Palliative Care
Showing 15 of 15 topics
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Advance care planning is an ongoing process of identifying values, choosing a surrogate, and documenting preferences for future medical decisions. An advance directive communicates wishes and surrogate authority broadly, while a POLST or equivalent portable medical order is intended for people with serious illness or advanced frailty whose current treatment preferences need to guide emergency care.
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Cancer-related bone pain should prompt assessment for impending or completed pathologic fracture, spinal cord compression, and weight-bearing instability. Analgesics are combined with local therapy such as palliative radiation when indicated, bone-targeted agents for selected cancers, corticosteroids for specific complications, and orthopedic stabilization when structural failure risk is high.
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Cancer pain should be assessed by mechanism, severity, functional effect, and treatment burden. Opioids are appropriate for moderate to severe pain caused by cancer or active cancer treatment when not contraindicated, with dose titration based on response, proactive management of adverse effects, and a separate rescue plan for breakthrough pain.
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Compassionate extubation is the planned withdrawal of invasive ventilatory support when continued ventilation no longer matches the patient's goals. A safe protocol anticipates dyspnea, pain, anxiety, secretions, and family needs before ventilator withdrawal, uses preemptive symptom medication, removes nonbeneficial monitoring, and continues active bedside comfort care after extubation or terminal weaning.
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Constipation in palliative care should be prevented rather than repeatedly rescued, especially during opioid therapy. Management combines assessment for impaction or obstruction, a scheduled stimulant and/or osmotic regimen, rectal measures when distal stool is present, and peripherally acting mu-opioid antagonists for selected refractory opioid-induced constipation.
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Dyspnea in advanced disease should be treated by identifying reversible contributors when consistent with goals, using nonpharmacologic measures such as airflow and positioning, providing oxygen for documented hypoxemia, and using systemic opioids for persistent distressing breathlessness when standard measures are insufficient.
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Hospice is an interdisciplinary model for patients with terminal illness whose prognosis is approximately six months or less if the disease follows its normal course and who elect comfort-focused hospice services. Referral should be based on clinical trajectory and goals, not delayed until the final days, and eligibility can be recertified when the patient continues to meet terminal-prognosis criteria.
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Hypercalcemia of malignancy can cause dehydration, constipation, nausea, weakness, delirium, arrhythmia, and coma. In advanced cancer, treatment intensity should reflect both biochemical severity and goals: hydration and antiresorptive therapy can provide meaningful symptom relief, but repeated burdensome correction may be inappropriate when the patient is actively dying and asymptomatic from the calcium level.
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Malignant bowel obstruction in advanced cancer can be partial or complete and may occur at one or multiple levels. Palliative management focuses on nausea, vomiting, colicky pain, continuous pain, secretions, hydration burden, and goals, while considering surgery or stenting only when expected benefit, performance status, anatomy, and prognosis justify the intervention.
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Neuropathic pain results from injury or disease affecting the somatosensory system and is often described as burning, electric, shooting, or associated with allodynia and numbness. Treatment uses mechanism-directed adjuvants such as duloxetine or gabapentinoids, local therapy when feasible, and opioids only when overall pain severity and context justify them.
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Noisy breathing near the end of life usually results from pooled oropharyngeal and upper-airway secretions in a patient too weak to swallow or cough effectively. It is often more distressing to family than to the unconscious patient; management emphasizes explanation, repositioning, reduced unnecessary fluids, and selective anticholinergic medication when secretions remain troubling.
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Opioid-induced neurotoxicity is a syndrome of new cognitive impairment, hallucinations, delirium, myoclonus, hyperalgesia, or seizures occurring during opioid therapy, often after dose escalation or physiologic stress. Management includes recognizing the syndrome, treating dehydration or infection, reducing or rotating the opioid, and avoiding the mistake of treating opioid-related hyperalgesia with endless dose escalation.
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Opioid rotation is the deliberate switch from one opioid to another because of inadequate analgesia, adverse effects, organ dysfunction, route problems, or practical barriers. Equianalgesic tables estimate potency but do not predict an individual patient's response, so the calculated new dose is usually reduced for incomplete cross-tolerance and then retitrated clinically.
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Palliative sedation is the monitored, proportionate reduction of consciousness to relieve otherwise refractory suffering in a patient with advanced life-limiting illness. It is ethically and clinically distinct from routine anxiolysis, opioid titration, and euthanasia; it requires a clearly refractory symptom, informed decision making, proportional dosing, documentation, and continued attention to comfort.
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Terminal delirium is an acute disturbance of attention and awareness near the end of life. Management should treat reversible causes only when doing so is consistent with goals, reduce environmental and medication triggers, address pain and retention, and use medication primarily when agitation or perceptual distress causes suffering or threatens safety.
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