Human Development

Palliative care: symptom management at end of life

Clinical Overview and When to Suspect End-of-Life Symptom Burden

— Metastatic cancer (especially lung, pancreatic) — early palliative consult improves QoL and may extend survival

— NYHA class III–IV heart failure with recurrent admissions

— GOLD stage D COPD with home oxygen, frequent exacerbations

— ESRD on dialysis with declining functional status

— Advanced dementia (FAST stage 7), Parkinson disease, ALS

— Frailty with the "surprise question" positive: "Would you be surprised if this patient died in the next 12 months?" If no, initiate goals-of-care discussion.

— Pain (70–80% of cancer patients)

— Dyspnea (50–70%, especially CHF, COPD, lung cancer)

— Delirium (>80% in last days)

— Nausea/vomiting, constipation, anorexia-cachexia, fatigue

— Secretions ("death rattle"), terminal restlessness

— Cancer with PPS ≤70% and disease progression

— Non-cancer: documented decline, weight loss >10%, albumin <2.5, recurrent infections, dependence in ≥3 ADLs

Palliative care is interdisciplinary care focused on relieving suffering and improving quality of life for patients with serious illness — provided alongside disease-directed therapy at any stage.

Hospice is a Medicare benefit subset of palliative care for patients with prognosis ≤6 months if disease follows its expected course, who forgo curative therapy for the qualifying illness.

When to integrate palliative care early:

Common end-of-life symptom clusters:

Hospice eligibility cues on Step 3:

Board pearl: Early palliative care referral in metastatic NSCLC (Temel trial) improved quality of life, reduced depression, and was associated with longer median survival despite less aggressive end-of-life care — making early integration a guideline-supported, evidence-based intervention, not a "giving up" decision.

Step 3 management: When a stem describes a patient with advancing serious illness and worsening function, the correct next step is often palliative care consultation — not another diagnostic workup or ICU transfer — particularly when goals of care have not yet been clarified.

Presentation Patterns and Key History

— Somatic: well-localized, aching (bone metastases)

— Visceral: deep, crampy, poorly localized (liver capsule, bowel)

— Neuropathic: burning, shooting, allodynia (chemo neuropathy, spinal cord compression)

— FICA (Faith, Importance, Community, Address) for spiritual assessment

— Screen depression with PHQ-2; anhedonia and hopelessness, not somatic symptoms, are most specific in advanced illness

— Existential distress, fear of being a burden, anticipatory grief

— "Ask-Tell-Ask" and NURSE (Name, Understand, Respect, Support, Explore) for emotion

— Document understanding of prognosis, values, acceptable trade-offs, surrogate decision-maker

— Karnofsky or Palliative Performance Scale (PPS) — PPS ≤50% suggests months; ≤30% weeks; ≤20% days

— ECOG 3–4 in cancer signals limited disease-directed options

Pain history — use OPQRST plus prior opioid exposure, opioid-naïve vs tolerant, breakthrough frequency

Dyspnea: assess at rest vs exertion, orthopnea, anxiety component; patient self-report is the gold standard — RR and SpO2 correlate poorly with perceived breathlessness.

Nausea: identify mechanism (opioid-induced, constipation, increased ICP, vestibular, gastric stasis, chemotherapy) — drives antiemetic choice.

Constipation: ask about last bowel movement on every visit; near-universal with opioids.

Delirium: family reports fluctuating attention, sleep–wake reversal, hallucinations, agitation or hypoactive withdrawal — screen with CAM.

Anorexia-cachexia: weight loss, early satiety, muscle wasting — distinguish from reversible causes (depression, oral candidiasis, constipation).

Psychosocial/spiritual history:

Goals-of-care clarification:

Functional status:

Key distinction: Total pain (Cicely Saunders) encompasses physical, psychological, social, and spiritual suffering — uncontrolled pain despite escalating opioids often reflects unaddressed psychosocial or spiritual distress, and the next step is chaplain, social work, or counseling involvement, not simply more morphine.

Physical Exam Findings and Functional Assessment

— Temporal wasting, sarcopenia, bitemporal hollowing → advanced disease

— Mottling of knees/feet (livedo reticularis) → death typically within hours to days

— Declining BP, irregular pulse, Cheyne–Stokes or agonal breathing

— Cool extremities, decreased urine output, mandibular breathing

— Decreasing level of consciousness, semipurposeful movements, terminal restlessness

— Pinpoint pupils → opioid effect; myoclonus → opioid neurotoxicity or uremia

— CAM-positive delirium: acute onset, fluctuating, inattention + disorganized thinking or altered consciousness

— Tachypnea, accessory muscle use, death rattle (oropharyngeal secretions pooling — distressing to family more than patient)

— Wheeze, crackles guide reversible-cause assessment

— Distension, tympany, absent bowel sounds → constipation/obstruction

— Hepatomegaly with capsular pain in liver mets

— Kennedy terminal ulcers — rapidly developing sacral pressure injuries in dying patients; not preventable, not a quality indicator

— Jaundice, pruritus excoriations in cholestasis

— PPS 100→0% in 10-point increments based on ambulation, activity, self-care, intake, consciousness

— Used for hospice eligibility documentation and prognostication

General appearance and cachexia:

Vital sign trends near end of life:

Neurologic:

Respiratory:

Abdominal:

Skin:

Oral exam: thrush (impairs nutrition, comfort), mucositis, dryness — easy reversible contributors to anorexia.

