Supportive, Palliative, and End-of-Life Care: Toxicity Control, Pain, and Goals
Symptom and toxicity management
Antiemetic prophylaxis is matched to emetogenicity: highly emetogenic regimens receive a 5-HT3 antagonist plus an NK1 antagonist plus dexamethasone, often with olanzapine, plus coverage for delayed nausea. Febrile neutropenia - one temperature of 38.3 °C or higher, or 38.0 °C sustained over an hour, with ANC below 500/µL (or below 1000 predicted to fall) - requires empiric broad-spectrum antibiotics within about 60 minutes. Colony-stimulating factor prophylaxis is standard when febrile neutropenia risk is 20% or greater. Mucositis is managed with oral care, analgesia, and hydration.
Pain and palliation
Follow the analgesic ladder, prescribe around-the-clock dosing with rescue doses, add adjuvants (gabapentinoids, corticosteroids, bisphosphonates), and proactively manage opioid-induced constipation. Palliative care is symptom-focused care delivered alongside disease-directed treatment from diagnosis; hospice is a benefit for patients with a prognosis of about 6 months or less who elect comfort-focused care. They are not synonyms.
Communication and end of life
Document goals-of-care discussions, advance directives, and POLST orders early. In the final days, treat dyspnea, pain, agitation, and secretions with opioids, benzodiazepines, and anticholinergics, and address caregiver burden and bereavement.
Worked example
A patient taking morphine 30 mg PO daily rotates to oral hydromorphone at roughly a 5:1 ratio, giving about 6 mg/day in divided doses, with a rescue dose around 10% of the daily total and monitoring for sedation and respiratory depression.
Traps: withholding opioids from a dying patient for fear of addiction, calling palliative care "giving up," and delaying antibiotics in febrile neutropenia.