Residency · Residency · Internal Medicine

Palliative Care and Goals-of-Care Conversations

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.

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