Functional/PPS scoring:

Board pearl: Mottling, mandibular ("guppy") breathing, and the death rattle are reliable signs of imminent death (hours–days). Recognizing these prompts a shift to comfort-focused orders: discontinue routine vitals, labs, finger sticks, non-essential meds, and reposition for comfort while preparing the family with anticipatory guidance about what to expect.

Diagnostic Workup — Targeted, Comfort-Focused Evaluation

— New severe back pain in cancer → urgent MRI for cord compression if patient would accept radiation/surgery and prognosis warrants

— Bone pain → plain films or bone scan only if treatment (radiation, bisphosphonate) is on the table

— CXR for pleural effusion (thoracentesis can relieve), pneumonia, pulmonary edema

— BNP, troponin only if treating decompensation aligns with goals

— D-dimer/CTPA rarely indicated unless PE treatment would alter trajectory

— Abdominal exam, KUB for constipation/obstruction

— Basic metabolic panel: hypercalcemia (cancer), uremia, hyponatremia all cause nausea and delirium

— Brain imaging only if focal neuro findings and treatment (steroids, radiation) is desired

— Medication review (anticholinergics, benzodiazepines, opioids)

— BMP, calcium, glucose, UA, pulse ox; consider TSH, B12 if longer trajectory

— Avoid LP, MRI in actively dying patients

— Routine CBC, BMP, coags, glucose checks, telemetry, daily weights

Diagnostic principle: every test must answer "Will the result change management in a way consistent with the patient's goals?" If not, defer.

Pain workup:

Dyspnea reversible-cause check (if consistent with goals):

Nausea workup:

Delirium workup — limited targeted panel:

Constipation: abdominal exam + rectal exam to exclude impaction before escalating laxatives.

Labs to stop in actively dying patients:

CCS pearl: In a hospice/comfort-care CCS case, ordering aggressive workups (CT, MRI, repeat labs, ABGs) lowers your score. Correct moves: discontinue non-comfort orders, order PRN opioid, antiemetic, antisecretory, anxiolytic, consult chaplain/social work, address family meeting, and update advance directive/POLST documentation.

Prognostication Tools and Confirmatory Assessment

— Palliative Performance Scale (PPS) — 0–100%, the most-cited bedside tool

— Karnofsky Performance Status — similar, cancer-oriented

— Palliative Prognostic Index (PPI) — incorporates PPS, intake, edema, dyspnea, delirium

— Seattle Heart Failure Model for HF

— BODE index for COPD (BMI, Obstruction, Dyspnea, Exercise)

— Decreased oral intake, bedbound, only sips of water, decreased consciousness, PPS ≤30%

— Loss of interest in surroundings, withdrawal

— CHF: NYHA IV, optimal therapy, EF ≤20%, recurrent arrhythmias/syncope

— COPD: dyspnea at rest, FEV1 <30%, cor pulmonale, hypoxemia on O2

— Dementia: FAST stage 7, ≥1 of aspiration pneumonia, pyelonephritis, septicemia, stage 3–4 ulcer, recurrent fever, weight loss >10%

— ESRD: not pursuing dialysis, CrCl <10, Cr >8

— Liver disease: INR >1.5, albumin <2.5, plus refractory ascites/SBP/encephalopathy/HRS

— Use time ranges ("hours to days," "weeks to short months") rather than precise estimates

— Acknowledge uncertainty; check readiness with "Ask-Tell-Ask"

— Document conversation, surrogate identification, code status, POLST/MOLST completion

— Advance directive / living will — patient-authored, activated when decisional capacity lost

— POLST / MOLST — physician orders, portable across settings, actionable immediately

— Durable power of attorney for healthcare (healthcare proxy)

Prognostication frameworks (Step 3 favors these by name):

Cancer-specific signals of weeks-to-days prognosis:

Non-cancer hospice qualifying criteria (Medicare local coverage determinations):

Communicating prognosis:

Advance care planning instruments:

Key distinction: A living will expresses preferences and requires a clinician to translate them into orders, while a POLST/MOLST is itself a medical order signed by a clinician that travels with the patient and is honored by EMS — Step 3 will reward recognizing which document governs prehospital and inter-facility care.

