific, short term (mucositis, GI distress, fatigue, ulceration), resolve at end of tx What are the SUBACUTE SE of radiation and how quickly do they appear? Subacute - appear within weeks/few months after treatment (pneumonitis, fractures, renal damage) What are the LATE SE of radiation and how quickly do they appear? Late - up to 6 months (small/large bowel injury, infertility) Mucositis What is the painful inflammation and ulceration of the mucous membranes lining the digestive tract, usually as an adverse effect of chemotherapy and radiotherapy treatment for cancer called? What is Pneumonitis? What is the inflammation of the walls of the alveoli in the lungs called? Usually caused by a virus. What is myelosuppression? What is the condition in which bone marrow activity is decreased, resulting in fewer red blood cells, white blood cells, and platelets called? Chemotherapy Kills all cells What is the purpose of combination therapy in chemotherapy? Targets cells at multiple life cycle stages for larger effectiveness. What are the SE of chemo? Stomatitis, alopecia, myelosupression, n/v/d, fatigue, anorexia Incidence and severity depend on the medication used. Long-term - occur weeks/months later Cardiotoxicity (presents like heart failure), neurotoxicity (stop/reduce dose by 50%), pulmonary toxicity, hepatotoxicity, nephrotoxicity What are the LONG TERM effects of Chemo and when can they occur? Long-term - occur weeks/months later Cardiotoxicity (presents like heart failure), neurotoxicity (stop/reduce dose by 50%), pulmonary toxicity, hepatotoxicity, nephrotoxicity In evidence of NEUROTOXICITY in chemo, what do you do? To stop or reduce dose by 50% is used to treat what in chemotherapy? How does cardiotoxicity present? (R/t Chemo?) Like Heart Failure (HF), but brought on by chemotherapy. Symptoms of this may include: Shortness of breath. Chest Pain. Heart palpitations. Fluid retention in the legs. Distention of the stomach. Dizziness. How does neurotoxicity present r/t chemo? Caused by brain damage in chemotherapy. Common symptoms can include problems with memory, concentration, reaction time, sleep, thinking, language, as well as depression, confusion, personality changes, fatigue, and numbness of the hands and feet. What are the sx of pulmonary toxicity r/t chemotherapy? Sx r/t this SE of chemo are Breathlessness during exercise. Fatigue. Dry cough. Shortness of breath. Discomfort or worsening symptoms when lying on your back. What are the sx and tx of hepatotoxicity r/t chemotherapy? Sx of this SE of chemo are: Severe fatigue, or jaundice. Abdominal pain, severe nausea and vomiting. No tx once this occurs. What are the sx of nephrotoxicity r/t chemotherapy? Sx of this SE of chemo Elevated serum BUN and Creatinine (can be temporary or permanent indicative of kidney failure) Normal Values - Kidney Function Tests* Blood Urea Nitrogen (BUN) - 10-25 mg/dL Creatinine - 0.7-1.4 mg/dL *normal values may vary from laboratory to laboratory What are some Complementary and Alternative (CAM) Therapies? Mind-body (hypnosis, imagery, relaxation), biologically based (enzyme therapy, melatonin), manipulative (chiro/reflexology), energy therapy (healing touch), acupuncture, spiritual What are some clinical indicators of poor prognosis? ** Poor performance stasis - decline in function Malignant hypercalcemia (except in breast/multiple myeloma???) Malignant Pericardial Effusion Carcinomatous Meningitis Multiple brain mets Malignant ascites Malignant pleural effusion Malignant bowel obstruction Hemorrhage Spinal cord compression Superior Vena Cava (SVC) Syndrome What is the best indicator of poor prognosis? Poor performance status - decline in function Malignant Hypercalcemia - how common, prognosis, and sx - up to 10-30% of cancer patients, 80% die within year Common in breast cancer, lung cancer, and myeloma Sx - often non-specific - fatigue, nausea, constipation, confusion. Worsening - dehydration, polyuria, polydypsia, N/V/C, anorexia, fatigue, delirium, myopathy. Severe - seizures, coma, cardiovascular collapse Malignant Pericardial Effusion A condition in which cancer causes extra fluid to collect inside the sac around the heart. The extra fluid causes pressure on the heart, which keeps it from pumping blood normally. Lymph vessels may be blocked, which can cause infection. - most often caused by lung cancer, breast cancer, melanoma, lymphoma, and leukemia. Sx of Malignant Pericardial Effusion You can have significant pericardial effusion without signs or symptoms, particularly if the fluid has increased slowly. If pericardial effusion symptoms do occur, they might include: SOB or dyspnea Discomfort when breathing while lying down (orthopnea) Chest pain, usually behind the breastbone or on the left side of the chest Chest fullness Malignant Pleural Effusion Shortness of breath. Dry cough. Pain. Feeling of chest heaviness or tightness. Inability to lie flat. Inability to exercise. Generally feeling unwell. Stage IV cancer also includes people who have a fluid collection around the lung (called a malignant pleural effusion) caused by the cancer. Stage IV non-small cell lung cancer cannot be cured, but treatment can reduce pain, ease breathing, and extend and improve quality of life. Top 10 most common cancers in America The Top 10 Cancers of America 1 - Skin cancer. 2 - Lung cancer. 3 - Prostate cancer. 4 - Breast cancer. 5 - Colorectal cancer. 6 - Kidney (renal) cancer. 7 - Bladder cancer. 8 - Non-Hodgkin's lymphoma. 9 - Thyroid 10 - Endometrial Lung Cancer Most common worldwide cancer. Average age. 71 y.o. 16% survival rate Common mets - brain, liver, bone, adrenal glands Sx - chest pain, fatigue, cough, dyspnea, wt loss, anorexia Breast Cancer Leading cause in women 20-59 50% occur in 61 y.o. Younger = poorer prognosis due to hormonal fluctuations. Common mets - bone (most common), skin, lung, lymphnodes, liver, brain, pleural effusion Sx - lymphedema, pain, nausea, fatigue, dyspnea, anorexia, alt. LOC. Pancreatic Cancer WORST PROGNOSIS, but only 5th most common cancer death - 1 year survival rate 24%, 5 year is only 6%. Most common in 60-80 y.o. - smoke and chemical exposures. Sx - wt loss, wasting, pain, jaundice, nausea, fatigue. Pts tend to present earliest when tumor is in head of pancreas. Colorectal Cancer 3rd leading cause of cancer. 