Palliative Care, Pain Management, and End-of-Life Care
What to know
Palliative care focuses on symptom relief and goals, not just hospice. Assess pain with validated tools (including for dementia patients via behavioral scales). Use the WHO analgesic ladder: non-opioids, then opioids, with adjuvants. In older adults, start opioids at low doses, monitor renal function (morphine metabolites accumulate), and prevent constipation. Opioid choice: avoid meperidine; use caution with codeine (variable metabolism). Dyspnea, nausea, and agitation are common end-of-life symptoms. Advance care planning and POLST/MOLST documents guide care. Hospice eligibility generally requires prognosis ≤6 months.
Traps
Don't undertreat pain out of fear of addiction-older adults are often under-treated. Watch for opioid-induced constipation and delirium. Renal impairment changes opioid choice (avoid morphine; consider fentanyl/hydromorphone with caution). Distinguish palliative care (any stage) from hospice (terminal prognosis). Discuss goals of care early.
Rule of thumb
"Treat the symptom, honor the goal": align analgesia and symptom control with the patient's stated goals.
Worked example
A hospice patient with severe pain and renal impairment: avoid morphine; consider low-dose hydromorphone or fentanyl with monitoring, plus a bowel regimen.
Worked example 2
A patient with advanced dementia and pain behaviors: use a behavioral pain scale and treat; don't dismiss as "just dementia."