Residency · Residency · Internal Medicine

Palliative Care and Goals-of-Care Conversations

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Hey there, tired intern. Let's talk about Mrs. Johnson, that sweet 88-year-old with end-stage heart failure we admitted last night. You're probably running on fumes, but imagine she wakes up short of breath, gasping for air. Your instinct might be to pull out all the stops – more diuretics, maybe even talk about BiPAP. But before you dive in, take a breath and think about what she would want. She's been in and out of the hospital three times this month. What if her goal isn't another aggressive intervention, but simply to be comfortable and spend her remaining time with her family, not tethered to machines? This is the core of palliative care – understanding what matters most to the patient, then aligning our medical care with those preferences, even alongside treatments aimed at improving her heart function.

This isn't about giving up; it's about shifting our focus. Instead of solely chasing numbers on a monitor, we're asking: "What does a good day look like for you, Mrs. Johnson?" Or, "What are you hoping for with this admission, and what are you most worried about?" These aren't easy conversations, especially when you're overwhelmed. But by asking these questions proactively, early in the course of a serious illness, we can make sure our medical plans truly reflect their wishes. It's about empowering patients and their families to make informed decisions, rather than feeling like they're just along for the ride.

So, when you see Mrs. Johnson today, consider how you might gently initiate a conversation about her priorities. Perhaps start by acknowledging her frequent hospitalizations and how tough that must be. Then, transition to asking about what she values most in life right now, or what her hopes and fears are for the future. You’re not deciding for her; you're simply opening the door for her to tell you how she wants to live, and how she wants her medical team to support that. This thoughtful approach, known as goals-of-care conversations, is one of the most impactful things you can do for your patients, making their journey through illness more aligned with their desires and values.

Introduction

Palliative care is specialized medical care focused on providing relief from symptoms, pain, and stress of serious illness at any stage of disease. It is distinct from hospice care and is appropriate alongside curative treatment. Goals-of-care conversations are among the most important clinical skills for internists, yet they are often delayed, poorly documented, or avoided entirely. Developing competency in these conversations improves patient outcomes and reduces unwanted aggressive interventions at end of life.

Defining Palliative Care

Core Principles

  • Patient-centered: aligns treatment with patient values, preferences, and goals
  • Multidisciplinary: physicians, nurses, social workers, chaplains, pharmacists
  • Concurrent with curative therapy: not limited to end-of-life care
  • Addresses physical, psychological, social, and spiritual dimensions of suffering
  • Appropriate at any stage of serious illness, regardless of prognosis

Palliative Care vs. Hospice

  • Palliative care: any stage of illness; concurrent with disease-directed therapy; no prognostic requirement
  • Hospice: prognosis of <= 6 months if disease follows expected course; comfort-focused; Medicare benefit requires forgoing curative treatment for the hospice diagnosis
  • Early palliative care referral improves quality of life and may extend survival (Temel et al., 2010)

Triggers for Palliative Care Consultation

  • Would you be surprised if this patient died within the next 12 months? (Surprise Question)
  • Frequent hospitalizations for the same chronic condition
  • Declining functional status despite optimal medical therapy
  • Symptom burden not adequately controlled
  • Complex decision-making about life-sustaining treatments
  • Patient or family distress about prognosis or goals

Goals-of-Care Conversations

Framework: REMAP

A structured approach for goals-of-care discussions:

  • R - Reframe: "Given what is happening with your illness, I think it is important for us to talk about what matters most to you going forward."
  • E - Expect emotion: pause, acknowledge, and respond to emotions before providing more information
  • M - Map values: "What is most important to you?" "What are you hoping for?" "What are you worried about?"
  • A - Align: "Based on what you have told me, it sounds like being comfortable and spending time with family is what matters most."
  • P - Plan: translate values into a specific medical plan; document clearly

Key Communication Skills

  • Ask-Tell-Ask: assess understanding, provide information, check comprehension
  • NURSE statements for responding to emotion:
  • Naming: "I can see this is overwhelming."
  • Understanding: "I can understand why you feel that way."
  • Respecting: "I can see how much you care about your mother."
  • Supporting: "We will be here with you through this."
  • Exploring: "Tell me more about what concerns you."
  • Use prognostic language carefully: "I hope for the best but want to prepare for the possibility that..."
  • Avoid medical jargon; use plain language

Common Pitfalls

  • Asking "do you want everything done?" (patients always say yes; it is too vague)
  • Conflating goals-of-care with code status discussions
  • Having the conversation too late (during acute crisis rather than proactively)
  • Making assumptions about preferences based on age, ethnicity, or diagnosis
  • Failing to document the conversation and decisions

Advance Directives and Code Status

Advance Directive Documents

  • Living will: written instructions about desired treatments in specific clinical scenarios
  • Durable power of attorney for health care (DPAHC): designates a surrogate decision-maker
  • POLST/MOLST: portable medical orders for patients with serious illness; signed by a clinician
  • Advance directives should be reviewed and updated with changes in health status