5 year 10% Risk - genetics, old age, poor diet, pile acid, ETOH abuse, lifestyle, IBS, choleycystectomy Sx - anemia, fatigue, partial/complete BO, pan, blood in stool, fistulas Gastric Cancer MF, 2 (white): 1 (black) Risks - H. Pylori, high salt/smoked/pickled food diet, smoking, living in Japan/Korea Sx - dyspepsia, wt loss, anorexia, fatigue, epigastric pain, abdominal distension, GI bleed, BO Liver Cancer Most common solid worldwide 5-year 15% Death occurs from cachexia, GI/esophageal varices bleeding, LF, coma, fatal hemorrhages. Sx - pain, jaundice, pruritis, ascites, dyspnea, N/V, early satiety, fatigue, wt loss Esophageal 6th cause of cancer death 50 y. o., white, obesity 5-year 15%, most die in 1st year. Risks - smoking, ETOH abuse, obesity, prior radiation to chest, GERD, Barrett's esophagus, male Sx - dysphagia, wt loss, diarrhea/constipation, excessive oral secretions, hemorrhage, dumping syndrome Prostate Cancer Most common malignancy in males, 2nd cause cancer death. Good prognosis - 5-year 99% Risk - age, lifestyle, genetics, African, fat consumption, smoking, ETOH abuse Sx - Usually present with urinary dysfunction, BPH, nocturia, cachexia, wt loss, bone pain, leg/scrotal edema, ED, coagulation disorders, bladder/urethra obstruction. Bladder Cancer MW 3:1 5-year 77% Risk - smoking, carcinogen exposure Sx - hematuria, dysuria, frequency, UTI Associated - sexual dysfunction (post bladder removal), pain, vaginal dryness, decreased libido Renal Cancer 5-year 10% for Stage IV, otherwise mostly cureable Risk - smoking, obesity, HTN, regular NSAID, genes, Hep C Sx - gross hematuria, costovertebral pain, wt loss, anorexia, pain, n/v, fatigue Cervical Cancer 2nd most common cancer women HPV biggest risk factor Usually asymptomatic - occasional intermenstrual bleed, postcoital bleed, heavy menses, pain, cachexia, bleeding/anemia, lymphedema, vaginal stenosis (secndary to tx) ureteral obst. Ovarian Cancer 5th leading cancer deaths Survival rate 45% if caught early Risk - nulliparity, use of infertility drugs, PID, use of talc, fam hx of breast/ovarian, Jewish, mutation of BRCA1 and 2 Sx - bloating, pelvic/abd pain, early satiety, urinary dysf, intestinal obst., ascites, malnutrition, lymphedema, fistula Frequently spreads beyond ovaries (liver, lung, peritoneum) Endometrial Cancer Most curable if caught early (80%) Risk - postmenopause, obesity, nulliparity, late menopause, DM, POS, breast cancer Sx - Hematuria, bowel incontinence, pain, ascites, bowel pattern change, fistulas Leukemia Survival rates depend on type Risk - hematological disorders, genetics, tx for malignancy, chemicals, radiation, autoimmune diseases Sx - fatigue, myelosuppression, thrombocytopenia, mucositis, GI disturb. Tumor lysis sx Lymphoma Hodgkins (one of the most curable) Non-hodgkins Those with t-cell most aggressive Sx - lymphadenopathy most common, fatigue, myelosuppresion, peripheral neuropathy, organ toxicity r/t treatment Multiple Myeloma Risk - increased age, African decent Sx - bone pain, sx of hypercalcemia, hyperuridemia, paraplegia (spinal compression), immunosuppression Head/Neck Cancers Cancers tend to be curable if diagnosed early, but most found late Risk - tobacco, ETOH abuse, HPV (in oral), Epstein-Barr virus, toxic chem inhalation and nitros Sx - dysphagia, speech D/O, mucositis, xerostomia (dry mouth), loss of taste, trismus (lockjaw), pain, fatigue, constipation/diarrhea (for those requiring gastrostomy and GI feedings) Malignant Melanoma Most serious type of skin ca Rising faster than any other malignancy Thickness is important factor of survival Risk - fair skin, large congenital moles, number of moles, family hx, UV exposure, close to equator Sx- ulceration, pruritis, bleeding/pain, sx from mets, fatigue, anorexia (tx related) Brain Cancers 5-year from 28-31%, unless glioblastoma (GBM) - 12-15 months Sx - range Spinal Cord Compression This Oncologic Emergency can occur from any cancer, but is most common from breast, lung, prostate cancer Direct pressure tumor mas/displacement of bony fragments into spine The most common cause of spinal cord compression in people with cancer is metastasis to the spine. About 60%-70% of metastases to the spine occur in the middle part of the back, which is called the thoracic spine. About 20%-30% of metastases happen in the lower back, or lumbosacral spine. Only about 10% of metastases happen in the upper back or neck area, which is called the cervical spine. About 30% of people with metastasis to the spine will have metastases in more than one area of the spine. Sx - may be mild at first. Back pain (most common), lower motor deficits (hypertonicity, hyperreflexia, paralysis), urinary dysfunction, constipation Tx - corticosteroids, external beam radiation, sx, chemo SIADH (Syndrome of Inappropriate Secretion of Antidiuretic Hormone) This oncological emergency causes hyponatremia, urine osmolality higher than plasma, urinary sodium elevation. Primarily associated with small cell lung cancer Sx - hyponatremia sx - headache, nausea, weakness, anorexia, fatigue, muscle cramps, changes in mental status, lethargy, psychosis Tx - underlying malignancy, water restriction, seizure precautions, hypertonic fluid admin (no more than 8 mEq/L), daily wts, fluid balance, demeclocycline (drug of choice for chronic) What medication is given to treat SIADH (Syndrome of Inappropriate Secretion of Antidiuretic Hormone)? Democlocycline - Tetracycline antibiotic that is used for therapy of mild-to-moderate infections due to susceptible organisms. It is also used off-label as therapy of hyponatremia and SIADH. We have an expert-written solution to this problem! Cardiac Tamponade Excess fluid in pericardial sac - compression of heart r/t treatment or mets/primary in heart Most common in sarcomas, teratomas, mesothelioma, breast, lung, hematological Sx - tachycardia, cyanosis, olig/anuria, hypotension, anxiety, sx of shock, dyspnea, weak, cough, dysphagia, peripheral edema, JVD, GI disturbances Tx - stabilization with oxygen, fluid resuscitation, inotropic agents, bed rest, pericardiocentesis, pericardial window last resort. Superior Vena Cava Syndrome Obstruction/compression of superior vena cava (blood from head/chest/arms/neck) resulting in increased venous pressure and decreased cardiac output Most common when malignancy in mediastinal area (small cell lung ca common) Sx - facial/neck swelling, magenta, bluish discoloration of skin, upper extremity swelling, dyspnea, cough, dilated collateral chest veins Disseminated Intravascular Coagulation Over coagulation leading to thrombosis (clots), and then bleeding Occurs in sepsis, acute leukemia, tumor lysis syndrome, massive tissue injury, transfusion Sx - focal ischemia, acrocyanosis (bluish or purple coloring of the hands and feet caused by slow circulation), superficial/frank gangrene, altered sensation, ulceration of GI, jaundice, decreased urine output, dyspnea, widespread bleeding/thrombosis Tx - underlying cause - oxygen, fluids, blood products if appropriate, anticoagulant therapy Septic Shock Overwhelming infection