Palliative, Supportive, and Survivorship Care
Whole-person care
Palliative care addresses pain, dyspnea, nausea, constipation, anorexia, fatigue, depression, and goals of care alongside disease therapy. Survivorship focuses on late effects, fertility, bone health, cardiovascular risk, secondary malignancy, vaccination, psychosocial needs, and care coordination. Ask about symptoms and function; validate with tools but trust the patient.
Concepts to master
Opioid selection and equianalgesic conversion, incomplete cross-tolerance (reduce 25-50% when rotating), bowel regimen with opioids, renal failure and morphine metabolites, adjuvant analgesics, dyspnea management, antiemetics by mechanism, and hospice eligibility. In survivorship, know anthracycline/trastuzumab cardiotoxicity monitoring, platinum ototoxicity/nephrotoxicity, radiation late effects, and fertility preservation.
Traps
Questions often test unsafe conversions: oral morphine to IV is roughly 3:1, not 1:1; methadone is not converted linearly; meperidine is avoided. Do not start laxatives only after constipation; start with opioids. Do not use NSAIDs without renal/GI risk review. Do not equate palliative care with hospice. Do not miss depression or caregiver distress.
Worked example
A patient on 60 mg oral morphine daily needs IV morphine. Convert 60 mg PO to about 20 mg IV over 24 hours, then reduce for incomplete cross-tolerance if switching to a different opioid. Reassess within 24 hours and titrate.
Rule of thumb: reassess pain and symptoms after every change; the right dose is the one that relieves suffering with acceptable toxicity.