ABFM Palliative Care cheat sheet

Palliative care is interdisciplinary care that relieves symptom burden and aligns treatment with goals for patients with serious illness; it is appropriate at diagnosis and can be delivered alongside disease-directed therapy.

US Medicare hospice eligibility requires physician certification that prognosis is 6 months or less if the illness runs its expected course, plus election of the hospice benefit in place of curative treatment for the terminal diagnosis.

Karnofsky Performance Status runs 0-100 in 10-point steps; ECOG runs 0-5. Both independently predict survival, and KPS at or below 50% or ECOG 3 or higher corresponds to substantial functional loss.

The surprise question ('Would I be surprised if this patient died in the next 12 months?') is sensitive but not specific; a 'no' answer identifies patients who warrant palliative assessment.

Illness trajectories differ: cancer typically shows steady functional decline with a short terminal phase; organ failure shows a long plateau interrupted by acute decompensations; frailty and dementia show a prolonged low-baseline decline.

The Palliative Prognostic Score combines dyspnea, anorexia, Karnofsky score, clinical prediction of survival, total white blood cell count, and lymphocyte percentage to estimate 30-day survival in advanced cancer.

The Palliative Performance Scale (0-100% in 10% steps) scores ambulation, activity, self-care, oral intake, and level of consciousness; lower scores correlate with shorter survival.

Clinician prognostic estimates tend to be optimistic; validated tools plus performance status improve calibration but remain probabilistic and should be communicated as ranges.

Classify pain as nociceptive (somatic or visceral), neuropathic, or mixed; neuropathic pain is suggested by burning, lancinating, or electric quality, allodynia, or dermatomal distribution.

Equianalgesic anchors: morphine 30 mg by mouth = morphine 10 mg IV = oxycodone 20 mg by mouth = hydromorphone 7.5 mg by mouth = hydromorphone 1.5 mg IV.

Oral-to-parenteral morphine ratio is approximately 3:1 (range 2:1 to 3:1); after any conversion reduce the calculated new opioid by 25-50% for incomplete cross-tolerance.

Breakthrough dosing is typically 10-20% of the total 24-hour opioid requirement given as needed; needs beyond 3-4 breakthrough doses daily indicate the scheduled regimen should increase.

Fentanyl transdermal is contraindicated in opioid-naive patients; steady state requires 12-24 hours, and each 25 mcg/h patch roughly corresponds to 60-90 mg oral morphine daily.

Methadone is a mu agonist and NMDA antagonist with variable half-life and QTc prolongation; start low, titrate slowly, and involve a specialist for opioid rotations.

Opioid-induced constipation does not develop tolerance; start a stimulant laxative such as senna prophylactically and add an osmotic agent such as polyethylene glycol if needed.

Neuropathic pain responds to gabapentinoids, duloxetine, tricyclics, and topical lidocaine; corticosteroids help malignant bone pain and nerve compression.

In renal failure avoid morphine and codeine because active metabolites accumulate; preferred agents are fentanyl, hydromorphone, and methadone with dose reduction and monitoring.

Dyspnea in advanced illness is treated with systemic opioids such as morphine, which reduce air hunger; supplemental oxygen helps only documented hypoxemia and benzodiazepines are not first-line.

Select antiemetics by mechanism: metoclopramide or haloperidol for gastric stasis and metabolic causes, ondansetron for serotonin-mediated causes, antihistamines for vestibular causes, anticholinergics for bowel obstruction.

Opioid-induced nausea and sedation usually improve within 3-7 days as tolerance develops; constipation does not, so laxative prophylaxis is required for the duration of opioid use.

Terminal secretions are managed with anticholinergics (glycopyrrolate, hyoscine butylbromide, atropine ophthalmic drops), repositioning, and limited suctioning; deep suctioning is not recommended.

Delirium: use nonpharmacologic measures first; haloperidol 0.5-2 mg is typical for hyperactive delirium; avoid benzodiazepines except in alcohol or benzodiazepine withdrawal.