leads to hypotension, low blood flow, impaired coagulation and clot breakdown leading to poor tissue perfusion, cell ischemia/hypoxia, and organ failure ** Cancer pt show highest rates of sepsis due to immunosuppression, UTIs, and vascular access catheters Sx - fever, shaking chills, hypotension, tachycardia, tachypnea, dyspnea, mental status changes, increased WBC count, oliguria. With immunosuppression, symptoms may be atypical. Tx - Abx therapy, hemodynamic support and volume replacement, blood product, vasopressor/inotrope, oxygen Tumor Lysis Syndrome Metabolic response and the inability for the kidneys to keep up to tumor cells being killed rapidly resulting in hyperuricemia, hyperkalemia, hyperphosphatemia, hypocalcemia Frequently caused by chemotherapy and most often in pts with hematological malignancies or poorly differentiated Burkitt's lymphoma Sx - fatigue/lethargy, N/V/D, anorexia, flank pain, cramps, muscle weakness, cloudy urine, increased HR and BP, neuromuscular symptoms as syndrome worsens (tetany and convulsions), sudden mental incapacity, emotional lability Tx - key is prevention 24-48 hrs prior to tx, freq labs, aggressive hydration and diuresis to clear kidneys, allopurinol hemodialysis if abnormalities do not quickly reverse What are some psychosocial issues frequently seen in advanced cancer pts and survivors? Fear of recurrence Depression Meaning Financial stressors/employment changes/loss Role clarification within family (i.e. no longer the breadwinner/caretaker) Cognitive impairments (i.e. - chemo brain) Anticipatory grief End of Life Considerations in Cancer Most are willing to seek tx for even a 1 month extension of life. Pt not well informed about prognosis, full benefits/burdens of their tx options. Decisions about fluids, enteral feeding, disabling defibs, code status need to be discussed. Conflict for those wanting to be in clincal trials/continue with curative tx while also needing support from services like palliative/hospice. 37% hospice admissions r/t cancer Location of care desired. Common symptoms for cancer pts at EOL Fatigue Pain Noisy breathing/rattle/terminal secretions Delirium Dyspnea/cough Urinary incontinence/retention Why are prognoses challenging for non-cancer conditions? Tendency to be lengthy, chronic, and debillitating trajectories leading to a sudden death/terminal stage. Freq. of exacerbations/remissions When do pt's with non-cancerous dx benefit the most from palliative and hospice? May benefit from palliative IDT care from diagnosis on, hospice at final stages. Persons with multi-system involvement... may be eligible, even if they don't meet certain criteria. Cardiac Disease Leading cause of death, but most preventable. Includes cardiomyopathies and CAD. What Sx impact QOL for Cardiac Disease sufferers? Progressive sx like edema, dyspnea, hypoxia, pain from cardiac ischemia, PVD, and vascular occlusions Pathophysiology of Heart Failure (HF)? Can result from any structural/functional cardiac D/O impairing ability for ventricle to fill/eject blood Decreased cardiac output/HF occur due to systolic/diastolic dysfunction Risks for Heart Failure? Risk - obesity, DM, genetics, inflammatory diseases, autoimmune diseases, chemo/other exposure to toxins, diseases of valves, coronary arteries, heart muscle/conduction system dysfunction Systolic Dysfunction - Left-sided Heart Failure less than adequate cardiac output leading to decreased perfusion of organs/tissues and decreased EF. Initially causes lung congestion - hypertrophic left ventricle (cardiomyopathy) - weakness of muscle What are the sx of LEFT heart failure? Sx of which sided heart failure? - dyspnea, orthopnea, paroxysmal nocturnal dyspnea, cough, fatigue, decreased exercise tolerance, anxiety, restlessness, insomnia, depression, tachycardia, palpitations What are the sx of Diastolic Dysfunction - Right-sided Heart Failure? Symptomatic of which sided heart failure? Preserved EF, but systemic congestion Sx - wt gain, dependent peripheral edema, ascites, weakness, anorexia, nausea Palliative Care in Heart Failure Palliative Care in Heart Failure Supporting QOL and goals of tx. Prognosis is difficult due to unpredictable nature of disease process. Palliative to become part of treatment plan once NYHA Class III-IV to help preserve QOL and education on sx management Focus on max quality, prolonged survival, controlling sx, and promoting self-care. ACC/AHA Stages in development of Heart Failure Stage A - Pt at high risk due to CAD, HTN, DM, obesity, metabolic syndrome, cardiotoxin use, or family hx of cardiomyopathy B - Pt with structural heart disease who never had S/S of HF C - Pt with current/prior HF sx associated with underlying structural heart disease D - Pt with advanced structural heart disease and refractory sx of HF requiring specialized interventions At what Stage (A-D) does a pt become diagnosed with HF using the ACC/AHA Stages in Development of Heart Failure? C and D, starting with current/prior HF sx and underlying structural issues C - Pt with current/prior HF sx associated with underlying structural heart disease D - Pt with advanced structural heart disease and refractory sx of HF requiring specialized interventions NYHA classification of HF All classes assumed to have underlying cardiac disease. Class I - No limitation of physical activity II - HF sx occur with ordinary physical activity, pt is comfortable at rest. III - HF sx occur with less than ordinary physical activity, but pt is comfortable at rest. IV - Sx occur with any activity and may occur at rest. Pharmacological Tx for HF Diuretics, ACE inhibs, ARBs, Beta Blockers, Aldosterone antagonists, Phophodiesterase-5 inhibition, Statins, Nitrates, Calcium Channel blockers, antiarrhythmics, Cardiac glycosides, Opioids, anti-anxiety agents Nonpharmacological Tx for HF Exercise conditioning Stress reduction Dietary Changes Supportive therapies (including home health, PT/OT) Oxygen supplementation Optimal management of comorbidities Surgical procedures -(Pacemaker, AICD, LVAD) Hospice Care for Cardiac Disease As disease progresses, review goals of care with provider, site of care, level of treatment, limitations on aggressive measures. Eligibility guidelines based on both pathological factors and frequency/severity of exacerbations on functional status Implanted devices like pacemakers (typically not deactivated at end of life as it does not impact dying process), AICDs - address deactivation once goal is comfort and a DNR is placed. AICDs that remain active at TOD can cause unnecessary pain and distress. When should AICDs be addressed with Heart Disease pts? AICDs - address deactivation once goal is comfort and a DNR is placed. AICDs that remain active at TOD can cause unnecessary pain and distress. *Pacemakers do not impact dying process. Hospice Eligibility for Heart Disease Pts are considered to be in terminal stage of heart disease (life expectancy 6 mo), if meeting following criteria. 