Symptom Management Logic — Stepwise Framework

— Anticipate common symptoms; write PRN orders before symptom escalates

— Treat the mechanism when known (e.g., opioid-induced nausea vs increased ICP nausea)

— Titrate to effect with short-acting agents, then convert to scheduled long-acting once stable

— Reassess within 24 hours of changes; document response on 0–10 scale

— Step 1: non-opioid (acetaminophen, NSAID) ± adjuvant

— Step 2: weak opioid (codeine, tramadol) — frequently skipped in modern practice for moderate-severe cancer pain

— Step 3: strong opioid (morphine, hydromorphone, oxycodone, fentanyl, methadone) ± non-opioid ± adjuvant

— PO preferred while patient can swallow

— When PO fails: subcutaneous infusion or boluses (preferred at home/hospice over IV), buccal/sublingual concentrates, transdermal patch (fentanyl) for stable pain

— Avoid IM (painful, erratic absorption)

— Neuropathic: gabapentin, pregabalin, duloxetine, TCAs

— Bone: NSAIDs, bisphosphonates, denosumab, palliative radiation

— Visceral/capsular: dexamethasone

— Malignant bowel obstruction: octreotide, dexamethasone, haloperidol, scopolamine

General framework for any end-of-life symptom:

WHO analgesic ladder (still board-tested):

Choosing the route:

Breakthrough dosing rule: 10–20% of 24-hour total opioid dose q1h PRN (PO) or q15–30min PRN (IV/SC).

If ≥3 breakthrough doses/day used → increase scheduled dose by sum of breakthroughs or by 25–50%.

Adjuvants by pain type:

Step 3 management: A cancer patient on MS Contin 30 mg PO BID (60 mg/day) requiring frequent breakthroughs should have breakthrough morphine IR 5–10 mg PO q1h PRN (10–15% of 60 mg). If using ≥3 doses/day consistently, escalate scheduled dose by ~50% to MS Contin 45 mg BID — do not simply add another non-opioid or refuse escalation due to "tolerance" concerns in end-of-life care.

Pharmacotherapy — Opioids and Core Symptom Drugs

— Morphine PO 30 mg = Morphine IV 10 mg = Hydromorphone PO 7.5 mg = Hydromorphone IV 1.5 mg = Oxycodone PO 20 mg

— When rotating opioids, reduce calculated equianalgesic dose by 25–50% for incomplete cross-tolerance

— Low-dose opioid (morphine 2.5–5 mg PO or 1–2 mg SC q4h) — first-line, evidence-based

— Fan to face, positioning, oxygen only if hypoxic (no benefit in normoxic dyspnea)

— Anxiolytic (lorazepam 0.5–1 mg) as adjunct if anxiety component

— Opioid-induced: haloperidol, metoclopramide, ondansetron

— Gastric stasis: metoclopramide

— Increased ICP: dexamethasone

— Vestibular: meclizine, scopolamine

— Chemotherapy: 5-HT3 antagonist + dexamethasone ± NK1 antagonist

— Senna ± polyethylene glycol scheduled; avoid bulk fiber (worsens without hydration)

— Refractory: methylnaltrexone, naloxegol (peripheral mu-antagonists)

Morphine — first-line for pain and dyspnea; renally cleared metabolites (M3G, M6G) accumulate in CKD → myoclonus, delirium.

Hydromorphone — preferred in renal impairment; ~5× more potent than morphine PO.

Oxycodone — PO only (in US); useful when morphine intolerance.

Fentanyl — transdermal patch for stable pain only (steady state 12–24 h); safe in renal failure; not for opioid-naïve patients or acute titration.

Methadone — long half-life, NMDA antagonist (helpful for neuropathic pain); QT prolongation, complex conversion — specialist use.

Avoid meperidine (normeperidine seizures) and codeine (CYP2D6 variability).

Opioid equianalgesic basics (PO morphine equivalents):

Dyspnea:

Nausea — pick by mechanism:

Constipation prophylaxis — mandatory with every opioid prescription:

Delirium/terminal agitation: haloperidol 0.5–2 mg q2–4h PRN; add lorazepam if benzodiazepine withdrawal or seizures; avoid benzos as monotherapy (worsens delirium).

Secretions ("death rattle"): glycopyrrolate 0.2 mg SC (no CNS effect, preferred) or scopolamine patch; reposition; minimize IV fluids.

Board pearl: Low-dose oral or parenteral opioids relieve dyspnea without hastening death — this is the doctrine of double effect in action and is the standard of care for refractory breathlessness in advanced cancer, COPD, and heart failure.

Procedures and Non-Pharmacologic Interventions

— Palliative radiation — single-fraction 8 Gy effective for painful bone metastases; ~60–80% response

— Vertebroplasty/kyphoplasty for vertebral compression fractures

— Celiac plexus block for pancreatic/upper abdominal cancer pain

— Intrathecal pump for refractory cancer pain with prolonged prognosis

— Nerve blocks, epidural for localized pain

— Therapeutic thoracentesis for symptomatic effusion; indwelling pleural catheter (PleurX) for recurrent malignant effusion

— Airway stenting for malignant central airway obstruction

— Noninvasive ventilation — short-term for reversible exacerbations; controversial at end of life unless aligned with goals

— Venting gastrostomy (PEG) for malignant bowel obstruction not amenable to surgery

— Paracentesis or tunneled peritoneal catheter for refractory ascites

— Biliary stenting for malignant obstruction with pruritus/cholangitis

— Artificial nutrition (TPN, PEG) in advanced dementia does not improve survival, aspiration, or pressure ulcers — recommend careful hand feeding instead

— IV/SC hydration may worsen secretions, edema, dyspnea in actively dying patients; case-by-case

— Reserved for refractory suffering (intractable pain, dyspnea, delirium) at end of life

— Use midazolam infusion with informed consent and ethics framework; intent is symptom relief, not death

— Distinct from physician-assisted dying (legal in some US states; intent and agent differ)

Palliative procedures should be goal-concordant, low-burden, and offer durable symptom relief.