Anorexia-cachexia: megestrol increases appetite without meaningful weight gain; short-course dexamethasone may improve appetite and fatigue but carries corticosteroid toxicity.

Depression screening uses PHQ-2 then PHQ-9; SSRIs take weeks, so terminal patients may receive psychostimulants such as methylphenidate for a faster effect.

Fatigue evaluation covers anemia, hypothyroidism, insomnia, depression, deconditioning, and medications; treatment is cause-directed plus energy conservation and psychosocial support.

SPIKES structures bad-news conversations: Setting, Perception, Invitation, Knowledge, Emotions with empathy, and Strategy/Summary.

Ask-tell-ask elicits what the patient already understands before information is given and confirms comprehension afterward.

NURSE statements respond to emotion: Naming, Understanding, Respecting, Supporting, and Exploring.

Decisional capacity requires four abilities: communicating a choice, understanding relevant information, appreciating the consequences, and reasoning about options.

A time-limited trial sets explicit goals, a defined duration, and stopping criteria for an intervention so the decision can be revisited with new information.

Explore 'wish' statements ('I wish you could...') rather than arguing; they usually signal values and fears that can be addressed directly.

Prognostic discussions pair honest information with the patient's hopes and worries, avoiding both deception and bluntness.

Family meetings should identify the surrogate decision-maker, summarize the medical situation, elicit goals and values, and end with documented, concrete next steps.

FICA spiritual history: Faith or belief, Importance of spirituality, Community of support, and Address in care.

HOPE screens Hope, Organized religion, Personal spirituality and practices, and Effects on care and end-of-life decisions.

Suffering differs from pain: it arises from threats to personhood such as meaning, dignity, and relationships, and may persist despite adequate analgesia.

Cultural humility means asking about preferences rather than assuming: use trained interpreters, avoid stereotyping, and negotiate care through LEARN (Listen, Explain, Acknowledge, Recommend, Negotiate).

Distress screening commonly uses the Distress Thermometer (0-10) paired with a problem list covering practical, family, emotional, spiritual, and physical concerns.

Life review and dignity therapy help patients articulate valued memories and legacy; both can reduce existential distress and create a document for survivors.

Spiritual distress may present as hopelessness, anger at God, or loss of meaning; chaplain involvement is a core hospice service rather than an optional add-on.

The four principles are autonomy, beneficence, nonmaleficence, and justice; autonomy generally takes precedence in decision-making for a capable adult.

The rule of double effect requires an intended good effect (relief of suffering), an unintended bad effect (possibly hastened death), proportionality, and that the bad effect not be the means to the good.

Withdrawing and withholding life-sustaining treatment are ethically and legally equivalent when they match patient goals; no ethical obligation exists to continue a burdensome treatment.

Palliative sedation lowers consciousness to relieve refractory symptoms; it is distinguished from euthanasia because the intent is symptom relief and doses are titrated to comfort.

Advance directives include living wills (care preferences) and durable power of attorney for health care (agent); POLST/MOLST forms convert preferences into actionable orders across settings.

Capacity is a clinical determination; competence is a legal status. A patient with capacity may refuse any treatment, including life-sustaining therapy.

Informed consent requires capacity, disclosure of risks, benefits and alternatives, comprehension, and voluntariness.

Futility disputes are best handled through a defined process including ethics consultation, institutional policy, and applicable state law rather than unilateral clinician refusal.

Signs of imminent death include mottled extremities, cool skin, Cheyne-Stokes respirations, diminished urine output, pooled oral secretions, and decreasing responsiveness.

In the last days, discontinue nonessential medications and continue symptom-controlling drugs by an appropriate route (subcutaneous, sublingual, rectal, transdermal).

Terminal agitation or restlessness requires ruling out pain, urinary retention, fecal impaction, and hypoxia before treating with haloperidol, midazolam, or lorazepam.

