Step 2 CK · Ethics, Biostatistics & Patient Safety

End-of-Life & Difficult Conversations

Name: End-of-Life & Difficult Conversations
Creator: Veli Bakalov, MD

Palliative vs hospice, withdrawing care, SPIKES, and who decides

Ethics, Biostatistics & Patient Safety·Ethics·5 min read·9 high-yield points·Reviewed by Veli Bakalov, MD @HemeOncBuddy

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High-yield

Palliative care = symptom and quality-of-life focus at any stage, concurrent with curative treatment; hospice = comfort care for a prognosis ≤6 months, forgoing cure (Medicare hospice benefit); children under 21 on Medicaid or CHIP may get hospice alongside curative care.
DNR/DNI limit only CPR or intubation; all other indicated care (antibiotics, analgesia, even surgery) continues, so clarify each intervention.
POLST/MOLST are clinician-signed portable orders EMS can act on now; advance directives are the patient's own documents guiding future care if capacity is lost.
Withholding and withdrawing treatment (including ventilators and feeding tubes) are ethically and legally equivalent; withdrawing unwanted life support is not euthanasia.
No duty to provide futile care, but involve the family, second opinions, and the ethics committee before any unilateral decision.
Double effect: opioids titrated for comfort are ethical even if they may hasten death; fear of this never justifies undertreating pain or dyspnea.
PAD (patient self-administers a prescribed lethal dose) is legal in some states, starting with Oregon in 1997; euthanasia (physician administers) is illegal throughout the US.
SPIKES: Setup, Perception, Invitation, Knowledge (warning shot, then plain language), Emotions, Strategy/Summary; small chunks and silence.
Decision order: patient's wishes → appointed proxy (outranks even the spouse) → spouse → adult children → parents → siblings; substituted judgment before best interest.

Care models, code status, and documents

Palliative care focuses on symptom relief and quality of life and can run alongside curative treatment at any disease stage or prognosis. It is a philosophy of care, not a place or a prognosis threshold. Hospice provides comfort-focused care for terminal illness when the prognosis is 6 months or less if the disease runs its usual course. Patients forgo curative and life-prolonging therapy, and care is covered by the Medicare hospice benefit. Children under 21 on Medicaid or CHIP are the exception: they may receive hospice concurrently with curative treatment (ACA concurrent care provision).

Palliative care vs hospice

Feature	Palliative care	Hospice
Prognosis	Any stage or prognosis	≤6 months
Curative therapy	Concurrent	Forgone; comfort only
Example	Metastatic cancer on chemotherapy aimed at cure, needing aggressive symptom control	Patient who stops chemotherapy to focus on comfort at home

DNR is not "do not treat." DNR (do not resuscitate) and DNI (do not intubate) orders limit only CPR or intubation. The patient still receives every other indicated treatment: antibiotics, analgesia, dialysis, even surgery. Clarify each intervention separately rather than assuming one limit implies another. Before surgery, revisit the DNR order with the patient instead of suspending it automatically.

Advance directives vs POLST

Feature	Advance directive (living will, health-care proxy)	POLST / MOLST
What it is	The patient's own legal document	A portable medical order signed by a clinician
Who it is for	Any adult	The seriously ill
When it applies	Guides future care if capacity is lost	Now, across all care settings
EMS can act on it?	Not directly	Yes, immediately

Withholding, withdrawing, and futility

Withholding equals withdrawing. Ethically and legally, not starting a treatment (withholding) and stopping one already begun (withdrawing) are equivalent. Any treatment, including a ventilator, dialysis, or a feeding tube providing artificial nutrition and hydration, may be withdrawn when that matches the patient's wishes. Removing a ventilator from a patient whose valid living will refuses life support allows death from the underlying disease; it is not killing and needs no court order. Treat dyspnea and distress proactively during withdrawal.

Clinicians sometimes feel that stopping a treatment is "worse" than never starting it. That discomfort is not an ethical distinction, and it should never deter a time-limited trial of therapy.

Futility. Physicians are not obligated to offer treatment that cannot achieve its physiologic goal. Because "futility" is contentious, involve the family, obtain second opinions, and consult the ethics committee before any unilateral decision, following the institution's process.

Hastening death: double effect, PAD, and euthanasia

Doctrine of double effect. Giving escalating opioids or sedatives to relieve suffering is ethical even if it may foreseeably hasten death, as long as the intent is symptom relief and not death. Fear of hastening death is never a reason to undertreat pain or dyspnea. Document the goal as symptom relief, titrate to comfort, and explain this to families who fear the morphine "will kill him."

End-of-life actions compared

Action	Who acts	Intent	US status
Withdrawing or withholding treatment	Team stops or does not start an unwanted treatment	Honor the patient's wishes	Legal and ethical
Double-effect symptom relief	Physician titrates opioids or sedatives	Comfort; death foreseen but unintended	Legal and ethical
Physician-assisted death (PAD)	Physician prescribes; a terminally ill, competent patient self-administers	Patient-chosen death	Legal in some states (Oregon Death with Dignity Act, 1997, and others)
Euthanasia	Physician administers the lethal agent	Death	Illegal throughout the US

Where PAD is legal, physicians may decline to participate but should not abandon the patient.

Breaking bad news: SPIKES

S: SetupPrivate room, sit down, silence phones, include whom the patient wants.
P: PerceptionAsk what they already know or suspect.
I: InvitationAsk how much they want to know; get permission before details.
K: KnowledgeGive a warning shot, then state the news plainly, without jargon.
E: EmotionsRespond with empathy; name the emotion and allow silence.
S: Strategy/SummaryAgree on next steps and check understanding.

The SPIKES protocol

Pace the information. Deliver news in small chunks, pause often, and let silence do some of the work. Respond to emotion before adding more facts, because a patient flooded with feeling cannot absorb data.

Culture and disclosure preferences. Some patients and cultures prefer family-centered decisions or non-disclosure of a terminal diagnosis. Rather than assuming, ask the patient: "How do you like to receive medical information?" Honor the answer while preserving the patient's own right to know or to defer to family. When relatives ask you to hide a diagnosis, explore their concerns, then ask the patient how much they want to know. Do not simply agree or refuse.

Who decides: surrogates and standards

The patientCurrent wishes if capacitated; otherwise prior expressed wishes or advance directive.
Appointed health-care proxyDurable power of attorney for health care; outranks all family, even the spouse.
SpouseFirst default surrogate.
Adult childrenThen parents, then adult siblings, then other relatives.

Decision-making order (default list varies by state)

A brother named years ago as health-care proxy outranks an adult daughter who disagrees. The appointment, not the closeness of kinship, decides.

Substituted judgment first. Surrogates should decide what this patient would have wanted, based on prior statements and values, not what they themselves would choose. Only when the patient's wishes are unknown do they fall back on the best-interest standard (what a reasonable person would choose). When family members disagree, return the conversation to the patient's own voice: "What would he say if he could join us?"