Pain:

Dyspnea:

GI:

Hydration/nutrition at end of life:

Palliative sedation:

Step 3 management: A patient with advanced dementia and recurrent aspiration who is no longer eating — recommend comfort feeding by hand and decline PEG placement. Counsel the family that tube feeding does not prolong life or reduce aspiration in this population (AGS Choosing Wisely).

Special Populations — Elderly and Renal/Hepatic Impairment

— Start opioids at 25–50% lower doses; longer dosing intervals due to decreased clearance

— Avoid Beers Criteria offenders: meperidine, long-acting benzodiazepines, anticholinergics, NSAIDs (in CKD/CHF/PUD)

— Higher risk of opioid-induced delirium, constipation, urinary retention

— Use acetaminophen as analgesic backbone (max 3 g/day in frail elderly)

— Avoid morphine and codeine — active metabolites accumulate → myoclonus, sedation, respiratory depression

— Preferred: fentanyl, methadone, buprenorphine (no active renal-cleared metabolites)

— Hydromorphone: metabolite H3G accumulates but better tolerated than morphine; use cautiously

— Adjust gabapentin/pregabalin (renally cleared) — gabapentin 100–300 mg/day in advanced CKD

— Many ESRD patients qualify for hospice if stopping dialysis — typical survival 8–10 days after dialysis discontinuation

— Reduced first-pass metabolism → start low, extend intervals

— Avoid acetaminophen >2 g/day in cirrhosis

— Avoid NSAIDs (variceal bleeding, HRS)

— Morphine clearance reduced; fentanyl and methadone require dose reduction but are generally preferred

— Benzodiazepines accumulate → encephalopathy; if needed, use lorazepam, oxazepam, temazepam (LOT — glucuronidated, no active metabolites)

— Deprescribe statins, bisphosphonates, vitamins, tight glycemic agents in last weeks

— Continue: analgesics, antiemetics, anxiolytics, antiepileptics if seizure-prone

Elderly considerations:

CKD/ESRD:

Hepatic impairment:

Polypharmacy review:

Key distinction: In end-stage renal disease with pain, morphine is contraindicated due to M6G accumulation causing neurotoxicity and respiratory depression — switch to fentanyl patch (stable pain) or hydromorphone/methadone (acute titration). On Step 3, "hospice patient with CKD started on morphine, now myoclonic and obtunded" is a classic rotate-the-opioid stem.

Special Populations — Pregnancy, Pediatrics, Veterans, Cultural Subgroups

— Concurrent care under ACA — children on Medicaid/CHIP may receive hospice and disease-directed therapy simultaneously (unlike adult Medicare hospice)

— Use validated pain scales by age: FLACC (preverbal), Wong-Baker faces (3–8 y), numeric (>8 y)

— Common conditions: congenital syndromes, neurodegenerative disease, pediatric malignancies

— Involve child-life specialists; assent from child when developmentally appropriate

— Maternal palliative care while balancing fetal considerations

— Avoid teratogenic agents (NSAIDs in 3rd trimester, certain anticonvulsants)

— Opioids: avoid chronic use near delivery (neonatal abstinence); short-term safe for acute symptoms

— Lethal fetal anomalies (e.g., trisomy 13/18, anencephaly) — birth planning with comfort care, bereavement support, photography, memory making

— Higher rates of PTSD, moral injury, substance use — affect end-of-life distress and opioid management

— VA offers integrated hospice; ask about combat history ("We Honor Veterans" program)

— Verify chosen surrogate — default state hierarchies may exclude partners without documentation

— Encourage durable power of attorney for healthcare and hospital visitation directives

— Some traditions discourage explicit prognosis disclosure → ask "How much information do you want?"

— Dietary, prayer, body-handling practices after death — consult chaplaincy

— Avoid assumptions; ask each patient

Pediatric palliative care:

Pregnancy with serious illness:

Perinatal palliative care:

Veterans:

LGBTQ+ patients:

Cultural and religious considerations:

Limited English proficiency: use certified medical interpreters — never family members for goals-of-care discussions (Joint Commission, federal regulation).

Board pearl: Pediatric hospice under the ACA permits concurrent curative and hospice care, removing the "either/or" forced on adult Medicare patients — a frequently tested policy distinction on Step 3 health-systems questions.

