Palliative Care & Symptom Management

Palliative care versus hospice

Palliative care relieves symptoms and suffering in any serious illness, at any stage, and alongside curative or disease-directed treatment. Hospice is a subset of palliative care for patients with a prognosis of 6 months or less who choose comfort-focused care and forgo curative therapy. All hospice is palliative, but not all palliative care is hospice.

The Medicare Hospice Benefit. Two physicians certify a prognosis of 6 months or less if the illness follows its usual course. The patient elects comfort care, waiving Medicare payment for curative treatment of the terminal illness. Patients who outlive the estimate can be recertified, so hospice is not revoked for surviving, and patients can revoke hospice and return to disease-directed care at any time.

Early palliative care is not "giving up." In metastatic lung cancer (Temel, NEJM 2010), adding it at diagnosis improved quality of life and even survival.

Goals-of-care conversations. Elicit the patient's values, what matters most, and what they fear, then align treatment with those goals. Prognosticate honestly and avoid over-optimism, respond to emotion before giving more information, and make a recommendation rather than handing over a menu. Avoid "Do you want us to do everything?"; frame the options against the patient's stated goals.

Cancer pain and opioid dosing

Adjuvants can be added at any step: a TCA or anticonvulsant for neuropathic pain, and a corticosteroid for bone pain, nerve compression, or swelling.

Baseline plus breakthrough. For constant pain, give a long-acting opioid around the clock plus a short-acting breakthrough dose of about 10% (10–15%) of the total 24-hour opioid dose, available every 1–4 hours as needed. Pure μ agonists such as morphine have no ceiling dose, so titrate to effect. If the patient keeps needing many breakthrough doses, raise the scheduled baseline dose, typically by folding the day's breakthrough use into it.

Opioid rotation. When switching opioids because of toxicity or poor response, calculate the equianalgesic dose of the new drug and then reduce it by 25–50%, because cross-tolerance is incomplete, before titrating. Methadone and transdermal fentanyl need extra caution because their conversions are nonlinear.

In renal failure, avoid morphine and codeine, whose active metabolites accumulate; hydromorphone or fentanyl is preferred. Avoid meperidine at the end of life (its metabolite normeperidine causes seizures).

Managing other symptoms

Constipation. Tolerance never develops to opioid-induced constipation (or miosis), so start a prophylactic stimulant laxative (senna, with or without docusate) with every opioid, adding an osmotic agent such as polyethylene glycol as needed. Avoid bulk-forming fiber, which worsens it. For refractory cases, use a peripherally acting μ antagonist (methylnaltrexone, naloxegol).

Dyspnea. A low-dose opioid such as morphine is first-line for the sensation of breathlessness in advanced illness. Supplemental oxygen helps only if the patient is hypoxemic and adds nothing when saturations are normal. A bedside fan or other airflow across the face helps. Add a benzodiazepine only for associated anxiety.

Nausea. Match the antiemetic to the mechanism:

Terminal delirium. Delirium is common near death. First look for reversible causes: medications, urinary retention, constipation, hypercalcemia, and infection. Use nonpharmacologic measures, then an antipsychotic (haloperidol) for agitation. Benzodiazepines, like anticholinergics, usually worsen delirium; reserve them for refractory terminal restlessness (palliative sedation) or for alcohol or benzodiazepine withdrawal.

End-of-life ethics

Doctrine of double effect. It is ethical to give enough opioid or sedative to relieve suffering even if it may foreseeably hasten death, provided that:

• The intent is symptom relief, not death; death is a foreseen but unintended risk
• The good effect is not achieved by means of the death
• The benefit is proportionate to the risk

Intent separates double-effect symptom relief from euthanasia, and double effect justifies aggressive symptom control at the end of life. Relieving a dying patient's air hunger with morphine is the right thing to do, and families who fear it will "kill him" deserve that explanation.

Advance directives

Living will vs healthcare proxy. A living will states which treatments the patient would want if incapacitated. A durable power of attorney for health care (healthcare proxy) names a surrogate decision-maker. It is generally more flexible, because the proxy can respond to situations no document anticipated, but which one prevails in a conflict varies by state; either way, the proxy must decide as the patient would have, following the patient's known wishes.

Surrogate standards. Surrogates use substituted judgment (what the patient would want) first, and fall back on the patient's best interests only when those wishes are unknown.

POLST or MOLST forms translate goals into portable medical orders, such as code status and the scope of treatment, for seriously ill patients, and they follow the patient across care settings.