CAQ-Palliative cheat sheet

Hospice and Palliative Medicine

• Palliative care is interdisciplinary care for serious illness at any stage, delivered alongside curative treatment; hospice is a Medicare benefit for terminal illness with prognosis ≤6 months if disease runs its normal course, requiring forgone curative treatment.

• Medicare hospice eligibility requires two physician certifications (attending and hospice medical director or physician designee); recertification at 90 days, then 90 days, then unlimited 60-day periods with face-to-face encounter before the third benefit period and each subsequent period.

• The four domains of palliative care per the National Consensus Project are structure and processes; physical; psychological and psychiatric; social; spiritual, religious, and existential; cultural; and care of the imminently dying-assess each domain with validated tools.

• Pain assessment: use a numeric rating scale (0–10) for adults able to self-report; for those unable, use PAINAD (Pain Assessment in Advanced Dementia) or FLACC (Face, Legs, Activity, Cry, Consolability) for children; reassess after each intervention.

• Total pain concept (Dame Cicely Saunders) includes physical, psychological, social, and spiritual components; uncontrolled pain requires evaluating all four contributors before escalating opioids.

• Opioid selection: morphine is first-line for cancer pain; hydromorphone is roughly 5–7 times more potent than morphine; oxycodone is roughly 1.5–2 times morphine; fentanyl transdermal is for opioid-tolerant patients only (≥60 mg oral morphine equivalents/day).

• Equianalgesic conversion: oral morphine 30 mg ≈ oral oxycodone 20 mg ≈ oral hydromorphone 6 mg ≈ IV morphine 10 mg ≈ IV hydromorphone 1.5 mg; when switching opioids, reduce the calculated equianalgesic dose by 25–50% to account for incomplete cross-tolerance.

• Opioid side effects: constipation does not develop tolerance-start a bowel regimen (senna plus docusate or polyethylene glycol) prophylactically; nausea and sedation usually tolerance within 1–2 weeks; respiratory depression risk increases with renal failure (morphine metabolites M6G accumulate).

• Dyspnea in advanced disease: first-line is nonpharmacologic (fan, oxygen if hypoxemic, positioning); opioids (low-dose morphine or hydromorphone) reduce air hunger; benzodiazepines are second-line for anxiety-associated dyspnea.