Complications and Adverse Outcomes of Therapy

— Constipation — universal, does not develop tolerance; prophylax always

— Sedation, respiratory depression — usually only with rapid escalation or naïve patients; tolerance develops to respiratory effects

— Nausea — tolerance develops in 3–5 days; pretreat with antiemetic

— Pruritus — histamine release (morphine); rotate to fentanyl/oxycodone

— Myoclonus, hyperalgesia, delirium = opioid neurotoxicity — rotate opioid, hydrate, reduce dose

— Urinary retention — especially elderly

— Naloxone 0.04–0.4 mg IV titrated to respiratory rate (not LOC) in palliative patients to avoid precipitating severe withdrawal and pain crisis

— In comfort care, low RR alone is not an indication for reversal if patient is comfortable

— Paradoxical agitation in elderly/delirium; worsens hyperactive delirium

— Avoid as first-line for terminal restlessness — use haloperidol

— Metoclopramide, haloperidol → EPS, NMS, QT

— Ondansetron → constipation, QT

— Scopolamine → anticholinergic delirium

— Abrupt opioid stop → withdrawal (anxiety, diarrhea, mydriasis, sweating)

— Abrupt benzo stop → seizures

— Taper gradually unless toxicity demands rotation

Opioid adverse effects:

Opioid overdose management:

Benzodiazepine pitfalls:

Steroid complications: hyperglycemia, candidiasis, myopathy, insomnia, agitation — taper if not benefiting.

NSAIDs: GI bleed, AKI, fluid retention — avoid in HF, CKD, cirrhosis.

TCAs: anticholinergic delirium, orthostasis, QT prolongation.

Methadone: QT prolongation — check baseline ECG; avoid with QTc >500 ms.

Antiemetic adverse effects:

Discontinuation syndromes:

Step 3 management: A cancer patient on chronic morphine develops myoclonus, confusion, and hyperalgesia — diagnose opioid neurotoxicity, rotate to hydromorphone or fentanyl at 50–75% of equianalgesic dose, ensure hydration, and treat myoclonus with low-dose benzodiazepine if persistent.

When to Escalate Care — Consults, Specialty Palliative, Crisis Triage

— Refractory symptoms despite first-line management

— Complex family dynamics or surrogate disagreement

— Existential/spiritual distress beyond primary team's scope

— Goals-of-care ambiguity in serious illness

— Request for hastened death — explore meaning, treat depression, address symptoms

— Prognosis ≤6 months AND patient/family elect comfort focus

— Repeated ED/hospital admissions for advanced disease

— Functional decline despite optimal disease-directed therapy

— Routine home care — most common

— Continuous home care — crisis-level symptom control at home (≥8 h/day, mostly nursing)

— General inpatient (GIP) — acute symptom crisis not manageable at home

— Respite care — up to 5 days to relieve caregivers

— Patient with documented DNR/DNI and goals favoring comfort

— Advanced disease where ICU prolongs dying without restoring function

— Use time-limited trial if uncertainty: define endpoints and duration upfront

— Comfort kit (hospice common): liquid morphine, lorazepam, haloperidol, atropine drops, acetaminophen suppositories

— 24/7 hospice nurse hotline; on-call visits

— Confirm and document code status on every admission; POLST/MOLST honored across settings

— DNR ≠ "do not treat" — patients still receive symptom management, antibiotics if goal-concordant

Specialty palliative care consultation indicated when:

Hospice referral triggers:

Levels of hospice care (Medicare benefit):

When NOT to escalate to ICU:

Crisis symptom management at home:

Rapid response and code status:

CCS pearl: When a hospice patient deteriorates in the ED, the first move is to confirm code status and goals of care, contact the hospice agency, and arrange GIP-level hospice transfer for symptom crisis — not intubation, central line, or pressors. Aggressive interventions discordant with goals lower the CCS score.

Key Differentials — Other Causes of End-of-Life Symptoms

— Urinary retention with bladder distension

— Fecal impaction (rectal exam)

— Pressure injury, oral mucositis

— Pathologic fracture

— Spinal cord compression (urgent dexamethasone + MRI + radiation if goal-concordant)

— Pneumonia (treat if consistent with goals)

— Pleural effusion (drain)

— CHF exacerbation (diuresis)

— Pulmonary embolism

— Anemia (transfusion if symptomatic and goal-concordant)

— Bronchospasm (nebulizers)

— Constipation, partial bowel obstruction

— Hypercalcemia (treat with hydration ± bisphosphonate if life expectancy supports)

— Hyponatremia, uremia

— Medication side effect (digoxin, antibiotics, chemo)

— Increased ICP from brain mets (dexamethasone)

— Drugs (opioids, benzos, anticholinergics, steroids)

— Infection (UTI, pneumonia)

— Metabolic (Na, Ca, glucose, urea)

— Hypoxia, hypercapnia

— Urinary retention, fecal impaction

— Withdrawal (alcohol, benzos)

— Depression (treat with SSRI or stimulant methylphenidate for rapid effect)

— Hypothyroidism, anemia, hypogonadism, adrenal insufficiency

— Oral thrush (treat with nystatin/fluconazole)

Pain — distinguish reversible contributors:

Dyspnea — reversible causes:

Nausea — reversible:

Delirium — reversible (mnemonic DELIRIUM / I WATCH DEATH):

Fatigue/anorexia:

Key distinction: Hypoactive delirium (quiet, withdrawn, inattentive) is frequently misdiagnosed as depression or just "dying" — it carries worse prognosis than hyperactive delirium and demands an active reversible-cause workup (medications, infection, metabolic) before attributing to terminal decline.

