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Palliative Care

BASICS

  • Definition: Focuses on preventing and alleviating suffering in patients and families at any stage of a life-limiting illness.
  • Goal: Improve or maintain quality of life despite serious illness, through relief of physical, emotional, social, or spiritual suffering.
  • Approach: Interdisciplinary team; identifies care goals based on patient/family values and preferences.
  • Setting: Hospital, rehab, skilled nursing, ambulatory.
  • Hospice: For patients with ≤6 months expected survival, focus is comfort, not cure; includes 24/7 support and bereavement care for families.

COMMONLY ASSOCIATED CONDITIONS

  • Physical: Chronic pain, neuropathic pain, bone metastases pain
  • GI: Ascites, cachexia, bowel obstruction, constipation, diarrhea, dysphagia, mucositis, xerostomia, nausea/vomiting
  • General: Delirium, fatigue
  • Pulmonary: Cough, dyspnea
  • Psychological: Anxiety, depression, insomnia
  • Skin: Decubitus ulcers, pruritus, complex wounds

DIAGNOSIS & ASSESSMENT

Tools

  • PEACE tool: Physical, Emotive/cognitive, Autonomy, Communication, Economic/practical issues
  • SPIKES: Six-step protocol for delivering bad news
  • Edmonton Symptom Assessment Scale: Comprehensive symptom review
  • FICA: Spiritual history (Faith, Importance, Community, Address)

History

  • Underlying conditions, symptoms, open-ended empathic inquiry
  • Review of psychological, social, spiritual, cultural, financial needs
  • Goals of care: Post-hospital care, hopes, fears, prognosis

Physical Exam

  • Symptom-driven, focused on maximizing function and comfort

DIAGNOSTIC TESTS

  • Order only if results will impact symptom management or goals
  • Avoid unnecessary investigations

TREATMENT

General Measures

  • Interdisciplinary approach: Address physical, emotional, social, spiritual suffering
  • Maximize quality of life and minimize symptom burden according to patient’s goals

Medication Principles

  • Minimize polypharmacy
  • Discontinue nonessential medications
  • Use medications to manage symptoms, not just to modify disease

Symptom Management

  • Pain:
  • Immediate-release opioids, titrate for control
  • Long-acting opioids for maintenance; use short-acting for breakthrough
  • Bone pain: Add NSAIDs to opioids
  • Neuropathic pain: Add gabapentin or anticonvulsants

  • Avoid morphine in renal failure (risk: delirium, agitation, seizures)

  • Nausea/vomiting:

  • Switch opioids or use sustained-release formulation

  • Dopamine antagonists: metoclopramide, prochlorperazine

  • Constipation:

  • Use prophylactic stimulant (senna, bisacodyl) or osmotic laxatives
  • Always combine with opioid therapy

  • Methylnaltrexone (SQ) for opioid-induced constipation (no withdrawal)

  • Dyspnea:

  • Oxygen if hypoxic
  • Low-dose opioids for advanced disease-related dyspnea

  • Benzodiazepines for anxiety

  • Delirium:

  • Review medications, treat underlying causes
  • Use low-dose antipsychotics (haloperidol, risperidone)

  • Benzodiazepines only when necessary

  • Pruritus: Moisturizers, avoid irritants

  • Anxiety: Nonpharmacologic preferred; limited evidence for medications

  • Anorexia/cachexia: Megestrol acetate (consider risks)

REFERRAL

  • Palliative care: Any patient with serious, life-limiting illness and burdensome symptoms or complex goals of care
  • Early referral in advanced cancer improves quality of life and survival
  • Hospice: Patients with life expectancy ≤6 months, multiple hospitalizations/ED visits, or as per local criteria

ONGOING CARE

  • Education: https://hospicefoundation.org/; https://www.nia.nih.gov/health/what-are-palliative-care-and-hospice-care
  • Advance care planning: Goals, expectations, symptom management, support for family/caregivers

ICD-10 Codes

  • Z51.5 Encounter for palliative care

Clinical Pearls

  • Palliative care is holistic and comfort-focused for life-limiting illness.
  • Early palliative care referral improves quality of life.
  • Adjuvant therapies (NSAIDs, anticonvulsants) are often more effective with opioids than opioids alone.
  • Always use laxatives with opioids to avoid constipation.