1 and 2 should be present. Factors from 3 will support. 1. At time of initial certification/recertification for hospice, pt is/has been optimally treated for heart disease and is not a candidate for surgical procedure or has declined. Optimally treated means pt who are not on vasodilators have medical reasons for refusing drugs (e.g. hypotension, renal disease). 2. Pt classificed as NYHA Class IV. May have significant sx of HF or angina at rest, inability to carry any activity. If active, distress increases. Significant CHF may be documented by EF of /= 20%, but not required if not already available. 3.Documentation of following will support, but not required to establish eligibility. - tx resistant symptomatic supraventricular or ventricular arrhythmias. - hx of cardiac arrest or resusitation - Brain embolism of cardiac origin Concomitant HIV disease. Neurologic Conditions Include CVA, trauma, degenerative diseases. Prognosis can be difficult. Most common - ischemic/hemorrhagic stroke and brain injury. Neurodegenerative diseases (MS, ALS) insidious onset and progress slowly Strokes (CVA) Ischemic = occlusion (87% of strokes) Risk - A-fib, septic emboli, embolism from heart, aorta, intracranial arteries Sx - one-sided weakness/paralysis Hemorrhagic - Sx - alterations in consciousness, HA, N/V Risk - head trauma Acute Sx - Difficulty walking, aphasia, paralysis/numbness of face, arm, leg, vision impairment, HA, possible vomiting. Chronic Sx - Hemiparesis/weakness, dysphagia, expressive/receptive aphasia, ataxia, apraxia (inability to perform particular purposive actions) Palliative care in CVAs Initial response - preserving as much function, preventing complications, and rehab. Complications - aspiration pneumonia, infections, debility causing decline/death. Realistic goals important Medical management - Disease/specific - anticoagulation therapy (within 4.5 hours of symptom onset) corticosteroids, reduction of risks for recurr. Opioids Antipsychotics/anxiolytics Anticholinergics Antidepressants Surgical Ischemic - Intra-arterial thrombolysis (delivering directly using cath), and mechanical thrombectomy (device to break/remove clot) Hemorrhagic - clipping, endovascular embolization (coiling), arteriovenous malformation removal Nonpharmacologic Speech eval Always communicate with veteran what you are doing Psychosocial support r/t loss of function Hospice care in CVAs Poor prognosis, size and location Pt goal = natural death and devastating functional loss. Prognosis based on expected complications - pneumonia/infection Neurodegenerative Conditions Tend to cause progressive decline, debility-related complications, malnutrition, and death. Dementias Rapid increase in prevalence due to increase in aging population 1 in 8 over 65 Alzheimer's 5.3 mil, 2 million = other types (vascular, Lewy body, frontotemporal) Pathophysiology - irreversible/progressive. Impaired cognition, memory, and eventually physical functioning Palliative care in Dementias Issues - behavioral changes, nutritional deficits, pain, functional decline - pt/family support Death = consequence of associated complications and needs increase Discuss artificial nutrition, mechanical ventilation, antibiotic therapy, and caregiver resources prior to end of life to respect patients wishes Tx - disease specific - Cholinesterase inhibitors (galantamine, donepezil, rivastigmine) used for mild-to-moderate N-methyl-D-Aspartate (NMDA) receptor antagonist (memantine) is used in moderate-to-severe slowing cognitive/functional decline Pain - Follow WHO guidelines Constipation due to decreased mobility (increase fiber, osmotic laxatives) Behavior disturbances - antipsychotics/anxiolytics based on stage/goals/and contraindications Non-pharmacologic - calm, consistent environments, meaningful activities, prevention of ulcers What class of drugs do you use for mild-moderate dementias? Cholinesterase inhibitors (galantamine, donepezil, rivastigmine) What class of drugs do you use for moderate-to-severe dementias? N-methyl-D-Aspartate (NMDA) receptor antagonist (memantine) is used in moderate-to-severe slowing cognitive/functional decline Parkingson's Disease - chronic degen of CNS. Presents subtly - characterized by pill-rolling/fine tremor at rest Not considered fatal, but shorter life expectancy r/t older age at diagnosis, scoring poorly on movement, psychotic symptoms, developing dementia. Deteriorating functional status Tx - Levodopa/carbidopa is most common to manage symptoms What medication frequently used for Parkinson's Disease? Which disease is Levodopa/carbidopa most commonly used for? ALS Incurable motor neuron disease causing general muscle weakness/wasting. Generally presents in localized, anatomical area, location does not correlate with survival time. Typical life expectancy ~3 years from onset. Tends to progress in linear fashion. Overall rate of decline is fairly constant/predictable. No single variable deteriorates at a uniform rate in all pt. Multiple clinical parameters are required to judge progression of ALS. By end stage, muscle deterioration widespread affecting all areas. Initial patterns do not exist. Respiratory failure generally cause of death. Discuss artificial nutrition and hydration, ventilation, tracheostomy, CPR Multiple Sclerosis (MS) Incurable CNS disease with periods of exacerbation/remission. Can also be progressive from onset Myelin sheath destruction in brain and spinal cord determine pathophys. Sx - muscle weakness, numbness, incontinence, mental/visual difficulties QOL and function. Prognosis is variable. MS pts can have an average lifespan. Palliative Care in Neurodegenerative Diseases Palliative care - Burden of care for caregiver/family is often high due to unpredictability Sx of agitation, fatigue, constipation common. Medications with careful monitoring for side-effects. Opioids, bowel regimen, psychostimulants - methylphenidate, antipsychotics/anxiolytics, secretion management, antispasticity - baclofen, tizanidine, gabapentin Nonpharm - calm, consistent environment, communication assistance (ALS), speech/swallow therapy, PT/OT for energy conservation techniques. Hospice in Neurodegenerative Conditions General guidelines - Provider opinion and consultations Rapid progression of symptoms with decline in physical and mental function - Karnofsky and Palliative Performance Scales 50% or less - requires considerable assistance with ADLs and other activities Impaired