Key Differentials — Distinguishing Syndromes and Mimics

— Depression: pervasive anhedonia, hopelessness, worthlessness, suicidal ideation — treat with SSRI (citalopram, sertraline) or methylphenidate if prognosis weeks (faster onset)

— Demoralization: loss of meaning, helplessness with preserved capacity for pleasure — meaning-centered psychotherapy

— Anticipatory grief: waves of sadness, intact function — normalize, support

— Adjustment disorder: time-limited stress response

— Delirium: acute, fluctuating, inattention, altered consciousness

— Dementia: chronic, progressive, attention relatively preserved until late

— Depression: psychomotor slowing, intact cognition (though "pseudodementia" possible)

— Restlessness in last days: often multifactorial (uremia, hypoxia, unresolved psychosocial issues) — treat with haloperidol; consider midazolam if refractory

— Always check for pain, urinary retention, impaction, withdrawal first

— Cachexia: inflammatory, irreversible with nutrition; muscle loss out of proportion to intake — nutrition does not reverse

— Starvation: reversible with feeding

— Tolerance: needing more for same effect — expected, manageable

— Pseudoaddiction: drug-seeking behavior driven by undertreated pain — resolves with adequate analgesia

— True addiction: rare in end-of-life cancer pain; characterized by compulsive use, harm, loss of control

Depression vs demoralization vs grief vs adjustment:

Delirium vs dementia vs depression:

Terminal restlessness vs reversible agitation:

Cancer cachexia vs starvation:

Opioid tolerance vs disease progression vs pseudoaddiction:

Death rattle vs pulmonary edema vs pneumonia: rattle is upper airway secretions, position change and glycopyrrolate; lower airway pathology needs different approach if goal-concordant treatment chosen.

Board pearl: A dying patient appearing "agitated" — always rule out reversible drivers first (full bladder, impaction, pain, opioid withdrawal, hypoxia) before labeling as "terminal agitation" and adding sedatives. This sequence is a high-yield Step 3 trap.

Long-Term Plan, Bereavement, and Transitions of Care

— Interdisciplinary team: physician, nurse, social work, chaplain, home health aide, volunteer

— Visit frequency tailored to symptom burden; 24/7 phone availability

— Medications related to terminal diagnosis covered by hospice benefit; unrelated meds may not be

— Hospital → home hospice: ensure medications, equipment, oxygen, comfort kit arrive before discharge; warm handoff to hospice agency

— SNF + hospice possible (hospice provides services; SNF provides room/board, often patient/family pays)

— Inpatient hospice unit / GIP for symptom crises

— Changes in breathing (Cheyne–Stokes, apnea, rattle)

— Decreased intake → do not force feed/fluids; mouth care, ice chips, lip balm

— Skin mottling, cool extremities, decreased urine

— Hearing is thought to persist — encourage talking, music, presence

— Pronouncement, death certificate (immediate, intermediate, underlying causes)

— Medical Examiner notification for unexpected, traumatic, suspicious deaths (not routine hospice deaths)

— Organ/tissue donation discussion when appropriate (corneas, skin even after natural death)

— Autopsy offer when cause unclear or family requests

— Hospice provides bereavement support for 13 months to family (Medicare-mandated)

— Screen for complicated/prolonged grief disorder (>12 months persistent intense yearning, impairment) — refer for grief therapy

— Distinguish normal grief from major depression in survivors

Hospice plan of care:

Transitions:

Anticipatory guidance for family:

After death:

Bereavement:

Step 3 management: When discharging a patient to home hospice, the orders set should include: discontinue non-comfort meds, PRN morphine, lorazepam, haloperidol, glycopyrrolate, acetaminophen suppositories (comfort kit), bowel regimen, mouth care, hospital bed/oxygen as needed, and explicit hospice agency follow-up within 24–48 hours.

