Goals of Care & Symptom Management
Palliative care is not hospice. It's about aligning treatment with the patient's values at any stage of illness. Every resident should be able to lead a goals-of-care conversation and manage common symptoms at end of life.
🤝 Goals of Care Conversation
When to Have the Conversation
- Any new serious diagnosis (advanced cancer, end-stage organ failure, severe dementia)
- Significant clinical deterioration or ICU admission
- Repeated hospitalizations for chronic progressive disease
- "Would you be surprised if this patient died in the next year?" -if no, initiate GOC discussion.
Framework -REMAP
| Step | What to Say |
|---|---|
| R -Reframe | "I want to step back and talk about the big picture of what's going on." |
| E -Expect emotion | Pause. Acknowledge. "I can see this is hard to hear." NURSE: Name, Understand, Respect, Support, Explore. |
| M -Map values | "What matters most to you?" "What does a good day look like?" "Are there things worse than death to you?" |
| A -Align | "Based on what you've told me -that being independent and not suffering are most important -I'd recommend..." |
| P -Plan | Concrete next steps. Document. Communicate with team. Revisit as things change. |
Code Status Discussion
- Avoid: "Do you want us to do everything?" (misleading -implies no CPR = giving up)
- Better: "If your heart were to stop, CPR involves chest compressions that often break ribs, a breathing tube, and electric shocks. In someone with your condition, the chance of surviving to leave the hospital is about ___%. Given what you've told me about what matters most to you, I would recommend..."
- Make a recommendation. Patients want guidance, not just options.
💊 Symptom Management
| Symptom | First-Line | Notes |
|---|---|---|
| Pain | Morphine (MS Contin) 2–5 mg IV/SC q2–4h PRN or oxycodone 5–10 mg PO q4h. Scheduled + PRN for constant pain. | Titrate to comfort. No ceiling for opioids in end-of-life care. Add adjuncts: acetaminophen (scheduled), gabapentin (neuropathic), dexamethasone (bone mets, inflammation). |
| Dyspnea | Morphine (MS Contin) 2–4 mg IV/SC q2–4h PRN. Fan to face. Oxygen if hypoxic. | Opioids are the most effective treatment for dyspnea in palliative care. They reduce the sensation of breathlessness centrally. Low doses are safe and don't hasten death Opioids for Dyspnea Trial, 2003. Anxiolytics (lorazepam 0.5–1 mg) if anxiety-driven. |
| Nausea / vomiting | Ondansetron (Zofran) 4–8 mg IV q6h or haloperidol 0.5–1 mg IV q6h (good for opioid-induced or chemical causes) | Match anti-emetic to mechanism: chemoreceptor trigger zone → haloperidol/ondansetron. GI dysmotility → metoclopramide. Raised ICP → dexamethasone. Vestibular → meclizine. |
| Terminal secretions ("death rattle") | Glycopyrrolate 0.2–0.4 mg IV/SC q4h or atropine drops 1% SL q4h | Anticholinergics reduce new secretion production. Suctioning is uncomfortable and often futile. Reposition to lateral. Reassure family -the sound is often more distressing to family than to the patient. |
| Terminal agitation / delirium | Haloperidol (Haldol) 1–2 mg IV/SC q4h. Add lorazepam 1–2 mg if refractory. | Rule out reversible causes first (urinary retention, constipation, pain, medication). If actively dying and refractory → palliative sedation with midazolam or phenobarbital infusion (requires palliative care consult + family discussion). |
🔍 Overview
Overview
Palliative care improves quality of life through symptom management, GOC discussions, and psychosocial support. Appropriate at any illness stage -concurrent with curative treatment. Palliative care ≠ hospice.
🧪 Workup
Workup
- ESAS symptom scores (0-10)
- Functional status -PPS, ECOG
- Prognostication -surprise question, PPI
- Advance directives review
- Psychosocial/spiritual screening
🚨 Management
Management
- Pain: WHO ladder + adjuvants (gabapentin, duloxetine, dexamethasone)
- Dyspnea: Morphine 2-5mg SL + fan at face + O₂ if hypoxic
- Nausea: Ondansetron, haloperidol, metoclopramide
- Delirium: Haloperidol 0.5-2mg. Treat reversible causes.
- GOC: REMAP framework
💊 Medications
Medications
| Drug | Dose | Route | Notes |
|---|---|---|---|
| Morphine | 2-5mg PO/SL q2-4h | PO/SL | Pain + dyspnea |
| Gabapentin | 100-900mg TID | PO | Neuropathic pain |
| Dexamethasone | 4-8mg daily | PO/IV | Bone mets, edema, obstruction |
| Haloperidol | 0.5-2mg q4-6h | PO/IV | Nausea + delirium |
| Glycopyrrolate | 0.2mg SL q4h | SL | Secretions |
| Lorazepam | 0.5-1mg SL q4h | SL | Anxiety, agitation |
📋 On Rounds
Pimp Questions
An attending asks you to 'make the patient comfortable' -what specific orders do you write?
