Palliative Care, End-of-Life Care, and Ethics
Palliative care versus hospice
Palliative care is symptom-focused care appropriate at any stage of serious illness alongside disease-directed treatment. Hospice is a benefit for patients with a prognosis of six months or less if the disease follows its usual course, with the "surprise question" ("Would I be surprised if this patient died within the year?") as a practical prompt. Hospice is not restricted to cancer; heart failure, dementia, COPD, and frailty qualify.
Symptom management
For pain, use scheduled opioids with short-acting rescue doses; titrate to comfort; anticipate constipation with a bowel regimen. Avoid meperidine. In renal failure, morphine accumulates active metabolites - prefer fentanyl or hydromorphone. For dyspnea, low-dose opioids and a fan are effective. For terminal secretions, anticholinergics such as glycopyrrolate or scopolamine reduce noise, though evidence is modest. Treat terminal delirium, but weigh sedation against interaction.
Ethics and decision-making
Distinguish decision-making capacity (task-specific) from legal competence (a court determination). Patients with capacity may refuse treatment, even life-sustaining treatment. Surrogate decision makers should use substituted judgment, then best-interest standards. Withholding and withdrawing treatment are ethically equivalent. The rule of double effect permits proportionate sedation or analgesia to relieve suffering even if it may hasten death. Cardiopulmonary resuscitation has poor outcomes in frail nursing home residents; discuss code status early and document it, using portable orders such as POLST where available. Report suspected elder mistreatment.
Traps
Equating palliative care with giving up; failing to ask about the patient's values before discussing code status; ordering burdensome tests in a dying patient; neglecting caregiver grief.
Rule of thumb
When goals are comfort, ask "Is this test or treatment going to change what we do, or only prolong the dying process?"