Follow-Up, Monitoring, and Caregiver Support

— Acute symptom changes: within hours

— Stable home hospice: nursing visits 1–3×/week, more frequently as decline progresses

— Outpatient palliative clinic: every 2–4 weeks for symptom monitoring, advance care planning updates

— Pain scores (0–10), function (PPS), bowel movements, intake, sleep, mood

— Medication side effects, opioid use trends, breakthrough frequency

— Caregiver burden — Zarit Burden Interview

— At every major clinical change (new diagnosis, hospitalization, functional decline)

— Update advance directive, POLST/MOLST, surrogate

— Respite care (up to 5 days inpatient under hospice Medicare benefit)

— Counseling, support groups

— Practical: home safety, equipment (hospital bed, commode, oxygen), training in medication administration, repositioning

— Recognize compassion fatigue, moral distress, burnout

— Debriefing after difficult deaths

— Schwartz Rounds, peer support, mindfulness

— Pain controlled within 48 hours of admission

— Dyspnea assessment and treatment

— Discussion of spiritual concerns

— Bereavement contact within 2 weeks of death

— CAHPS Hospice Survey family experience

— Normalize ambivalence ("hoping for the best, preparing for the worst")

— Use "hope reframing" — shift from cure to comfort, dignity, time with loved ones

— Address legacy work (letters, recordings, life review) when appropriate

Reassessment cadence:

Monitoring parameters:

Goals-of-care revisitation:

Caregiver support:

Self-care for clinicians:

Quality metrics in palliative/hospice care:

Counseling pearls:

CCS pearl: In longitudinal CCS cases, scheduling palliative care clinic follow-up at 2-week intervals during active symptom titration — with reassessment of pain, dyspnea, bowel function, mood, and goals — earns advancement-of-care credit; failing to follow up after starting opioids loses points.

Ethical, Legal, and Patient Safety Considerations

— Autonomy — patient's right to accept/refuse any treatment, including artificial nutrition/hydration and CPR

— Beneficence/nonmaleficence — comfort vs harm balance

— Justice — equitable access to palliative services

— Permits action with foreseen but unintended harmful consequence (e.g., opioid for dyspnea risking respiratory depression) when intent is symptom relief, action is proportionate, and good is not achieved through the bad effect

— Ethically and legally equivalent in US law — both are accepted patient refusals of treatment

— Includes ventilator withdrawal, dialysis cessation, ICD deactivation

— Legal in select US states (OR, WA, CA, CO, VT, NJ, NM, ME, HI, NY [pending], DC, MT [court])

— Requires terminal illness <6 months, decisional capacity, voluntary repeated requests, waiting periods, self-administration of the drug (distinguishing from euthanasia, which is illegal in US)

— Sedation intent: relieve refractory suffering; agent: sedative titrated to comfort; outcome: not aimed at death

— Distinct ethically and legally from hastened death

— Court-appointed guardian → DPOA-HC → spouse → adult children → parents → siblings

— Use substituted judgment first (what would patient want?), then best interest if unknown

— Task-specific; assess understanding, appreciation, reasoning, expression of choice

— Refusal of life-sustaining treatment by a capacitated patient is legally protected

— Elder abuse/neglect suspicion in home hospice — report to Adult Protective Services

— Suspicious deaths to medical examiner

— Medication reconciliation at every transition (hospital→home, home→hospice GIP)

— High-risk for opioid errors, duplicate orders, abrupt benzo withdrawal

— POLST/MOLST travels with patient — prevents unwanted CPR/intubation by EMS

Core ethical principles at end of life:

Doctrine of double effect:

Withholding vs withdrawing:

Physician-assisted dying (medical aid in dying):

Palliative sedation vs assisted dying:

Surrogate decision-making hierarchy (varies by state, typical order):

Decisional capacity:

Mandatory reporting:

Transition-of-care safety:

Step 3 management: A patient with capacity refuses tube feeding despite family insistence — the correct action is to honor the patient's refusal, document capacity and discussion, offer family meeting with palliative care/ethics support, and continue comfort-focused care. Family disagreement does not override a capacitated patient's autonomous choice.

High-Yield Associations and Rapid-Fire Clinical Facts

Morphine + CKD → myoclonus → switch to fentanyl or hydromorphone.

Bone metastasis pain → NSAID + opioid + single-fraction 8 Gy radiation + bisphosphonate/denosumab.

Malignant bowel obstruction (inoperable) → NPO trial → octreotide + dexamethasone + haloperidol + scopolamine; venting PEG if persistent.

Cord compression → dexamethasone 10 mg IV stat, urgent MRI, radiation oncology consult — preserve function if prognosis supports.

Hypercalcemia of malignancy → IV fluids + zoledronic acid or denosumab; calcitonin for rapid temporary relief.

SVC syndrome from malignancy → elevate head, steroids, radiation or stenting.

Death rattle → reposition + glycopyrrolate 0.2 mg SC; reduce IV fluids.

Terminal agitation → rule out reversible causes → haloperidol first-line; midazolam if refractory.

Opioid-induced constipation refractory to senna/PEG → methylnaltrexone SC.

Dyspnea in advanced disease, normoxic → low-dose opioid + fan; oxygen only if hypoxic.

Cancer-related anorexia → first treat reversible (thrush, constipation, depression); pharmacologic options (megestrol, mirtazapine, dexamethasone) of limited benefit; do not pursue PEG in advanced dementia.

Pediatric hospice under ACA → concurrent care with disease-directed therapy allowed.

Hospice eligibility = prognosis ≤6 months if disease runs expected course, forgo curative therapy for that diagnosis.

General inpatient hospice (GIP) = symptom crisis level of hospice care.

