14.6 Palliative Care, Hospice & Advance Care Planning
Key Takeaways
- End-of-life and palliative care of the elderly and ethics in the elderly are separately enumerated Geriatric Syndromes subsections.
- Palliative care is appropriate at any stage of serious illness alongside disease-directed treatment and is not restricted by prognosis.
- Hospice eligibility generally requires a prognosis of six months or less if the disease follows its expected course.
- Opioid conversion between agents requires reduction for incomplete cross-tolerance when calculating the new dose.
- Physician orders for life-sustaining treatment are actionable medical orders, distinct from an advance directive, which appoints a surrogate and states preferences.
Last updated: August 2026
1. Palliative Care vs. Hospice & Symptom Management
Palliative Care vs. Hospice Care: Clinical Distinctions
- Palliative Care: Specialized interprofessional medical care for patients living with serious, chronic, or life-threatening illness (advanced cancer, heart failure, COPD, ESRD, ALS, dementia). The central focus is symptom management, psychosocial/spiritual support, and aligning treatments with personal goals. Palliative care is appropriate at ANY stage of disease, can begin at the time of initial diagnosis, and is delivered CONCURRENTLY with curative, life-prolonging, or disease-modifying therapies (e.g., chemotherapy, radiation, dialysis, LVAD).
- Hospice Care: A specific Medicare insurance benefit and delivery model of comprehensive palliative care reserved for patients with a certified terminal prognosis of <= 6 months if the disease follows its natural course. The patient (or surrogate) elects to shift the treatment focus entirely to comfort and quality of life, foregoing curative, life-prolonging, or disease-directed therapies. Care is provided in the patient's home, nursing facility, or inpatient hospice unit, and includes 13 months of bereavement support for the family post-death.
Palliative Pain Management & Opioid Conversion Science
Equianalgesic Opioid Conversion Ratios
When titrating or rotating opioids for refractory pain, dose calculations must utilize validated standard equianalgesic conversion factors:
\text{Oral Morphine } 30\text{ mg} &= \text{IV Morphine } 10\text{ mg} \quad (3:1 \text{ oral-to-IV ratio}) \\ &= \text{Oral Oxycodone } 20\text{ mg} \quad (1.5:1 \text{ oral morphine-to-oxycodone ratio}) \\ &= \text{Oral Hydromorphone } 7.5\text{ mg} \quad (4:1 \text{ oral morphine-to-hydromorphone ratio}) \\ &= \text{IV Hydromorphone } 1.5\text{ mg} \quad (5:1 \text{ oral-to-IV hydromorphone ratio; } 7:1 \text{ IV morphine-to-hydromorphone}) \\ &= \text{Transdermal Fentanyl } 25\text{ mcg/hr patch} \approx 60-90\text{ mg/day Oral Morphine} \end{aligned}$$ #### Safe Opioid Rotation Protocol (4-Step Method) 1. **Calculate Total 24-Hour Baseline Dose:** Sum all scheduled and PRN doses consumed in the preceding 24 hours. 2. **Convert to Equianalgesic Baseline:** Use conversion ratios to calculate the equivalent 24-hour dose of the new opioid. 3. **Apply Incomplete Cross-Tolerance Reduction:** **Reduce the calculated daily dose by 25% to 50% (standard: 33%)** to prevent fatal overdose from incomplete receptor cross-tolerance. 4. **Formulate Breakthrough PRN Doses:** Prescribe immediate-release breakthrough medication at **10% to 15% of the total 24-hour baseline scheduled dose**, available every 1 to 2 hours PRN for oral agents (or every 15-30 minutes for IV PCA). #### Renal Failure & Opioid Selection - **Morphine & Hydromorphone:** Metabolized to active glucuronide metabolites (Morphine-6-glucuronide [analgesic/sedative], Morphine-3-glucuronide [neurotoxic: hyperalgesia, myoclonus, allodynia], Hydromorphone-3-glucuronide) that **accumulate in renal impairment / ESRD**, causing severe toxicity. - **Fentanyl & Methadone:** **Safest opioids in severe renal failure and ESRD**; undergo hepatic clearance without active neurotoxic renal metabolites. #### Mandatory Prophylactic Bowel Regimen Opioids bind $\mu$-receptors in the myenteric plexus, impairing peristalsis and mucosal secretions. **Tolerance to opioid-induced constipation (OIC) NEVER develops.