ABIM Palliative Care cheat sheet

Pain intensity is measured with a validated tool: 0–10 numeric rating scale in adults, faces scales in children, and PAINAD or Abbey in advanced dementia; reassess after each intervention.

The WHO ladder steps from nonopioid for mild pain (1–3) to weak opioid for moderate (4–6) to strong opioid for severe (7–10); adjuvants are added at any step for neuropathic or bone pain.

Opioid-naive adult starting doses: oral morphine 5–10 mg every 4 hours, oral oxycodone 2.5–5 mg, oral hydromorphone 0.5–1 mg, or IV morphine 2.5–5 mg; lower doses in renal or hepatic impairment and frailty.

Breakthrough pain is treated with 10–20% of the total daily opioid dose every 1 hour as needed; frequent breakthrough doses prompt recalculation of the scheduled regimen.

Equianalgesic ratios: oral morphine 30 mg ≈ parenteral morphine 10 mg ≈ oral oxycodone 20 mg ≈ oral hydromorphone 7.5 mg; reduce the calculated new opioid by 25–50% for incomplete cross-tolerance.

Neuropathic pain responds to gabapentin, pregabalin, duloxetine, or tricyclics; bone pain responds to NSAIDs, radiation, and bisphosphonates; visceral pain often responds to opioids.

Opioid adverse effects: constipation does not develop tolerance and requires a prophylactic bowel regimen; nausea and sedation usually tolerance within days; respiratory depression is rare with titration.

Renal failure: avoid morphine and meperidine; fentanyl is preferred, and hydromorphone or methadone require reduced dosing; naloxone 0.04–0.4 mg IV titrated reverses respiratory depression.

Dyspnea: systemic opioids are first-line for refractory dyspnea; supplemental oxygen is indicated for hypoxemia (SpO2 <90%) but not for normoxemic breathlessness.

Nausea: select antiemetic by pathway-haloperidol for metabolic/CTZ, ondansetron for serotonin, scopolamine for vestibular, metoclopramide for gastric stasis, olanzapine for mixed.

Complete malignant bowel obstruction: octreotide reduces secretions, dexamethasone reduces edema, antiemetics control nausea; avoid metoclopramide and other prokinetics.

Constipation: opioid-induced constipation is treated with a stimulant laxative plus an osmotic laxative; methylnaltrexone or naloxegol is used for refractory opioid-induced constipation.

Delirium: identify and reverse causes such as infection, urinary retention, constipation, medications, and metabolic derangement; antipsychotics treat agitation or hallucinations but do not treat the delirium itself.

Terminal delirium: haloperidol or quetiapine is used for agitation; benzodiazepines are reserved for alcohol or benzodiazepine withdrawal or seizures because they can worsen delirium.

Anorexia-cachexia: megestrol, dexamethasone, and olanzapine may stimulate appetite; megestrol increases thrombosis and adrenal suppression; artificial nutrition rarely reverses cachexia.

Fatigue: screen for anemia, hypothyroidism, depression, sleep disturbance, and offending medications; methylphenidate or short-course corticosteroids may help selected patients.

Hiccups and pruritus: chlorpromazine or baclofen for hiccups; cholestyramine, naltrexone, gabapentin, or antihistamines for pruritus depending on cause.

SPIKES: Setting, Perception, Invitation, Knowledge, Empathy, Strategy/Summary; the Invitation step establishes how much information the patient wants.

Ask-Tell-Ask: elicit the patient's understanding, give information in small chunks, then check understanding before discussing next steps.

Capacity requires four abilities-understanding, appreciation, reasoning, and expressing a choice; capacity is decision-specific and distinct from legal competence.

Surrogate decision-making uses substituted judgment first; if the patient's wishes are unknown, the surrogate uses the best-interest standard.

Advance directives record values and preferences; POLST/MOLST converts them into portable medical orders for seriously ill patients; neither replaces a goals-of-care conversation.

Prognosis discussions give ranges and acknowledge uncertainty; hope for the best, prepare for the worst supports dual framing without false reassurance.

Professional interpreters are required for limited-English-proficiency goals-of-care and consent discussions; teach-back confirms understanding and is documented.

Family meetings: summarize the medical situation, ask about values and goals, explore fears, make a recommendation, and agree on an action plan with documentation.

Distress screening uses validated tools such as the Distress Thermometer; positive screens trigger social work, chaplaincy, psychology, or psychiatric referral.

Spiritual history tools include FICA (Faith, Importance, Community, Address) and HOPE (Hope, Organized religion, Personal spirituality, Effects); chaplain referral follows positive screening.

Major depression requires persistent depressed mood or anhedonia plus functional impairment; grief typically comes in waves, with yearning and preserved self-esteem.

Anxiety in advanced illness is treated with SSRIs, CBT, and short-term benzodiazepines; benzodiazepines are avoided in delirium and in older adults when possible.

Four ethical principles: autonomy, beneficence, nonmaleficence, and justice; informed consent requires capacity, disclosure, understanding, and voluntariness.

