Palliative Care, End-of-Life Care, Ethics, and Goals of Care
Goals first
Palliative care addresses symptoms and goals at any stage of serious illness; hospice is a model for patients with a prognosis of about 6 months or less who forego curative treatment. Advance care planning includes health care proxies, living wills, and POLST/MOLST for seriously ill patients. Capacity is decision-specific; a patient may lack capacity for complex finances but retain capacity for a simple treatment choice. Surrogate decision-makers use substituted judgment, then best interests.
Symptom management: opioids for pain and dyspnea, with bowel regimens; anticholinergics for secretions; treat delirium, depression, and anxiety. Artificial nutrition does not prevent aspiration in advanced dementia and may cause discomfort; discuss carefully.
Ethical principles: autonomy, beneficence, nonmaleficence, and justice. Withholding and withdrawing life-sustaining treatment are ethically equivalent. Avoid the trap of 'doing everything' when it conflicts with the patient's goals.
Traps: equating palliative care with giving up; assuming opioids cause addiction in dying patients; placing a feeding tube in advanced dementia without a goals discussion; and missing depression or grief.
Worked example: a 90-year-old with advanced dementia has recurrent aspiration pneumonia. A goals-of-care conversation reveals the patient valued comfort and had stated she never wanted a feeding tube. Focus on comfort, hand feeding with aspiration precautions, and treat dyspnea; avoid PEG placement.
Rule of thumb: ask 'What matters most to you?' and let the answer guide treatment.