breathing, SOB, difficulty taking deep breath with associated respiratory infections/increase secretions, refusal of ventilator, or ineffectiveness Difficulty achieving adequate nutritional intake, decreased efficiency/refusal of medically administered nutrition/hydration, wt loss of 10% body weight in 6 months, albumin =/ 2.5 gm/dL Infections, sepsis, wounds, repeated hospitalizations, deferring future hospitalization, willingness to seek comfort care Hospice Eligibility Criteria for ALS Tends to progress in a consistent decline pattern making prognosis somewhat easier. In end stage, 2 factors critical in determining prognosis: ability to breathe, and to a lesser extent, the ability to swallow. Former can be managed with art. vent, the second artificial feed. These options significantly alter prognosis. Exam by neurologist within 3 months of assessment for hospice is advised to assist. Criteria - Pt considered end stage (6mo) meeting following criteria: 1. Critically-impaired breathing capacity - all following characteristics w/i 12 mo. prior to initial hospice cert: vital capacity 30% of normal, if avail.; dyspnea at rest; pt declines mech vent. External vent for comfort only. 2. Both rapid progression and critical nutritional impairment. Decline - All following in 12 month period - Prog from indep. amb to w/c or bedbound; normal to barely/unintelligibile speech; Normal to pureed; indep w/ ADLs to major assist. Nutrit - 12 month - oral intake food/fluids insuff to sustain life; cont. wt loss; dehydr/hypovolemia; absence of art. feeding methods/suff to sustain life, but not relieve hunger. 3. Rapid progression and life-threat complications. Life-threat - 1 of following in 12 month before Recent asp. pneum w/ or w/o tube feed; Upper UTI; sepsis; recurrent fever after abx thx; stage 3/4 decubitus ulcer(s) Pulmonary conditions Third leading cause of death Increasing incidence Classified as obstructive/restrictive Sx - dyspnea, cough, secretions, and pain Pathophysiology - Increasing dyspnea, initially exertion followed by at rest, decreasing oxygenation, increasing CO2 retention, and functional impairment, inability to mobilize secretions and prevent aspiration - terminal event What are the "Obstructive" pulmonary conditions? COPD Type A - Emphysema Distension of air space and destruction of alveolar walls. Use of access muscles, barrel chest, dim. LS, decreased ability to cough/expectorate, wt loss. Forced exp volume in 1 second (FEV1) typically used to assess disease progress/response to tx. Type B - Chronic Bronchitis Increase mucus secretions and productive cough. Adventitious BS with resonance on percuss. Central cyanosis, often overwt. What are some examples of restrictive pulmonary conditions? examples: interstitial, pneumonitis, sarcoidosis, idiopathic fibrotic disease, and connective tissue disease. Secondary to extrapulmonary processes like ALS or myasthenia gravis. Characterized by decrease in total lung capacity (TLC) and reduced lung volumes. Expiratory airflow is normal and airway resistance is normal. Gas transfer reduced - desaturation with activity. Palliative Care for Pulmonary Conditions Pharmacological - Opioids Anxiolytics Cough remedies/expectorants Secretion management (suction, tracheostomy) Oxygen PRN, increasing to continuous, BiPAP, High flow NC Steroids - oral/inhaled Bronchodilators Antibiotics Antidepressants Nonpharm- Distraction, massage, aromatherapy, dietary changes, stress management, alternative activity with rest, fan/air conditioner and light covers, upright/side-lying position changes, efforts to mobilize secretions, pulmonary rehab When to begin discussing Hospice in pt with pulmonary conditions? Increasing freq. of hospitalizations, pneumonia, exacerbation episodes. Hospice Criteria in Pulmonary Conditions 1-2 must be present. Document of 3, 4, 5 lends support. 1 ) severe, chronic lung disease (both a and b) a) disabling dyspnea at rest, poor response to bronchdilators resulting in decrease funct. capacity (bedto-chair existence, fatigue, cough.) Documentation of FEV1 30% of predict is objective evidence, but not req. b) Prog. of end stage evident by increase visits to ER/hospital for infx/resp. fail, or increase MD home visits prior to initial cert. Document of decrease in FEV1, 40 mL/yr is objective evidence, not necessary to obtain. 2. Hypoxemia at rest on room air; evidenced by PO2 /= 55 mm Hg or O2 Sat /+ 88% by ABG/Ox Sat monitors. OR Hypercapnia, as evidenced by PCO2 /= 50 mm Hg (within 3 months.) 3. Right HF secondary to pulmonary disease (cor pulmonale), not Left HF/vualvulopathy. 4. Unitnentional, prog. wt loss 10% of body wt over last 6 mo. 5. Resting HR 100/min ESRD (end stage renal disease) Multiorgan involvement increases risk of death from ESRD. Hemodyalisis has helped renal failure pts live longer and have better QOL. Approx 60% of dialysis patients die within 5 years. Influences on prognosis - Increased with diabetes and obesity rates, age, functional status, albumin level 3.5 g/dL. Refusing/compliance. Pathophysiology of Acute Kidney Injury (AKI) Sudden/intermittent complete loss of renal function. Can be caused by medication, metabolic conditions, infections, urine flow obstruction, injury Predominant underlying cause = hypovolemia/hypotension Can sometimes be reversed with dietary management and short-term hemodialysis, most common within hospital/ICU settings. May lead to oliguria, occasionally maintain urine output. Pathophysiology of Chronic Renal Failure (CRF) Stage V chronic kidney disease Irreversible, less than 1.5% function from nephron and uremic symptoms present. Uremia is diagnosed following persistent proteinuria and retention of toxin occurs. Common causes - DM, HTN. Tx - Dialysis/transplant offered/considered at this stage. Focus - fluid balance, electrolyte management, acidosis, anemia Palliative Care in ESRD As disease progresses, occasionally cognitive impairment due to uremia Sx - Fatigue, neuropathy, xerostomia, pain, and pruritus Tx - Fluid management - diuretics, wt monitoring, underlying conditions (DM, heart disease), dietary restrictions, dialysis, transplant, electrolyte management, pruritus Opioids for pain and dyspnea (Avoid morphine and codeine, Hydromorphone and oxycodone with caution. Fentanyl and methadone relatively safe - start low, titrate slowly.) Antianxiety/neuroleptic agents for restlessness and delirium Medications for pruritus Discuss d/c of treatments such as dialysis when cost outweighs benefit. Prepare family - "days" vs. "weeks". What opioid medications do you want to AVOID in ESRD? Avoid MS and codeine; use hydromorphone and oxycodone with caution. Which opioid medications are SAFER to use in ESRD for pain? Fentanyl and methadone are typically safe to use. - start low and titrate slowly. Hospice Eligibility Criteria for Acute Renal Failure 1 and either 2/3 should be present. 