Palliative Care, Advance Care Planning, and Goals

Palliative Care, Advance Care Planning, and Goals

Palliative care across the continuum

Palliative care is specialized care focused on relief of suffering and quality of life for people with serious illness. It can begin at diagnosis, continue during curative or life-prolonging treatment, and intensify as disease advances. It is not limited to the last days of life. OCN questions often test this misconception. A patient with metastatic lung cancer receiving immunotherapy and struggling with dyspnea, anxiety, and family conflict may benefit from palliative care while treatment continues.

What palliative care addresses

Palliative care teams assess physical symptoms, emotional distress, spiritual concerns, communication needs, caregiver strain, and practical burdens. Symptoms may include pain, nausea, constipation, dyspnea, fatigue, anorexia, mucositis, neuropathy, insomnia, delirium, and depression. The oncology nurse should perform focused symptom assessment, implement standing orders or protocols when available, teach medication safety, and escalate uncontrolled symptoms.

Goals-of-care communication

The nurse is often the first person to hear that a patient is afraid, tired, or confused about the plan. The OCN response is not to give false reassurance or independently decide treatment should stop. The nurse should assess what the patient understands, ask permission to discuss concerns, explore values, and communicate findings to the oncology team. Useful prompts include: "What have you heard about where things stand?" "What matters most if time is shorter than hoped?" "Who should speak for you if you cannot speak for yourself?"

Goals of care are not the same as code status. A patient may want aggressive symptom control, time at home, and continued cancer treatment if it preserves function. Another patient may choose no further disease-directed therapy but still want hospitalization for a reversible infection. The nurse helps translate values into specific decisions and ensures that the team revisits goals as disease and treatment response change.

Advance care planning

Advance care planning is a process, not a single form. It includes identifying a health care proxy or durable power of attorney for health care, discussing values and acceptable quality of life, documenting preferences, and sharing documents with family and clinicians. The nurse should encourage completion before crisis, especially for patients with advanced disease, high-risk treatment, cognitive decline risk, or limited support. If family members disagree, the nurse should return to the patient's expressed wishes and involve the provider, social work, ethics, or palliative care as needed.

Symptom relief and safety

Pain management requires careful assessment of location, quality, severity, functional impact, prior therapies, and adverse effects. The nurse should distinguish persistent pain from breakthrough pain, monitor sedation and respiratory status, prevent constipation with opioids, and address myths about addiction when opioids are used appropriately for cancer pain. Dyspnea management may include treating reversible causes, positioning, fan or airflow, oxygen when hypoxemic, opioids for refractory breathlessness, and anxiety support.

Nausea management depends on cause, such as chemotherapy, bowel obstruction, constipation, vestibular disease, brain metastases, or medications.

Ethical and cultural considerations

Palliative conversations must respect culture, religion, family roles, and patient autonomy. Some patients want detailed prognostic information; others prefer that family members hear information first. The nurse should use qualified interpreters, avoid assumptions, and clarify the patient's preference for information sharing. Hope can be reframed from cure to comfort, time at home, symptom control, reconciliation, or attending a meaningful event.

When hospice enters the discussion

Hospice is a form of palliative care for patients who are expected to have limited prognosis and who generally prioritize comfort rather than curative treatment. Palliative care, however, can be concurrent with active oncology therapy. On the OCN exam, the best nursing response often corrects the misunderstanding: accepting palliative care does not mean the oncology team is abandoning the patient.