What are the management options for a patient with a focus on comfort and no desire for hospitalization?

Management of Patients Prioritizing Comfort Over Hospitalization

For patients declining hospitalization with goals focused on comfort, discontinue disease-directed therapies, intensify palliative care interventions, and arrange immediate referral to specialized palliative care services or hospice for home-based symptom management and end-of-life support. 1

Immediate Care Transitions

Discontinue Disease-Directed Interventions

• Stop all anticancer or disease-modifying therapies immediately when the patient's estimated life expectancy is weeks to days and comfort is the primary goal 1
• Redirect focus from life-prolonging treatments to symptom control and comfort measures 1
• Provide guidance to the patient and family regarding the anticipated dying process and what to expect 1

Establish Palliative Care Framework

• Refer immediately to specialized palliative care services or hospice to enable home-based care delivery 1
• Hospice services allow patients to receive comprehensive comfort care at home, avoiding hospitalization while maintaining dignity 1
• Early palliative care involvement improves both quality of life and can paradoxically improve survival outcomes in some populations 1

Symptom Management Priorities

Pain Control

• For opioid-naive patients, initiate morphine 2.5-10 mg PO every 2-4 hours as needed for pain or dyspnea 1
• For patients already on chronic opioids, increase the dose by 25% for breakthrough symptoms 1
• Morphine remains the first-line opioid for comfort-focused care in the home setting 2

Dyspnea Management

• Administer opioids as first-line therapy (morphine 2.5-10 mg PO every 2-4 hours or 1-3 mg IV every 2-4 hours if IV access available) 1
• Add benzodiazepines for anxiety-associated dyspnea: lorazepam 0.5-1 mg PO every 4 hours as needed if benzodiazepine-naive 1
• Provide oxygen only if the patient reports subjective relief, not based solely on oxygen saturation 1
• Use nonpharmacologic measures including fans directed at the face, cooler room temperatures, and positioning for comfort 1

Secretion Management

• Reduce excessive respiratory secretions with scopolamine 0.4 mg subcutaneously every 4 hours as needed, or 1.5 mg patches (1-3 patches every 3 days) 1
• Alternative agents include atropine 1% ophthalmic solution 1-2 drops sublingually every 4 hours or glycopyrrolate 0.2-0.4 mg IV/subcutaneous every 4 hours 1

Fluid Management

• Discontinue or decrease enteral and parenteral fluids if fluid overload contributes to dyspnea or discomfort 1
• Consider low-dose diuretics if fluid overload is contributing to symptoms 1

Communication and Documentation

Goals of Care Discussion

• Confirm the patient's understanding of disease incurability and redirect goals toward achievable comfort-focused outcomes 1
• Document the patient's decision-making capacity, specific interventions to be withheld, and the rationale for comfort-focused care 3
• Foster patient participation in preparing loved ones for the dying process 1

Advance Care Planning

• Ensure documentation clearly states the patient's preferences regarding specific interventions (e.g., no CPR, no mechanical ventilation, no vasopressors) 3
• Clarify that all appropriate comfort treatments will continue despite declining hospitalization 3
• Provide anticipatory guidance regarding the expected course and timeline 1

Home-Based Care Coordination

Essential Support Services

• Coordinate with hospice teams to provide 24/7 availability for symptom crises and family support 1
• Ensure availability of emergency medications in the home (opioids, benzodiazepines, anticholinergics) 1
• Arrange for durable medical equipment as needed (hospital bed, oxygen if providing subjective relief, commode) 1

Family Education and Support

• Provide educational materials and counseling about what to expect during the dying process 1
• Offer psychosocial and emotional support resources for both patient and family 1
• Ensure family understands medication administration and when to contact hospice services 1

Common Pitfalls to Avoid

Do not continue disease-directed therapies when life expectancy is weeks to days, as this distracts from comfort measures and may cause harm without meaningful benefit 1

Avoid delaying hospice referral - earlier involvement consistently improves quality of life and family satisfaction 1

Do not withhold opioids due to concerns about respiratory depression in actively dying patients prioritizing comfort; adequate symptom control is the priority 1, 4, 2

Avoid using oxygen based solely on oxygen saturation - only provide if the patient reports subjective improvement in dyspnea 1