4 lends support. 1. Pt not seeking or D/Cing dialysis or renal transplant. 2. Creat clearance 10 mL/min (15 in DM) or 15 ml/min (20 ml/min in DM) with comorbid CHF. 3. Serum creat 8.0 (6 for DM) 4. Comorbid: mech. vent; malignancy of other organ system; chronic lung disease; advanced cardiac/liver disease; sepsis; immunosuppress/AIDs; albumin 3.5 gm/dL; cachexia; platelet 25k; DIC ; GI bleed Hospice Eligibility Criteria for Chronic Renal Failure 1 and 2/3 present, 4 lends support. 1. Pt not seeking or D/Cing dialysis or renal transplant. 2. Creat clearance 10 mL/min (15 in DM) or 15 ml/min (20 ml/min in DM) with comorbid CHF. 3. Serum creat 8.0 (6 for DM) 4. S/S of RF (uremia; oliguria (400ml/day); intractable hypercalemia (7.0 mEq/L) not responsive to tx; uremic pericarditis; hepatorenal syndrome; intractable fluid overload not resp. to tx. DM 7th leading cause of death in US Linked with increased risk for cancer. Having DM with cancer = increased mortality Palliative pt with diabetes fall into 3 stages: 1. Active comorbid disease with stable diabetes, 2. Relatively stable diabetes with impending death/organ/system failure 3. Actively dying Pathophysiology of DM Common Types I and II. Type I - usually diagnosed in children. Autoimmune loss of beta cells in pancreas leading to absolute insulin deficiency Type II - insulin resistance and decreasing insulin resistance Focus - maintaining as close to normal BG levels as possible: Type I - insulin, meal planning, exercise, self-monitoring Type II - meal planning, exercise, oral hypoglycemic, wt loss Hypoglycemia Can increase morbidity, decreased QOL Sx -tremors/shake, palpitations, tachycardia, diaphoresis, anxious, nervous, dizziness, weakness, HA, irritability, confusion, decreased LOC, seizures in extreme If alert - 1 cup milk, half cup of orange juice, several pieces of hard candy or 15-to-20 grams of glucose tablets/gel. Repeat within 15 min if sx persist. Follow with snack or meal. Unconscious - IV dextrose, subQ, IM, or IV glucagon, or buccal glucose with oral stimulation to encourage swallow Know onset, peak, half-life of insulins and oral agents, doses need adjusted, changes in renal/hepatic function, decreased nutritional intake (N/V, anorexia, food aversion), infection - ketoacidosis Hyperglycemia Sx - dry skin, drowsiness, blurred vision, nausea, polydipsia, polyphagia Risk - hyperosmolar state and associated complications (osmotic diuresis, recurrent infection, poor wound healing) Assess for drugs that might increase BG levels (glucocorticoids, diuretics, octreotide) Which drugs can increase BG levels? Some examples - glucocorticoids, diuretics, octreotide Palliative Care for DM Finger-stick testing D/C indicative of progression of disease, shorter-life, loss of control Hemoglobin AIC (mean glucose last 1-2 months) - used to monitor effectiveness - striving for 7% (8% may be appropriate if history of hypoglycemia/limited life expectancy, microvascular/macrovascular complications, extensive comorbid conditions. Liver Failure Chronic - 12th leading cause of death in US Caused by multiple conditions - cirrhosis, hepatitis, hepatorenal syndrome, and hepatobiliary malignancy. Can be classified as acute/chronic - can be treated/reversed prior to liver failure Pathophysiology of Liver Failure Liver has many functions, diseases can cause widespread disorders in body Hepatitis is inflammation of liver (usually caused by infection of A, B, C,D, or E), toxins, medications Cirrhosis may be caused by substance misuse/chronic viral hep B and C as well as primary biliary pathology. - Damage to liver may be transient or permanent leading to liver failure Hepatorenal syndrome typically associated with poor prognosis Transplant only definitive treatment, not enough candidates Sx of Liver Failure Hepatic encephalopathy, ascites, infections (spontaneous bacterial peritonitis), malnutrition and cachexia, jaundice, portal vein thrombosis, portal hypertension, pruritus, anorexia, nausea, liver capsule distension pain, malaise, esophageal varices Palliative Care in Liver Failure Cognitive impairments can be problematic. Risk for bleeding. Tx - Wt monitoring/fluid balance, avoid ASA/other NSAIDs, abstain/reduce ETOH intake, Fluid/sodium restriction, dietary modification, small, frequent meals, monitor for bleed/prevent bleeding, paracentesis, transjugular intrahepatic portosystemic shunt (TIPS), Denver shunt, transplantation, pharmacological management, skin care to prevent wounds and injuries Diuretics and spironolactone (for edema/ascites), Lactulose/rifaximin to reduce ammonia levels and improve cognitive function, Cholestyramine - pruritus if biliary function ruled out, Acetaminophen - mild pain - restrict to 1 g daily, Opioids - reduce dose - for pain and dyspnea (Fentanyl opioid of choice), skin care to prevent wounds and injury What is the opioid of choice for pain and dyspnea in Liver Failure? Fentanyl What medications do you give to reduce ammonia levels and improve cognitive function in Liver Failure? Lactulose or rifaximin Hospice Criteria for Liver Disease Progressive malnutrition, muscle wasting, hepatitis, noncompliance with medications 1 and 2, 3 lend support. 1. Show both: a) Prothrombin time prolonged more than 5 seconds over control OR INR 1.5 b) Serum albumin 2.5 2. End state liver disease and at least 1 of following: a) ascites; refractory to tx/pt noncompliant b) spontaneous bacterial peritonitis c) hepatorenal syndrome (elevated creat and BUN with oliguria (400ml/day) and urine Na concentration 10 mEq/L d) hepatic enceph; refractory tx/noncomply e) recurrent variceal bleed, despite tx 3. Documentation of following support a) prog malnutrition b) muscle wasting w/ reduced str/endurace c) continued active ETOH abuse (80 g ethanol/day) d) Hepatocellular carcinoma e) Hep B positive. f) Hep C refractory to interferon tx Pt waiting for liver transplant who otherwise fit criteria may be certified for Medicare hospice benefit, but if donor organ procured, must be D/Ced from hospice. HIV/AIDS Progressed from terminal to chronic illness in last few years with ARTs. 1.2 million people living with HIV in US. ARTs recommended for all HIV-infected individuals, reducing risk of progression/prevent transmission. Timing is important. Onset of opportunistic infections/comorbid conditions may reduce life expectancy. Pathophysiology of HIV/AIDS Transmitted by sex, mother-to-child during childbirth, parenterally. Attacks CD4 cells within immune system through RNA. Primary infection characterized by