Palliative care, hospice, and DNR are terms that are often misunderstood or conflated. We will start with definitions:

Palliative Care can be provided to anyone who has a serious illness, from the time of diagnosis to end of life. It can be for any age, and during can be provided while curative efforts are underway and when patients are pursuing comfort care. It has 3 main goals:

1. To provide active symptom management, along any stage of a serious illness, from onset to end of life, including through both treatments with curative intent and when goals of care have shifted to comfort measures or non-curative treatments.
2. To help support the patient and family through the course illness.
3. To ensure that the plan of care is in line with the patient’s goals of care and that there is a better understanding between patient and physicians of what those goals are.

Hospice is a specific insurance benefit that provides multi-disciplinary care and 24 hour nurse access for patients who are deemed by 2 physicians to have less than 6 months to live if their illness takes its expected trajectory. Hospice patients are ideally managed at home or the place of their residence (assisted living, skilled nursing, etc), but may need to come to the hospital if their symptoms cannot be managed at their place of residence. It is helpful to call the on-call hospice nurse to coordinate the patient’s care as they may be able to increase the home resources to manage the patient at home. Hospice can be revoked by the patient at any time if they wish to pursue more aggressive treatment.

DNR is a specific order generated by the patient that if their heart went into a non-perfusing rhythm, ie they lost pulses, that they would not want CPR done. It does not necessarily include DNI, although often patients request both DNR and DNI. It also does not imply that they do not want maximal treatment with curative efforts, including IV fluid resuscitation, pressors, central lines, surgery, and ICU admission.

At the end of life, it is important to let patients and families know that just because curative efforts have ended or are unlikely to be effective that we as medical caregivers are not abandoning them, but will continue to actively manage their symptoms. Start by assessing their symptoms. See reference 4 for a more in-depth discussion, but here are a few medications that can help for common symptoms:

Opioids: Are helpful for pain, dyspnea, and cough, starting at a low dose, and titrating up as needed and depending on the goals of care and patient wishes. Some patients may want to be less sedated to communicate with family and will tolerate more pain or dyspnea. Others may want to reduce their pain even if it causes sedation.

Benzodiazepines: Can help with anxiety, myoclonic twitching, hiccups, insomnia.

Haloperidol: Can help with agitation, nausea, hallucinations:

Scopolamine patches: Can help with respiratory secretions. Other options include 1% atropine eye drops under the tongue Q8 hours, or glycopyrrolate 1mg PO or 0.2mg IV.

Being diagnosed with or suffering from a severe illness can cause emotional stress, loss of sense of self, anxiety, depression, and fear. One way to help connect with patients is to make sure you sit down and take time to listen to them and their concerns. “Wish, Worry, Hope” statements such as “I wish things were different” or “I worry that the current treatment is not working”. Acknowledging that they have been suffering with a disease process if that is something they communicate to you, can also help validate them. Leave space for silence as patients process new information or diagnoses, or process their own thoughts.