Medicare hospice: two 90-day benefit periods followed by unlimited 60-day periods; recertification occurs at each boundary and a face-to-face encounter is required before the third period.

Four Medicare hospice levels of care: routine home care, continuous home care for crisis, general inpatient care for uncontrolled symptoms, and respite care capped at 5 days.

The hospice interdisciplinary group meets at least every 15 days to review and revise each plan of care.

Hospice provides bereavement support to the family for up to 1 year after the death.

Terminal weaning of mechanical ventilation reduces ventilator support incrementally while treating dyspnea with opioids and anxiolytics, with the goal of comfort rather than immediate extubation.

Pronouncement of death requires absent heart sounds and respirations, unreactive pupils, and no response to stimulation; document the time, findings, and who was notified.

The core hospice interdisciplinary team includes a physician, nurse, social worker, chaplain, home health aide, and trained volunteers, coordinated through an individualized care plan.

Palliative care consultation triggers include metastatic cancer, ICU stay beyond roughly 7 days, multiple recent hospitalizations, advanced dementia, and NYHA class III-IV heart failure.

Hospice care is reimbursed under Medicare Part A as a per-diem benefit; hospital and clinic palliative care is billed through usual fee-for-service or value-based arrangements.

Team communication relies on daily huddles, structured interdisciplinary group meetings, and shared documentation of goals of care in the medical record.

Palliative care quality measures include pain and dyspnea screening and treatment, documented advance care planning, timely hospice referral, and rates of death in the ICU.

Health literacy affects comprehension; plain-language materials, trained interpreters, and teach-back improve shared understanding across language and cultural barriers.

Clinician burnout and moral distress are mitigated by manageable workloads, structured debriefs, Schwartz Rounds, and clear ethics and administrative support pathways.

Pediatric palliative care is family-centered and can be delivered concurrently with curative treatment from diagnosis onward; it is not limited to end-of-life care.

Perinatal palliative care begins prenatally after a life-limiting diagnosis and includes a written birth plan, delivery-room comfort measures, and bereavement support.

Pediatric pain scales are age-specific: NIPS and PIPP for neonates, FLACC and Wong-Baker FACES for young children, and numeric rating scales for older children and adolescents.

Neonates have immature hepatic and renal clearance, so opioids are weight-based with longer dosing intervals and close monitoring for apnea.

Children's understanding of death is developmental: preschoolers often see it as reversible, school-age children as concrete and universal, and adolescents as abstract and personal.

Under Medicaid concurrent care, children enrolled in hospice may continue disease-directed therapy alongside hospice services, unlike the adult requirement to forgo curative treatment.

Perinatal bereavement practices such as holding and naming the infant, memory boxes, photographs, and mementos reduce later complicated grief for parents and siblings.

NICU and PICU family meetings should include parents as decision-makers, describe what the child will experience, and document the agreed goals.

DSM-5-TR prolonged grief disorder requires persistent intense longing or preoccupation with the deceased plus associated symptoms and impairment, lasting beyond 12 months in adults and 6 months in children and adolescents.

Kubler-Ross stages (denial, anger, bargaining, depression, acceptance) are neither linear nor mandatory; they describe common reactions rather than a required sequence.

Worden's tasks of mourning: accept the reality of the loss, process the pain of grief, adjust to a world without the deceased, and find an enduring connection while moving forward.

Anticipatory grief occurs before death, can coexist with caregiving burden, and does not necessarily reduce the intensity of grief after the death.

Risk factors for complicated grief include sudden or violent death, death of a child, lack of social support, prior psychiatric illness, caregiver strain, and multiple recent losses.

Disenfranchised grief is loss that is not socially recognized or openly mourned, such as perinatal loss, stigmatized relationships, or the death of a pet.

Caregiver burden can be measured with tools such as the Zarit Burden Interview; respite services and caregiver support groups are core hospice offerings.

Children's grief often appears intermittently through play and behavior; regression, somatic complaints, and school changes may signal a need for additional support.