** Every patient prescribed an opioid must be co-prescribed a scheduled prophylactic stimulant bowel regimen: - **Stimulant Laxative:** **Senna** (1-2 tablets PO daily to BID) or **Bisacodyl** (5-10 mg PO/PR daily) $\pm$ Osmotic agent (**Polyethylene Glycol / PEG 3350** 17 g daily). - *Caution:* Bulk-forming laxatives (Psyllium) are contraindicated in debilitated palliative patients due to risk of fecal impaction and bowel obstruction. - *Refractory OIC:* Peripherally Acting Mu-Opioid Receptor Antagonists (**PAMORAs**: *Methylnaltrexone 8-12 mg SC*, *Naloxegol 25 mg PO*); PAMORAs block peripheral bowel receptors without crossing the blood-brain barrier, reversing constipation without precipitating central opioid withdrawal or reversing analgesia. ### Management of Dyspnea & Terminal Secretions | Palliative Symptom | Pathophysiology & Clinical Presentation | Non-Pharmacologic Management | First-Line Pharmacologic Therapy | | :--- | :--- | :--- | :--- | | **Palliative Dyspnea** | Subjective breathlessness in advanced cardiopulmonary disease or malignancy; mismatched ventilatory drive and mechanical capacity | 1. **Handheld Fan blowing cool air across trigeminal ($V_2/V_3$) facial dermatomes** (stimulates mechanoreceptors, dramatically reducing central perception of dyspnea).<br/>2. Upright positioning (orthopneic position).<br/>3. Pursed-lip breathing and bedside relaxation techniques. | **Low-Dose Opioids (Oral Morphine 2.5 to 5 mg PO q4h PRN or IV Morphine 1 to 2 mg q2h PRN)**:<br/>- Gold standard: reduces central perception of air hunger, blunts respiratory center anxiety, and improves ventilation-perfusion matching without causing hypercapnia or respiratory arrest when titrated carefully.<br/>*(Note: Supplemental Oxygen is ONLY beneficial if patient is documented to be hypoxemic [$SpO_2 <90\%$]; oxygen provides no added benefit over room air in non-hypoxemic dyspnea).* | | **Terminal Secretions ("Death Rattle")** | Accumulation of saliva and mucus in the hypopharynx and trachea due to loss of swallowing reflex and pharyngeal muscle tone in the final hours/days of life | 1. **Repositioning:** Turn patient onto side (lateral semi-prone recovery position) to facilitate postural gravity drainage.<br/>2. Gentle wiping of anterior mouth.<br/>*CONTRAINDICATION:* **Avoid deep tracheal or pharyngeal suctioning**, which causes severe gagging, coughing, mucosal trauma, and agitation. Reassure family that secretions cause no distress to the comatose patient. | **Anticholinergic / Antimuscarinic Drying Agents:**<br/>1. **Glycopyrrolate (0.2 to 0.4 mg IV/SC q4h PRN):** **Preferred agent** because it is a quaternary amine that does NOT cross the blood-brain barrier, avoiding central delirium and hallucinations.<br/>2. **Scopolamine Transdermal Patch (1.5 mg applied behind ear q72h)**: Tertiary amine; crosses blood-brain barrier (risk of delirium).<br/>3. **Sublingual Atropine 1% Ophthalmic Solution (1 to 2 drops SL q2-4h PRN)**. |2. Advance Care Planning: Decisional Capacity & Medical Orders
The 4 Core Elements of Clinical Decisional Capacity
Decisional capacity is a clinical assessment made by any licensed physician for a specific decision at a specific point in time (unlike "competency", which is a global legal status determined solely by a judge).
To possess decisional capacity for a proposed intervention, the patient must demonstrate all 4 elements:
- Understanding: Ability to comprehend the diagnosis, proposed treatment, potential risks, benefits, and reasonable alternatives (including no treatment).