POLST/MOLST = portable medical orders honored by EMS; living will = patient-authored statement of preferences.

Bereavement support under hospice Medicare benefit = 13 months for family.

Methylphenidate = rapid-onset option for depression and fatigue when prognosis is weeks.

Mirtazapine = SSRI alternative useful for depression + insomnia + appetite loss in cachectic patients.

Withholding = withdrawing ethically and legally.

Surprise question: "Would you be surprised if this patient died in the next year?" — "No" triggers palliative planning.

Board pearl: Across organ systems, the single intervention that improves quality of life most consistently in advanced illness is timely palliative care consultation — and the Step 3 exam strongly rewards selecting it when offered as an answer choice.

Board Question Stem Patterns

Stem 1 — Early palliative consult in metastatic cancer: Newly diagnosed metastatic NSCLC, ECOG 1, on chemo. Best next step? → Early palliative care referral (improves QoL, may extend survival).

Stem 2 — Opioid rotation in CKD: Cancer patient on escalating morphine develops myoclonus and confusion, Cr 3.5. Next step? → Rotate to hydromorphone or fentanyl at reduced equianalgesic dose.

Stem 3 — Dyspnea in advanced COPD: GOLD D patient, SpO2 94%, dyspnea at rest despite max therapy. Next step? → Low-dose oral morphine; oxygen does not help if normoxic.

Stem 4 — Advanced dementia and feeding: Family asks about PEG for repeated aspiration. Best advice? → Recommend against PEG; offer careful hand feeding (no survival or aspiration benefit).

Stem 5 — Death rattle: Imminently dying patient with noisy upper airway secretions; family distressed. Best action? → Reposition + glycopyrrolate; counsel family that the patient is not suffering.

Stem 6 — POLST in EMS context: Patient with hospice and DNR is found apneic at home, family calls 911. EMS sees valid POLST/DNR. Action? → Do not initiate CPR; transport for comfort if needed.

Stem 7 — Terminal agitation workup: Cancer patient becomes agitated last 24 h. First step? → Check for bladder distension, fecal impaction, pain, opioid withdrawal, hypoxia; then haloperidol.

Stem 8 — Decisional refusal: Capacitated patient with metastatic cancer refuses chemo, family insists. Action? → Honor patient's autonomous choice.

Stem 9 — Hospice eligibility: NYHA IV CHF, EF 15%, 3 admissions in 6 months, optimal therapy. Best plan? → Hospice referral.

Stem 10 — Pediatric concurrent care: Child with metastatic neuroblastoma still receiving chemo — family wants hospice support. Answer? → Concurrent hospice + disease-directed therapy allowed under ACA.

Stem 11 — Methadone caution: Adding methadone for refractory neuropathic cancer pain. First step? → Baseline ECG to assess QTc.

Stem 12 — Bereavement red flag: Spouse 14 months after death with persistent intense yearning, impaired function. Diagnosis/Action? → Prolonged grief disorder; refer for grief-focused therapy.

Key distinction: Step 3 vignettes often hinge on distinguishing patient-centered comfort actions from default reflexive workups — when the stem emphasizes documented goals favoring comfort, the right answer is symptom-directed and goal-concordant, not another scan or ICU transfer.

One-Line Recap

Palliative care relieves suffering at any stage of serious illness through goal-concordant symptom management, advance care planning, and interdisciplinary support — and hospice extends that care to patients with ≤6-month prognosis who choose comfort over cure.

— Pain → opioids titrated by mechanism, with breakthrough = 10–20% of 24-h total; rotate for toxicity, switch from morphine in CKD

— Dyspnea → low-dose opioid first-line; oxygen only if hypoxic; fan and positioning adjuncts

— Nausea → match agent to mechanism (haloperidol/metoclopramide/ondansetron/dexamethasone/scopolamine)

— Constipation → prophylax with every opioid (senna + PEG); methylnaltrexone if refractory

— Delirium/terminal agitation → rule out reversible causes → haloperidol; avoid benzos as monotherapy

— Secretions → glycopyrrolate + repositioning; counsel family

— Use the surprise question to trigger goals-of-care discussions

— Withholding = withdrawing; doctrine of double effect justifies symptom-relieving opioids

— POLST/MOLST = portable medical order; living will = patient's written preferences

— Capacitated refusal of any treatment is legally protected, even over family objection

— Early palliative consult improves QoL and survival in metastatic cancer

— Pediatric concurrent care under ACA; adult Medicare hospice requires forgoing curative therapy for the qualifying diagnosis

— Bereavement support = 13 months under hospice Medicare benefit

— PEG in advanced dementia does not help — recommend hand feeding

Symptom toolkit recap:

Communication and ethics recap:

Systems and special-population recap:

Step 3 management: When a Step 3 stem describes advanced illness with worsening symptoms, declining function, or repeated admissions, the answer is almost always palliative care consultation, goals-of-care clarification, and goal-concordant symptom relief — rather than another diagnostic study, ICU escalation, or curative-intent intervention discordant with the patient's stated values.