Palliative Care Across Disease Trajectories
Three trajectories
Cancer typically produces steady functional decline with a recognizable terminal phase. Organ failure - heart, lung, liver, kidney - shows gradual decline punctuated by acute exacerbations, making prognosis difficult and sudden death possible. Frailty and dementia follow a long, slow dwindling with prolonged dependency.
Disease-specific priorities
Heart failure: dyspnea, fatigue, edema, depression, and sudden death; discuss ICD deactivation when goals shift to comfort; hospice eligibility often requires NYHA class IV, ejection fraction ≤20%, and refractory symptoms. COPD: opioids for dyspnea, anxiety management, NIV decisions, and pulmonary rehabilitation; oxygen for hypoxemia. Neurologic disease (ALS, Parkinson disease, MS, dementia): dysphagia and feeding-tube decisions, communication support, spasticity, and aspiration risk; dementia hospice eligibility uses FAST stage 7 and complications such as aspiration pneumonia. Renal disease: dialysis withdrawal or conservative kidney management; pruritus, restless legs, cramping, and uremic symptoms; avoid morphine because of metabolite accumulation and use fentanyl or hydromorphone. Cirrhosis: ascites, varices, encephalopathy, and coagulopathy; lactulose for encephalopathy, cautious paracentesis, and avoidance of NSAIDs and benzodiazepines. Infection (HIV, tuberculosis, sepsis): treat reversible components while aligning with goals, and support caregivers.
Worked example
Ask the 'surprise question': 'Would I be surprised if this patient died in the next 12 months?' A 'no' should trigger a goals-of-care conversation and palliative referral - it is a prompt, not a prediction.
Trap: waiting for a cancer-style terminal phase in organ failure, where death may come suddenly or after a long decline.