- Appreciation: Ability to appreciate how the medical information applies directly to their own personal health situation and future.
- Reasoning: Ability to process the information logically, compare the options, and articulate rational reasons behind their decision congruent with their values.
- Expressing a Choice: Ability to clearly and consistently communicate a voluntary choice (verbally, in writing, or through unambiguous gestures).
Advance Directives & Surrogacy Standards
- Living Will: A legal document detailing specific medical treatments a person wishes to receive or refuse under hypothetical end-of-life circumstances (e.g., persistent vegetative state, terminal illness).
- Durable Power of Attorney for Healthcare (Healthcare Proxy): Designates a specific surrogate decision-maker to make healthcare decisions if the patient loses decisional capacity.
- Hierarchy of Surrogate Decision-Making:
- Substituted Judgment Standard (Primary Standard): The surrogate must make the exact medical decision that the patient would have made based on known personal values, religious beliefs, and prior expressed wishes. The surrogate's personal preferences are irrelevant.
- Best Interests Standard (Secondary Standard): Used ONLY when the patient's prior wishes and values are completely unknown. The surrogate and medical team decide based on what a reasonable person would choose to maximize net benefit and minimize suffering.
POLST / MOLST vs. Traditional Advance Directives
POLST (Physician Orders for Life-Sustaining Treatment) / MOLST (Medical Orders for Life-Sustaining Treatment) translate patient preferences into immediately actionable, legally binding medical orders signed by a clinician (MD/DO/NP/PA) and the patient/surrogate. They are active across all healthcare settings (home, EMS, ED, ICU).
| POLST / MOLST Section | Clinical Order Options | Practical Board Scenarios |
|---|---|---|
| Section A: Cardiopulmonary Resuscitation (CPR) | 1. Attempt Resuscitation / CPR<br/>2. Do Not Resuscitate / DNR (No CPR) | Applies ONLY when the patient is in full cardiopulmonary arrest (unresponsive, pulseless, apneic). If patient has a pulse, Section B governs care. |
| Section B: Medical Interventions | 1. Full Treatment: Intubation, mechanical ventilation, defibrillation, ICU admission, invasive arterial/central lines.<br/>2. Selective / Limited Interventions: IV fluids, IV antibiotics, non-invasive positive pressure ventilation (CPAP/BiPAP), transfer to hospital; NO endotracheal intubation.<br/>3. Comfort-Focused Treatment: Maximizing comfort, oral pain/dyspnea medications, positioning; transfer to hospital ONLY if comfort cannot be managed at home/facility. | A patient with a DNR order can still receive Full Treatment under Section B (e.g., intubation for severe pneumonia with DNR if cardiac arrest occurs). DNR does NOT mean 'do not treat'. |
| Section C: Artificially Administered Nutrition | 1. Long-Term Feeding Tube (PEG)<br/>2. Defined Trial Period of Feeding Tube<br/>3. No Artificial Nutrition / Comfort Feeding by Mouth Only | Feeding tubes in advanced dementia do NOT prolong survival, prevent aspiration pneumonia, improve functional status, or heal pressure ulcers. Hand-feeding for comfort is the recommended gold standard. |
Test Your Knowledge
An 81-year-old man with metastatic castrate-resistant prostate cancer and diffuse, painful osteoblastic bone metastases is admitted to the oncology ward for severe breakthrough bone pain. For the past month, he has been taking oral Morphine extended-release 60 mg every 12 hours, plus oral Morphine immediate-release 15 mg every 4 hours as needed (consuming an average of 4 PRN doses per day). His total 24-hour baseline oral morphine consumption is 180 mg/day. Because he has developed intractable nausea and severe dysphagia, the palliative care team decides to rotate his regimen to a continuous intravenous Hydromorphone infusion via patient-controlled analgesia (PCA) pump. Using standard equianalgesic conversion parameters (Oral Morphine 30 mg = IV Morphine 10 mg = IV Hydromorphone 1.5 mg) and applying a 33% dose reduction to account for incomplete cross-tolerance, which of the following is the most appropriate target total 24-hour intravenous Hydromorphone dose?
A
B
C
D