flu-like symptoms a month or two after infection. Some asymptomatic. Sx of HIV/AIDS Primary infection characterized by flu-like symptoms a month or two after infection. Some asymptomatic. Mild flu-like symptoms and swollen lymph nodes may be noted. Diarrhea, wt loss, cough, SOB may develop. Late-stage = severely damaged immune system - opportunistic infections Diagnosis of late-stage HIV (AIDS) a) Infection with HIV, CD4 count of 200 cells/mm3 b) Presence of AIDS-defining malignancies (Kaposi's sarcoma, invasive cervical cancer) and/or opportunistic infections (TB, pneumocystis jiroveci pneumonia) HIV-1 and HIV-2, the latter limited mostly to Africa Diagnosis of late-stage HIV (AIDS) Diagnosis of late-stage HIV (AIDS) a) Infection with HIV, CD4 count of 200 cells/mm3 b) Presence of AIDS-defining malignancies (Kaposi's sarcoma, invasive cervical cancer) and/or opportunistic infections (TB, pneumocystis jiroveci pneumonia) HIV-1 and HIV-2, the latter limited mostly to Africa Palliative Care for HIV/AIDS Tx - ARTs and prophylaxis for opportunistic infections Frequent communication changing needs, goals, and counseling Sx management - opioids, antidiarrheals, antidepressants and antianxiety, skin care moisturizers and antipruritic creams, nutritional support Hospice in HIV/AIDs Hospice - Factors affecting prognosis - age, failure of ARTs, opportunistic infections, complications, functional level, nutritional status, CD4 count, viral load. Continue medications to prevent and treat cytomegalovirus retinitis even when other ARTs and anti-TB meds are D/Ced. Even when ARTs and anti-TB meds are D/Ced in HIV/AIDS... Continue meds to prevent/treat cytomegalovirus retinitis. Hospice Eligibility Criteria for HIV/AIDS 1 AND 2, 3 supports 1. CD4 25 or persistent (2 or more at least 1 month apart) viral load 100k plus one of following a) CNS lymphoma b) untreated or persistent despite tx wasting (loss of 10% lean body mass.) Mycobacterium avium complex (MAC) bacteremia, untreated/unresponsive to tx/tx refused. d) Progressive multi-focal leukoencephalopathy e) Systemic lymphoma with advanced HIV and partial response to chemo f) Visceral Kaposi's sarcoma, unresponsive to tx g) Renal failure in absence of dialysis h) Cryptosporidium infection i) toxoplasmosis, unresponse to tx. 2. Decrease performance status measured by Karnofsky Performance Status (KPS) scale, /= 50% 3) Support: a) Chronic persistent diarrhea for 1 year b) persistent serum albumin /= 2.5 c) Concomitant, active substance abuse d) Age 50 e) Absense of/resistance to ART, chemotx,prophy drug tx r/t specific HIV disease f) Advanced AIDS dementia complex g) Toxoplasmosis h) CHF, sx at rest i) Advanced liver disease Prevalence of Pain Varies by diagnosis, stage of disease, and setting of care. Approx 1/3rd of cancer pt report pain at time of diagnosis, 2/3 report with met cancer. Higher pain intensity and pain interferes with QOL and can hasten death. Screen ALL PTS for pain. Barriers when it comes to pain for Providers and Healthcare System Providers: Instruction inadequate, assessment of pain using simple screening is not sufficient, fears regarding addiction/tolerance/SE r/t medications continue. Healthcare: Inadequate reimbursement, low priority of pain management; restrictive regulations, lack of availability, and poor reimbursement. Pt and Family Barriers about Pain Reluctant to report r/t stoicism, concern about distracting providers, belief that pain is expected, or that this means they are admitting their disease is worse. May fear addiction/tolerance/SE. This also limits compliance. Common Myths about Pain Good patients don't complain Pain is inevitable with aging Strong medication only comes in injectable forms Bearing pain is better than the SE of pain medication Addiction to pain med is common Strong pain meds should only be used for very severe pain Morphine/other opioids are used as last resort and only when death is imminent Morphine/opioids hasten death Nursing Role in Dispelling Pt/Fam Concerns and Myths about Pain Assess pt barriers, validate fears, provide reassurance and empathy, along with cognitive interventions such as verbal, print, or video education What is the definition of pain? Pain is what the pt says it is. (Believing is important to empathetic care). It is a subjective experience. Definition of Misuse Use of medications other than as directed/indicated, whether willful or unintentional, whether harmful or not. I.E. pain meds for sleep Addiction Primary, chronic, neurobiological with genetic, psychosocial, and environmental factors. Characterized by behaviors - impaired control over drug use, compulsive use, continued use despite harm and craving. Definition of Physical Dependence Adaption manifested by drug class-specific withdrawal syndrome produced by abrupt cessation, rapid dose reduction, decreasing blood level, and/or administration of antagonist What are the sx seen in physical dependence following withdrawal? Drug class-specific. Common examples: Anxiety, irritability, lacrimation, rhinorrhea, sweating, N/V/D, abdominal cramps, insomnia, tachycardia, elevated BP, rarely multifocal myoclonus (multiple sites of mild-to-severe twitching) How do you calculate the approximate time until symptoms of physical dependence should appear? Appearance dependent upon half-life (example - sx appear between 6-12 hours and peak 24-72 hours following last dose of medication with short (2-3 hour) half-life, like morphine. Conversely, meds with a longer half-life, the appearance of abstinence symptoms are delayed (in methadone, up to 36-48 hours since last dose, but varies) Substances with shorter half-lives tend to have more severe symptoms. Define Opioid Pseudoaddiction Syndrome in which pts develop behavioral characteristics of dependence as a consequence of inadequate pain treatment. Feel they must continually demonstrate their need for analgesics. Described as difficult, chronic complainers, drug seekers, and/or addicts. Often resort to strange behaviors to prove their pain is real so analgesics are provided. Definition of Double Effect Ethical Principle that permits an action intended to have a good effect when there is also a risk of a harmful effect ONLY when the intention was to produce the good effect. Inaccurately applied to EOL care. No evidence use of opioids hastening death. An analysis of potential benefits of therapy weight against possible risks should be conducted when considering any therapy. Assessment of Pain Site - Have pt point to site of on diagram, identify, assess all sites, as well as sites of radiation. Pt may have more than one site of pain. Character - use pt's own words. Careful description will lead to diagnosis