Care of the Dying patient in primary care

Ask-tell-ask model

Stepwise structure for breaking bad news.

-Assess → Educate → Reassess understanding.

-Lead communication, manage symptoms, coordinate goals of care.

-ex: Facilitate advance care planning and DNR/DNI discussions.

role of physician in end of life care

hospice services

Focus exclusively on comfort for life expectancy

Discuss and document living will, health-care proxy, code status (DNR/DNI).

main components of advance care planning

palliative care involvement

Addresses symptom management, emotional and spiritual needs; can coexist with curative care.

palliative care

Specialized medical care focused on relief of symptoms, pain, and stress associated with serious illness — at any stage, alongside curative treatment.

- Chronic or life-limiting illness (e.g., cancer, CHF, COPD, ESRD)

-Poor symptom control or significant psychosocial distress

primary indicates for palliative care

part A

hospice care is covered by what medicare part

- Terminal illness with prognosis ≤6 months

- Discontinuation of curative therapy

- Focus on comfort, symptom relief, and family support

indications for hospice care

opioids

first line treatment for pain at the end of life

- Opioids (low-dose morphine): ↓ dyspnea perception

- Oxygen if hypoxic

-anxiolytics

treatments for dyspnea (air hunger) at the end of life

Benzodiazepines: lorazepam, midazolam

- Antipsychotics: haloperidol for terminal restlessness

treatments for anxiety/agitation at the end of life

- Haloperidol (dopaminergic cause)

- Ondansetron (serotonergic cause)

- Metoclopramide (motility aid)

treatments for nausea/vomiting at the end of life

- Stool softener + stimulant: docusate + senna- Osmotic laxatives: polyethylene glycol

treatments for constipation at the end of life

- Haloperidol (low-dose)-

- Quiet, familiar environment

treatment for delirium at the end of life

Pooling of oropharyngeal secretions as swallowing declines

cause of "death rattle"

- Anticholinergics: glycopyrrolate, scopolamine patch

- Repositioning to lateral decubitus; avoid suctioning (may worsen noise)

treatment for "death rattle" secretions

- Reversible condition with recovery potential (e.g., acute stroke, post-op recovery)

- Short-term supplementation while addressing treatable cause of anorexia

indications for artificial nutrition and hydration (ANH)

- End-stage illness (advanced cancer, dementia, multi-organ failure)

- Actively dying phase: may increase discomfort (fluid overload, secretions, aspiration)

when is artificial nutrition NOT indicated?

ANH

In the actively dying phase, withholding or withdrawing_____is ethically and medically appropriate when consistent with patient goals — comfort is prioritized through mouth swabs, lip moisturizers, and gentle hydration.

morphine

first-line for moderate-severe pain unless renal impairment.

Hydromorphone

preferred opioid in renal failure (less active metabolite accumulation)

- Morphine: 2.5-5 mg PO q4h (or 1-2 mg IV q3-4h)

- Oxycodone: 2.5-5 mg PO q4h

- Hydromorphone: 0.2-0.5 mg IV q4h or 1-2 mg PO q4h

starting doses for opioids

- Reassess every 30-60 min for IV, 1-2 hr for PO.

- If pain persists → ↑ total daily dose by 25-50% for mild-mod pain, 50-100% for severe pain.

how to titrate opioids up?

PRN dose = 10-15% of total 24-hr opioid dose, given q1h PRN PO (q15-30 min IV).

how to manage breakthrough pain (define dose)

NSAIDs, gabapentin, corticosteroids, antidepressants for multimodal pain relief.

adjuvants for pain in addition to opioids

- Constipation (always start bowel regimen)

- Nausea (often transient)

- Sedation (monitor early, tolerance develops)

- Respiratory depression (rare if titrated correctly)

common side effects of opiates

- Opioids + antispasmodics (e.g., hyoscamine, dicyclomine)

- Corticosteroids for inflammation

- Octreotide for bowel obstruction secretions

treatment for Deep, cramping, poorly localized; from organ distention or obstruction

- Anticonvulsants: gabapentin, pregabalin

- Antidepressants: duloxetine, nortriptyline

- Topicals: lidocaine, capsaicin

- Adjunctive opioids if severe

treatment for neuropathic pain

No CPR if cardiac/respiratory arrest

-May still allow other interventions (IV fluids, antibiotics)

define key features of a DNR status

No intubation or mechanical ventilation

-May still receive oxygen or noninvasive support

key features of DNI status

Health Care Proxy / Medical Power of Attorney

Legal document naming another person to make medical decisions if the patient cannot

-activated when the patient lacks decision making capacity

living will

-Written statement of specific treatment preferences in end-of-life care

-Guides providers when patient cannot communicate

advanced directive

General term encompassing living will + health care proxy

-Should be reviewed and updated regularly; recognized in all states

POLST / MOLST (Physician Orders for Life-Sustaining Treatment)

Medical order that specifies patient's preferences for resuscitation, feeding, antibiotics, hospitalization

-Used in patients with serious illness; travels between care settings