End-of-Life Care and Palliative Principles

• Palliative care is not hospice. Palliative care is symptom-directed care appropriate at any stage of serious illness and alongside disease-directed treatment. Hospice in the United States generally requires a prognosis of six months or less if the illness runs its usual course, and a decision to forgo curative therapy.
• The doctrine of double effect: giving an opioid in doses intended to relieve suffering is ethically permissible even if it may foreseeably hasten death, provided the intent is symptom relief and the dose is proportionate. This is categorically distinct from euthanasia.
• Withholding and withdrawing treatment are ethically and legally equivalent. A trial of a therapy may therefore be started without committing to continue it — an important reassurance when time-limited trials are proposed.
• "Do not resuscitate" means do not attempt resuscitation — nothing more. It does not imply withholding antibiotics, nutrition, surgery or intensive care.
• Artificial nutrition and hydration are legally treatments and may be declined or withdrawn like any other.
• A competent patient may refuse life-sustaining treatment, and honouring that refusal is not assisting suicide.

Who decides

• Decision-making capacity: a clinical, decision-specific judgment made by any physician — the patient must communicate a choice, understand the information, appreciate how it applies to them, and reason among options. Competence is the parallel legal term determined by a court. Capacity can fluctuate and can be present for one decision and absent for another.
• Advance directive: a living will states which treatments a patient would want; a durable power of attorney for health care (health care proxy) names a person. When both exist and conflict, the named agent generally interprets the living will rather than being overridden by it.
• POLST/MOLST: a signed medical order set, portable across settings, covering CPR, intubation, and hospitalization for patients with serious illness. Unlike an advance directive, it is actionable by EMS immediately.
• Surrogate standards, applied in order: (1) the patient's own prior expressed wishes, (2) substituted judgment — what this patient would have chosen, (3) best interest — used only when the patient's values are unknowable (never-competent patients, young children).

Structure of services

• Medicare Hospice Benefit (CMS): requires two physicians to certify a prognosis of six months or less; care is delivered at four levels — routine home care, continuous home care for crises, inpatient respite, and general inpatient care for uncontrolled symptoms. Benefit periods are recertified, and a patient who stabilizes may be discharged or may revoke hospice to pursue curative therapy.
• Concurrent palliative care: the National Consensus Project guidelines and ASCO both endorse specialty palliative care introduced early alongside disease-directed treatment in advanced cancer, not as a last resort.

Ethical boundaries

• Double effect requires four elements: the act itself is neutral or good, the intent is symptom relief, death is not the means of relief, and there is proportionate reason. Titrating opioid to a respiratory rate is treatment; administering a paralytic to a breathing patient is not.
• Physician aid in dying (patient self-administers) differs from euthanasia (clinician administers); the AMA Code of Medical Ethics addresses both separately from palliative sedation for refractory symptoms.

• Step 1 — assess capacity, not agreement. He communicates a choice, understands his prognosis, and reasons consistently. A refusal of life-sustaining treatment is not itself evidence of incapacity. With capacity intact, the daughter's preferences are informative but not authoritative; a surrogate acts only when the patient cannot.
• Step 2 — treat the symptom mechanistically. Opioids are first-line for cancer-related dyspnea: they blunt the central perception of breathlessness and reduce ventilatory drive to hypercapnia. Supplemental oxygen benefits the hypoxemic patient; in the non-hypoxemic patient, a bedside fan directed at the face (trigeminal afferents) is a reasonable adjunct. Dose escalation guided by symptom response satisfies double effect.
• Step 3 — anticipate predictable toxicities. Start a stimulant laxative (senna) with every scheduled opioid — tolerance never develops to constipation, and bulk fiber worsens it. Prefer hydromorphone over morphine in renal impairment because morphine-6-glucuronide accumulates and causes myoclonus and sedation. Avoid meperidine entirely (normeperidine seizures).
• Step 4 — manage the family, not just the patient. Explore what "stopping the morphine" means to her — usually fear of causing death or of abandonment. Explain that untreated dyspnea, not proportionate opioid dosing, drives suffering.
• Step 5 — address other terminal symptoms. Antipsychotics such as haloperidol for terminal delirium and nausea; antimuscarinics such as glycopyrrolate for death rattle; benzodiazepines for anxiety but not as monotherapy for delirium, which they worsen.
• Step 6 — when conflict persists, involve the ethics committee and palliative care consultation, per the AMA Code of Medical Ethics; courts are a last resort.

• DNR is not "do not treat." A DNR patient may still receive ICU care, pressors, dialysis, antibiotics, and surgery. The classic distractor is a stem in which a resident withholds antibiotics or transfusion because of a DNR order — that is the error being tested.
• Withdrawing = withholding. The correct answer for a stunned family is that a time-limited trial of ventilation or dialysis can be stopped if goals are not met; this ethical equivalence is affirmed in the AMA Code of Medical Ethics.
• A capacitated patient's refusal wins, even over unanimous family objection and even if death follows. Refusing treatment is not suicide, and honoring it is not assisted death.
• When a patient asks for "something to end it," the single best next step is to explore the request — ask what they are most afraid of. Uncontrolled pain, loss of dignity, and depression drive most such requests; screen for depression before anything else.
• Feeding tubes in advanced dementia do not prolong survival, prevent aspiration, or heal pressure ulcers. The American Geriatrics Society (Choosing Wisely) recommends careful hand feeding instead. Artificial nutrition is a treatment, not basic care.
• Terminal delirium → antipsychotic (haloperidol), not a benzodiazepine. Benzodiazepines are the classic wrong answer here; they deepen delirium except in alcohol/benzodiazepine withdrawal or when palliative sedation is the explicit goal.
• Hospice requires a prognosis of six months or less certified by physicians (CMS), while palliative care requires only serious illness — the most commonly missed distinction on Step 2 CK. A patient may leave hospice to pursue curative therapy and re-enroll later.
• "Don't tell my father he has cancer." Do not agree outright and do not override outright: ask the patient how much he wants to know and whom he wants involved. Therapeutic privilege is essentially never the answer.