of pain type and use of appropriate analgesics Onset - when did it start? Did/does a specific event trigger pain? This distinguishes between new and pre-existing pain Assess for breakthrough pt (transient flares in those with chronic pain) These can be incidental (i.e. movement), idiopathic (i.e. cause unknown), can occur as end-of-dose failure (pain recurs prior to next dose of pain medication available.) Duration/Frequency - how long has it persisted? Constant/intermittent? Acute/Chronic/Acute on chronic (i.e. pain crisis in sickle cell disease in pt with persistent bone pain)? Intensity - Pain intensity. Commonly used is a scale. Numerical (0-10) Exacerbating factors - what times, activities, other circumstances make it worse? Associated symptoms? - symptoms occurring before, with, or after pain? Alleviating factors - what makes pain better? What treatments (including nonpharm) have been successful in the past and what has been unsuccessful? Include medication history that includes adverse effects that would have occurred with previous exposure to pain medications Medication History - What meds have been ordered? Presently taking? Disparity? What worked in the past? Beliefs about pain medications from pt, family, caregivers? Impact on QOL - What does pain mean? How long has it affected them? Does it keep them from doing what they want to do? What do they know about pain? Do they have expectations? Are there emotions/physical/spiritual components to pain? Does unrelieved pain increase fear or anxiety or to fears that death is imminent? Physical Exam - observe site, validate pts pain. Note skin color/warmth/irritation/integrity/swelling/ etc. Watch for changes in expression Values - What are pt's goals for pain? What is self-identified threshold? Cultural aspects of pain for this patient? Types of Pain in Cancer Pain Syndromes 1. Pain associated with direct tumor involvement (i.e. bone mets, nerve compression/infiltration, hollow viscus) 2. Pain associated with cancer therapy - Any pain occurs in the course/as result of surgery, chemo, radiation, hematopoietic stem cell transplant, hormonal, or other treatments (i.e) mucositis, chemo-induced neuropathy, phantom pain, etc.) 3. Unrelated pain (i.e. arthritis, migraines, lower back pain, etc.) Pain in HIV Pain associated in HIV is with virus (direct involvement in sensory), pain related to treatment (neuropathy, r/t ARTS), and unrelated. Most common: peripheral neuropathy secondary to virus and treatment. Late-stage often associated with infections Cardiac Pain Examples Chest pain - angina, panic attacks, PVD (can go from mild-to-severe) Neurologic Pain: Central or Post-Stroke Pain Central/Post-Stroke Pain may occur immediately after stroke/be delayed by several years. Accompanied by decreased temperature sensation, may be superficial/deep, often intense and accompanied by hyperalgesia (increased pain) and allodynia (pain from sensation that does not usually cause pain, like touch.) Hyperalgesia definition increased sensitivity to pain. ... is the definition of...? Allodynia definition Pain from a stimulus that doesn't normally cause pain, things like touch. ... is the definition of...? Neurologic Pain: Spinal Cord Injury Pain Central pain in spinal cord injuries may occur from an injury on any level of the spinal column Neurologic Pain: MS Pain in MS is associated with Paroxysmal trigeminal neuralgia, optic neuritis, periorbital pain, spasms, as well as extreme pain including dysesthesia, allodynia, and painful electric shock sensations. Neurologic Pain: ALS Pain in ALS is associated with decondition and loss of muscle mass, spasticity, muscle fasciculation (muscle twitching) Hematologic Pain: Sickle Cell Disease Sickle Cell Disease - pain is severe and acute, focal (bone, joint, and muscle) and visceral from ischemia and infarction Types of Pain: Acute vs Chronic Acute - Usually clear cause, maybe observable signs (increase HR, BP, non-verbal S/S). Can be warning sign (example - MI, postop, acute appendicitis) Chronic - etiology unclear, does not serve purpose, often associated with decreased social interaction, insomnia, depressed affect Quality of Pain: Nociceptive Pain Nociceptive Pain includes Somatic and Visceral pain Quality of Pain: Somatic A type of nociceptive pain. Well-localized. Often described as deep, dull ache. Examples: Bone mets, inflammation of soft tissue, tumor invasion. Quality of Pain: Visceral A type of nociceptive pain Poorly localized. Cramping, deep ache, pressure, often referred to distant sites. Examples: Bowel obst., cholecystitis, Very common in mets to liver, pancreas, lower esophagus, stomach, or retroperitoneal area to have referred pain to the back. Gallbladder liver - in back or right shoulder. Rectosigmoid - pain in sacrum/rectal area Quality of Pain: Neuropathic Described as sharp, burning, shooting, shock-like Examples: Spinal nerve root compression, tumor invasion, neuralgia, phantom limb pain. Opioids relieve neuropathic pain, but higher doses usually indicated. Adjuvant analgesics indicated. Non-opioid analgesics are rarely beneficial. What types of medications do you want to give for neuropathic pain? Opioids, but typically require higher doses. Utilize adjuvant analgesics. Non-opioids rarely help this type of pain. Biopsychosocial Model of Pain Numerous variable influence experience of pain. Total pain includes physical, psychological, social, spiritual. When adequate assessment and management of symptoms precede psychological social, and spiritual assessment and intervention, overall outcomes often improve. Common Effects of Pain: Physical Decreased functioning ability, decreased strength and endurance, nausea, anorexia, insomnia, and impaired immune response. Common Effects of Pain: Psychological Increased fear, anxiety, depression, hopelessness, despair, loss of control. If pain uncontrolled, consideration of suicide/physician assisted suicide. Common Effects of Pain: Social Effects Alt to social and close relationships (roles, responsibility, intimacy, sexual function), loss of self-esteem and worth. Common Effects of Pain: Spiritual and Existential Increased suffering, reevaluation and perhaps doubt regarding religious foundations/beliefs, questioning the meaning of suffering. Common Effects of Pain: Financial Inability to work or earn income, loss of caregiver income, issues of workplace discrimination, applying for government assistance, loss of health insurance Common Effects of Pain: Cultural Issues Ethnic miniority, females, and the elderly receive less than optimal pain management -Consider origins and manner of expressing pain. How might suffering be valued? - Explore perceptions of pain, EOL, afterlife