Code Status Discussions

  • Frame within the context of the patient's goals and overall prognosis
  • Full code does not mean "do everything"; it means attempt CPR and intubation
  • Provide realistic expectations: in-hospital CPR survival to discharge is approximately 15-25% overall; much lower with metastatic cancer or multiorgan failure
  • Document as specific medical orders, not vague preferences

Symptom Management in Palliative Care

Pain

  • Follow the WHO analgesic ladder; start with non-opioids, escalate as needed
  • Opioids are appropriate for moderate-to-severe pain in serious illness
  • Adjuvants: gabapentin/pregabalin for neuropathic pain, corticosteroids for inflammatory pain
  • Scheduled dosing with as-needed breakthrough doses

Dyspnea

  • Low-dose opioids (morphine 2-5 mg PO every 4 hours) are first-line for refractory dyspnea
  • Fan blowing air on the face provides symptomatic relief (stimulates V2 branch of trigeminal nerve)
  • Supplemental oxygen only if hypoxemic; no benefit for non-hypoxemic dyspnea
  • Benzodiazepines for associated anxiety component

Nausea

  • Identify and treat reversible causes (constipation, medications, obstruction)
  • Ondansetron, prochlorperazine, haloperidol, metoclopramide based on mechanism
  • Dexamethasone for refractory nausea, especially in malignancy

Delirium at End of Life

  • Non-pharmacologic measures first
  • Haloperidol 0.5-1 mg for distressing symptoms
  • In actively dying patients, prioritize comfort over etiology workup

Transitioning to Comfort-Focused Care

  • Discontinue medications and interventions that do not contribute to comfort
  • Ensure standing orders for pain, dyspnea, secretions, and agitation
  • Secretion management: glycopyrrolate or hyoscine (atropine) for death rattle
  • Allow family presence and spiritual support
  • Notify the palliative care or hospice team for ongoing support

Key Clinical Pearls

  • Palliative care is appropriate at any stage of serious illness, not just at end of life
  • Goals-of-care conversations should be proactive, not reactive; do not wait for a crisis
  • Use frameworks (REMAP, NURSE) to structure difficult conversations consistently
  • Low-dose opioids are first-line for refractory dyspnea in serious illness
  • Document goals-of-care discussions and advance directives clearly in the medical record

References

  1. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-742.
  2. Bernacki RE, Block SD. Communication about serious illness care goals: a review and synthesis of best practices. JAMA Intern Med. 2014;174(12):1994-2003.
  3. Childers JW, Back AL, Tulsky JA, Arnold RM. REMAP: a framework for goals of care conversations. J Oncol Pract. 2017;13(10):e844-e850.
  4. Blinderman CD, Billings JA. Comfort care for patients dying in the hospital. N Engl J Med. 2015;373(26):2549-2561.

For the intern

At 3am, focus on immediate symptom relief: use low-dose morphine (2-5 mg PO/IV) for dyspnea or pain, haloperidol (0.5-1 mg) for agitation or nausea, and glycopyrrolate for distressing secretions. Document what you gave and why. The formal goals-of-care conversation can wait until morning when the primary team and family are available—trying to have this discussion in the middle of the night without continuity rarely goes well. If a patient is actively dying and family has questions, focus on explaining comfort measures and ensuring symptom control rather than initiating new advance directive discussions. Page palliative care for urgent consults only if there's uncontrolled suffering despite your interventions.

Common pitfalls

  • Asking "do you want everything done?" This question is too vague and always gets a "yes." Instead, describe specific interventions (CPR, intubation, dialysis) in the context of realistic outcomes for this patient's condition.
  • Conflating code status with overall goals. DNR (Do Not Resuscitate) does not mean "do not treat"—patients can still receive antibiotics, transfusions, and intensive symptom management while being DNR/DNI (Do Not Intubate).
  • Waiting for a crisis to discuss goals. Proactive conversations when patients are stable lead to better-informed decisions. The intensive care unit at 2am is the worst time for a first goals-of-care discussion.
  • Forgetting to document clearly. Write specific orders, not vague preferences. "Patient prefers comfort measures; DNR/DNI; no ICU transfer" is actionable. "Patient wants quality of life" tells the overnight team nothing useful.

Make it stick

You're on call, and Mrs. Rodriguez, an 85-year-old with metastatic pancreatic cancer, is increasingly agitated and dyspneic. Her son, visibly distressed, asks, "Are we doing everything we can?" Instead of rattling off treatment options, you sit, make eye contact, and say, "This is incredibly hard to watch, and I can see how much you care for your mother. What are you most hoping for her right now?" He quietly replies, "I just want her to be comfortable, without pain or gasping for air." This simple reframe, acknowledging his emotion, opens the door to aligning medical care with what truly matters, guiding your symptom management and reassuring the family that "everything" means optimizing comfort.

If you remember one thing

Effective goals-of-care conversations require acknowledging emotion and aligning care with patient values, which often means prioritizing comfort over aggressive interventions. Proactive, clear communication in these moments builds trust and ensures care truly reflects what matters most to the patient and their loved ones.

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