This is a practical question that catches many interns off guard. A complete comfort care order set includes: (1) Pain: morphine 2–5 mg IV/SC q2h PRN (or current opioid equivalent). Scheduled if constant pain. (2) Dyspnea: morphine 2–4 mg IV/SC q2h PRN (opioids are first-line for dyspnea). (3) Anxiety/agitation: lorazepam 0.5–1 mg IV/SC q4h PRN. (4) Secretions (death rattle): glycopyrrolate 0.2 mg IV/SC q4h PRN or atropine 1% drops SL q4h.
How do you know when to give morphine for dyspnea vs when it will hasten death?
This is one of the most common misconceptions in medicine. Appropriately dosed opioids for dyspnea do NOT hasten death. This was definitively shown by Abernethy et al. (2003): low-dose morphine significantly improved dyspnea without affecting respiratory rate, oxygen saturation, or survival.
What is the REMAP framework for goals of care conversations?
R eframe -Set the stage: "I want to make sure we're on the same page about what's happening." Clarify medical reality without jargon. E xpect emotion -Pause. Let silence work. Acknowledge: "I can see this is really hard." Don't fill silence with medical facts.
How do you manage terminal dyspnea?
Dyspnea is the symptom patients and families fear most in the terminal phase. Management: (1) Morphine is first-line -2-5 mg PO/SL/SQ q2-4h PRN. Reduces central perception of breathlessness without clinically significant respiratory depression at appropriate doses Opioids for Dyspnea Trial, 2003. (2) Fan directed at face -stimulates V2 branch of trigeminal nerve → reduces sensation of air hunger. Evidence-based and free
Clinical Examples
📋 Case 1, Transitioning to Comfort Measures
Patient: 78M with metastatic pancreatic cancer, ECOG 4, declining PO intake × 2 weeks. Family ambivalent about hospice. Current: morphine PCA, ondansetron, IV fluids.
Key findings: PPS 20%. Recurrent SBO from peritoneal carcinomatosis. No further oncologic options. Patient previously expressed "no machines" but no formal advance directive.
Management:
- Goals of care conversation using REMAP framework with patient and family
- Transition PCA to SQ morphine infusion 2 mg/hr for comfort
- D/C IV fluids (contributes to secretions and edema at end of life)
- Add glycopyrrolate 0.2 mg SQ q4h PRN for secretions
- Hospice referral, inpatient hospice given symptom burden
Teaching point: IV fluids at end of life often worsen symptoms (secretions, edema, dyspnea). Discontinuing is not "giving up", it is symptom management.
📋 Case 2, Refractory Cancer Pain
Patient: 62F with metastatic breast cancer to bone. Pain 9/10 despite oxycodone 40 mg q4h. Somnolent but still reporting severe pain. Cr 2.4 (new).
Key findings: Opioid neurotoxicity (myoclonus, somnolence with persistent pain). Renal failure accumulating active metabolites. Current opioid dose equivalent: 360 MME/day.
Management:
- Opioid rotation to hydromorphone (no active renal metabolites), reduce by 25-50% for cross-tolerance
- Dexamethasone 4 mg IV q6h for bone pain and peritumoral edema
- Radiation oncology consult for palliative XRT to painful metastases
- Add gabapentin 100 mg TID (renal dose) for neuropathic component
- IV hydration to address prerenal AKI
Teaching point: Opioid rotation is indicated when dose escalation causes toxicity without adequate analgesia. Hydromorphone and fentanyl are preferred in renal failure.
📋 Case 3, Terminal Dyspnea Management
Patient: 85M with end-stage IPF, on 15L high-flow, SpO₂ 78%. DNR/DNI. Progressive dyspnea with visible distress. Family at bedside.
Key findings: Terminal respiratory failure. No reversible cause. Patient previously documented desire for comfort-focused care. PPS 10%.
Management:
- Morphine 2 mg IV q15min PRN for dyspnea (titrate to comfort, not respiratory rate)
- Fan directed at face, stimulates trigeminal V2 branch, reduces air hunger
- Lorazepam 0.5 mg SL q4h PRN for anxiety component
- Continue supplemental O₂ for comfort (not to target SpO₂)
- Proactive family communication: normalize Cheyne-Stokes breathing, explain death rattle
Teaching point: Morphine for dyspnea does not hasten death at appropriate doses. The principle of double effect permits symptom management even if it theoretically shortens life.
📣 Sample Presentation
One-Liner
"Mr. Washington is a 82-year-old with advanced dementia (FAST 7c), recurrent aspiration pneumonia × 3 admissions this year, and worsening functional status. Family requesting "everything" but primary team is concerned about escalating interventions."
