What are the recommendations for end of life care in a hospital setting?

End-of-Life Care in the Hospital Setting

All hospitalized patients with serious illness at the end of life require regular assessment of pain, dyspnea, and depression, with evidence-based pharmacologic management and advance care planning initiated early in their hospital course. 1, 2, 3

Core Symptom Assessment and Management

Pain Management

• Assess pain regularly using standardized validated tools throughout the hospital stay 1, 4
• Use opioids as the primary analgesic for severe pain, with morphine being the essential medication requiring careful titration based on symptom severity 2, 3
• For cancer-related pain specifically, combine NSAIDs, opioids, and bisphosphonates (particularly effective for bone pain in breast cancer and myeloma) 1, 2, 3
• The usual starting IV morphine dose is 0.1-0.2 mg/kg every 4 hours, administered slowly 5
• Do not reduce opioid doses solely for decreased blood pressure, respiration rate, or level of consciousness when necessary for adequate symptom management 2
• Have naloxone and resuscitative equipment immediately available when initiating morphine therapy 5

Dyspnea Management

• Assess dyspnea regularly using standardized tools 1, 4
• Use opioids for severe and unrelieved dyspnea in cancer and cardiopulmonary disease—the concern about respiratory depression should not prevent appropriate treatment when properly dosed 1, 2, 3
• Provide oxygen therapy for short-term relief of hypoxemia in conditions like advanced COPD 1, 2, 4
• For patients extubated in anticipation of death, document dyspnea assessments (this is frequently missed in practice) 6

Depression Management

• Screen for depression regularly throughout hospitalization 1, 3
• Treat with tricyclic antidepressants, selective serotonin reuptake inhibitors, or psychosocial interventions, particularly in cancer patients 1, 2, 3

Additional Symptom Management

• Reassess all medications and discontinue those no longer necessary when goals shift to comfort measures only (antiplatelets, anticoagulants, statins, hypoglycemics) 1
• Address oral care, delirium, respiratory secretions, incontinence, nausea, vomiting, constipation, skin and wound care, seizures, and anxiety 1

Advance Care Planning and Communication

Timing and Process

• Ensure advance care planning, including completion of advance directives, occurs for ALL patients with serious illness upon hospital admission—not when death is imminent 1, 2, 3
• Address surrogate decision makers, resuscitation preferences (DNR orders), emergency treatment preferences, and issues related to the patient's specific clinical course 2, 3
• Initiate "goals of care" discussions early when there is potentially poor prognosis, establishing consensus on direction of care (comfort-focused vs. life-prolonging) 1
• Reassess care plans when significant clinical changes occur 3

Communication Content

• Provide ongoing information and counseling to patients, families, and caregivers regarding diagnosis, prognosis, and management 1
• Discuss appropriateness of life-sustaining measures including mechanical ventilation, enteral/intravenous feeding, and intravenous fluids 1
• For patients on mechanical ventilation (only 13% undergo withdrawal prior to death in current practice), explicitly discuss withdrawal options 7
• For patients on artificial nutrition and hydration (only 19% undergo withdrawal prior to death currently), discuss withdrawal as appropriate 7

Communication Skills

• Use structured family conferences with clear, compassionate communication about prognosis and goals of care 4
• The interdisciplinary stroke team (applicable to all serious illness teams) should have appropriate communication skills to address physical, spiritual, psychological, and social needs 1

Palliative Care Integration

When to Apply Palliative Approach

• Apply a palliative care approach when there has been catastrophic illness (e.g., large hemispheric stroke, severe hemorrhagic stroke) or illness in the setting of significant pre-existing comorbidity 1
• Palliative care can begin at any stage of illness, including at diagnosis, and can be provided concurrently with curative or life-prolonging treatments 3
• Early palliative care consultation improves both quality and duration of life 3

Specialist Consultation

• Consult palliative care specialists for patients with difficult-to-control symptoms, complex or conflicted end-of-life decision making, or complex psychosocial family issues 1, 4
• For high-risk ICU patients, early integration of palliative care improves quality of life and enhances alignment with patient goals 4

Family and Caregiver Support

Assessment and Support

• Screen adult caregivers routinely for practical and emotional needs 2, 3
• Provide support including listening to concerns, attention to grief, and regular information updates about the patient's condition 3
• Allow and encourage family members to be with the patient 2
• Extend bereavement services to families up to one year after the patient's death 3

Family Involvement

• Presence of a health care proxy is significantly associated with DNR orders and comfort care plans—actively facilitate proxy designation 7
• Higher family satisfaction is associated with adequate nursing assistance, family involvement with decision making, respecting patient dignity, and being told when death is imminent 1

Multidisciplinary Team Approach

• A multidisciplinary team approach improves quality of life, functional status, and reduces hospital readmissions and costs 3
• Coordination between primary physicians and specialists, nurse case management, education, and patient and family activation improves outcomes 3
• Communication training for hospital staff and printed communication aids for families improve outcomes and satisfaction 4

Environmental Considerations

• Provide a safe, private, customizable environment that accommodates family, is homelike in ambiance and aesthetics, and is conducive for reflection 8
• Attention to room size, layout, aesthetics, and ambiance supports person-centered care focused on comfort and quality of life 8

Common Pitfalls to Avoid

Timing Errors

• Delaying transition to end-of-life care negatively impacts patient and family experiences—on average, comfort care plans are put in place only 15 days after admission with mean length of stay of 17 days 7
• Failing to complete advance care planning early in the course of serious illness leads to inadequate end-of-life care 3

Treatment Continuation Errors

• Substantial proportions of patients with comfort care plans continue to receive antibiotics (41%) and blood draws (30%)—actively discontinue non-beneficial interventions 7
• Starting or continuing non-beneficial life-sustaining treatments that merely prolong the dying process is associated with moral distress among healthcare providers 4

Symptom Management Errors

• Undertreatment of dyspnea due to concerns about respiratory depression from opioids—evidence supports their safety and efficacy when appropriately dosed 2, 3
• Follow-up for distressing symptoms is performed less well than initial assessment—establish systematic reassessment protocols 6

Documentation and Assessment Gaps

• Goals of care are addressed in a timely fashion for ICU patients only approximately half of the time—implement structured decision-making strategies 6
• Only 29% of patients extubated in anticipation of death have documented dyspnea assessments—mandate symptom documentation protocols 6