--- module: 068-01 language: en chapter: 68 title: "Palliative Medicine, Symptom Control, Dying, Grief, and Bereavement" module_title: "Foundations" source_sha256: 142e84d61d2b1bba054854eae934a7b21260f8cd9c391fdc519a2d81b45b827a --- # Palliative medicine foundations ## Scope and identifying need ### Symptoms, decisions, coordination, whole-person needs ### Begins alongside disease treatment #### Not limited to cancer or final days ### Recognising dying shifts effort to comfort ### Triggers: progression, admissions, decline, carer strain ### Surprise question finds unmet planning #### Not a prognosis ### Trajectories differ by disease #### Cancer may decline predictably #### Organ failure fluctuates with crises #### Frailty or dementia declines slowly ## Goals and shared decisions ### Understanding, detail wanted, what matters now ### Hope shifts from cure to achievable priorities ### Compare benefit, burden, uncertainty, alternatives ### Time-limited trial #### Intervention, markers, duration, plan if no benefit ### Record substitute, directives, resuscitation, place ## Communication and prognosis ### Warn, speak plainly, pause, acknowledge emotion ### Prognosis is a range, not a date #### Best, worst, and likely scenarios ### Patient declines details: identify a recipient ### Conflict reflects facts, values, grief, trust #### Shared goals, second opinion, mediation #### Recommend when treatment cannot meet goals ## Holistic symptom assessment ### Symptoms are multidimensional ### Investigate only if management changes ### Non-drug care: explanation, positioning, fan, mouth care ### Stop preventive drugs mismatched to prognosis #### Avoid withdrawal of dependence-producing drugs ## Pain ### Identify pain type, treat cause if proportionate ### Steroids, bisphosphonates, radiotherapy, nerve blocks ### Opioids central but not the only treatment ### Transdermal systems adjust slowly #### Unsuitable for rapidly escalating pain ### Conversion tables are estimates #### Reduce for incomplete cross-tolerance ### Respiratory depression: escalation, interaction, renal failure, error ### Fear of addiction must not leave pain untreated ## Breathlessness ### Multiple mechanisms, including anxiety and perception ### Oxygen helps hypoxaemia, adds little otherwise ### Upright, handheld fan, pacing, calm coaching ### Low-dose opioid alters central perception ### Benzodiazepine only for severe associated anxiety ### Non-invasive ventilation needs explicit purpose #### Relieves symptoms or prolongs life ## Nausea, bowel, and secretions ### Manage obstruction according to goals #### Avoid prokinetics in complete obstruction ### Constipation causes pain, nausea, delirium #### Stimulant plus osmotic for opioid constipation #### Avoid rectal measures in neutropenia, low platelets ### Noisy secretions distress family more than patient #### Antimuscarinics do not remove existing fluid #### Deep suction distresses without lasting benefit ## Delirium, agitation, and distress ### Delirium: infection, retention, drugs, organ failure #### Familiarity, orientation, sleep cues, safety #### Antipsychotics for danger, may worsen some syndromes ### Terminal agitation: pain, bladder, fear, withdrawal ### Catastrophic bleed: dark towels, rapid sedation ### Sadness does not exclude depression ### Meet desire for hastened death with curiosity ### Antidepressant onset may exceed prognosis ## Nutrition and hydration ### Treat mouth pain and nausea without forcing intake ### Preferred foods over calorie targets ### Cachexia not reversed by calories alone ### Artificial nutrition for selected reversible states #### Often no benefit in advanced dementia or dying ### Assisted hydration may worsen oedema, secretions #### Mouth care often relieves dryness better ## Last days, death, and grief ### Signs: bedbound, minimal intake, mottling, no swallow ### Stop observations, tests, devices not aiding comfort ### Anticipatory medicines by a usable route ### Resuscitation decisions are not abandonment ### Withholding and withdrawing are ethically equivalent ### Palliative sedation: minimum required, reviewed ### Verify death, certification, time with the body ### Grief is not linear #### Risk: traumatic death, isolation, low support #### Follow up without medicalising normal sorrow