Key Points to Cover on Rounds
Goals of care conversation needed. Current trajectory: advanced dementia with recurrent aspiration -antibiotics are treating the symptom, not the underlying cause. REMAP framework used: R (reframe: "his dementia is causing the pneumonias -antibiotics can't fix that"), E (expect emotion -family is grieving), M (map values: "what would he say if he could tell us?"), A (align), P (plan). Family shared that he previously said he "never wanted to be a burden." After discussion, family chose: comfort-focused care, treat symptoms (dyspnea with morphine 2 mg SL q2h PRN), no more antibiotics for aspiration, no intubation, no ICU. Hospice referral initiated. Palliative care following.
⚡ Summary
Summary
Palliative Care Is Not Hospice
It is about aligning treatment with the patient's values at any stage of illness, alongside disease-directed therapy. Hospice is a subset for patients with a prognosis of about 6 months who have chosen comfort-focused care. Conflating the two is why referrals are refused, so name the difference explicitly when you raise it.
Refer Early
Early palliative care improves quality of life, reduces depression and, in some populations such as metastatic lung cancer, is associated with longer survival (Temel). Trigger the conversation at diagnosis of a serious illness, at a change in trajectory, at recurrent admissions, or when the surprise question is answered 'no', not in the last week.
Use REMAP
Reframe why the status quo is not working, Expect emotion and respond to it, Map what matters to the patient, Align with those values, Plan the treatment that fits. Mapping before planning is the whole point: recommendations built on stated values are accepted, and recommendations built on prognosis alone are resisted.
Ask About Values, Not About Interventions
'What matters most to you?', 'What would an unacceptable outcome look like?', 'What are you hoping for, and what are you worried about?' Do not open with the ventilator and the feeding tube: a list of procedures forces a technical decision onto a frightened family and produces answers that do not reflect what they actually want.
Make a Recommendation
'Based on what you have told me matters to your mother, I would recommend...' Never ask 'do you want us to do everything?', which is unanswerable and implies the alternative is nothing. Sharing the burden of the decision is a clinical duty, not a paternalistic overreach.
Treat Dyspnea With Opioids
Low-dose opioids are the most effective treatment for refractory breathlessness, and at appropriate doses they do not hasten death. Add a fan to the face, positioning and treatment of the reversible cause. Oxygen helps only if the patient is hypoxemic; in a normoxic patient it adds nothing over a fan.
Match the Symptom to the Drug
Nausea: identify the pathway, so ondansetron for chemotherapy and metoclopramide for gastroparesis, haloperidol for opioid or metabolic causes. Terminal secretions: reposition, stop artificial hydration, glycopyrrolate or scopolamine, and explain that it distresses the family rather than the patient. Delirium: treat reversible causes, non-pharmacologic measures first, haloperidol for distressing agitation.
Say the Words and Support the Family
Use 'dying' and 'died' rather than euphemisms, which are frequently misunderstood at exactly the moment clarity matters. Never say 'there is nothing more we can do': there is always more care, just not more disease-directed treatment. Document the conversation, not just the order, and involve chaplaincy, social work and bereavement support as part of the plan rather than as an afterthought.
📄 One Pager
Text version
Palliative Care · One Pager
Palliative Care
REMAP framework for goals of care. Code status ≠ GOC. Morphine for dyspnea. Fan at face. Consult for refractory symptoms, complex GOC, family conflict.
REMAP Framework
Reframe (medical reality without jargon). Expect emotion (pause, acknowledge). Map values ("what matters most?"). Align (recommendation based on values). Plan (concrete next steps).
Symptom Management
Pain: WHO ladder (non-opioid → weak → strong opioid) + adjuvants (gabapentin, duloxetine). Dyspnea: morphine (first-line) + fan at face + O₂ if hypoxic. Nausea: ondansetron, haloperidol. Delirium: haloperidol, lorazepam.
When to Consult
Refractory symptoms despite standard management. Complex goals of care conversations. Family conflict. Transition to hospice. Withdrawal of life-sustaining treatment. Existential/spiritual distress.
Key Drugs
Morphine2-5 mg PO/SL q2-4h PRN (dyspnea + pain)
Gabapentin100-900 mg TID (neuropathic)
Dexamethasone4-8 mg daily (brain mets, obstruction)
Haloperidol0.5-2 mg q4-6h (nausea/delirium)
Pitfalls
- Jumping to code status without mapping values first
- Withholding morphine for dyspnea (effective and safe at appropriate doses)
- Not considering palliative care consult until patient is dying
- O₂ for non-hypoxic dyspnea (fan at face is equally effective Fan for Dyspnea Trial, 2010)
Related Topics
Code Status & Advance DirectivesFamily Meeting FrameworkHospice Eligibility CriteriaNon-Opioid Symptom ManagementOpioid Rotation ConversionPalliative Extubation