Withdrawing and withholding life-sustaining treatment are ethically equivalent when burdens outweigh benefits; double effect requires good intention, proportionality, and the bad effect not as the means.

Cultural humility means asking about family roles, truth-telling norms, religious rituals, and preferred decision-maker rather than assuming beliefs from ethnicity.

Caregiver burden and financial toxicity are screened and addressed through respite, social work, and resource referral; chosen family is honored in LGBTQ+ care.

Cancer: anticipate malignant bowel obstruction, hypercalcemia, spinal cord compression, brain metastases, and superior vena cava syndrome; treat symptoms while clarifying goals.

Hypercalcemia of malignancy: IV isotonic fluids plus a bisphosphonate or denosumab; calcitonin acts within hours but tachyphylaxis limits it to severe or refractory cases.

Spinal cord compression: new back pain with neurologic deficit or bowel or bladder dysfunction requires urgent MRI and dexamethasone before confirmation.

Heart failure: palliative care is triggered by NYHA III–IV symptoms, recurrent admissions, or device decisions; ICD deactivation is discussed separately from other treatments.

COPD: dyspnea, anxiety, and fatigue dominate; pulmonary rehabilitation, opioids for refractory dyspnea, and noninvasive ventilation may improve comfort and function.

Dementia and ALS: advance care planning occurs early while capacity remains; dysphagia, secretions, and communication loss guide feeding and secretion management.

CKD: dialysis withdrawal or conservative kidney management treats uremic symptoms with opioids, antiemetics, and anxiolytics; fentanyl is preferred over morphine.

Cirrhosis: ascites, varices, encephalopathy, and spontaneous bacterial peritonitis drive prognosis; lactulose targets 2–3 stools per day and rifaximin reduces recurrence.

HIV and infectious disease: integrate palliative care with antiretroviral therapy; address stigma, isolation, pain, and goals; drug interactions affect opioid and antipsychotic choice.

Imminent dying signs: mottling, Cheyne-Stokes respirations, decreased urine output, terminal secretions, and progressive drowsiness often indicate death within days.

Discontinue nonessential medications such as statins, vitamins, and glucose monitoring in the last days; continue opioids, anxiolytics, anticonvulsants, and other comfort medications.

Terminal secretions: reposition and suction gently; glycopyrrolate or scopolamine may reduce secretions, but evidence is limited and benefit is mainly for observers.

Terminal agitation: rule out pain, urinary retention, constipation, and delirium; treat with antipsychotics or benzodiazepines based on the likely cause.

Opioid escalation at end of life is titrated to comfort; proportionate sedation for refractory suffering is ethically distinct from euthanasia when intention and proportionality are documented.

Medicare hospice eligibility: prognosis of 6 months or less if the disease follows its usual course, certified by two physicians, with a plan focused on comfort.

Prolonged grief disorder: disabling yearning or preoccupation persisting at least 12 months in adults with functional impairment; children require 6 months.

After death: pronounce, notify family and authorities as required, honor cultural and religious rituals, offer bereavement support, and document.

Geriatric: apply Beers criteria, review anticholinergic burden, deprescribe medications without short-term benefit, and assess falls, cognition, and function.

Dementia pain: use PAINAD or Abbey and observe facial expression, vocalization, body language, and behavior; untreated pain often presents as agitation.

Pediatric: parents or guardians consent, children assent by developmental stage; weight-based opioid dosing and concurrent palliative and curative care are standard.

Limited English proficiency: use qualified interpreters, translated forms, and teach-back; avoid using children or family members as interpreters for consent or goals of care.

LGBTQ+ and marginalized patients: honor chosen family, protect confidentiality, and explicitly ask about discrimination and safe support networks.

Rural and homebound patients: telehealth, home hospice, and community paramedicine expand access; transportation and caregiver availability shape the plan.

Vulnerable adults: screen for abuse, neglect, exploitation, and caregiver strain; report to adult protective services when mandated.

Palliative care is appropriate at any stage and alongside curative treatment; hospice requires a prognosis of 6 months or less and focuses on comfort.

Medicare hospice levels: routine home care, continuous home care, general inpatient care, and inpatient respite care; the level changes with symptom intensity and caregiver need.

The hospice interdisciplinary group meets at least every 15 days and includes physician, nurse, social worker, chaplain, and other disciplines.

Hospice certification requires two physicians to certify a prognosis of 6 months or less if the illness runs its expected course.

Quality domains include structure, process, and outcomes; measure pain, dyspnea, constipation, goal-concordant care, hospice utilization, and caregiver support.

Advance care planning CPT 99497 covers the first 30 minutes and 99498 each additional 30 minutes; time and discussion content must be documented.

Opioid prescribing systems include prescription drug monitoring programs, controlled-substance safeguards, and naloxone co-prescribing for high-risk patients.

Interdisciplinary team care improves symptom control and goal concordance; clear role delineation, documentation, and family meetings reduce conflict.