Comfort Medications in Hospice Patients with PPS 20%
Yes, absolutely continue comfort medications for hospice patients at PPS 20%—in fact, symptom management should be intensified at this stage, not withdrawn. 1, 2
Understanding PPS 20% in Hospice Context
A Palliative Performance Scale (PPS) of 20% indicates a patient who is:
- Totally bed-bound
- Unable to perform any self-care
- Experiencing extensive disease progression
- Requiring total assistance with all activities
- Typically within days to weeks of death 2
This functional status demands aggressive symptom palliation, not medication withdrawal. 1, 3
Core Principle: Comfort Measures Only Does Not Mean No Medications
The American College of Chest Physicians explicitly clarifies that "comfort measures only" occurs when treatments become more burdensome than the disease itself, but this specifically refers to life-prolonging interventions—not symptom management medications. 1 The goal shifts from cure to comfort, which actually requires maintaining and often intensifying medications that relieve suffering. 1
What to Continue and Intensify
Medications that should absolutely continue or be escalated include:
- Opioids for pain and dyspnea (first-line treatment for breathlessness) 2, 4
- Anxiolytics for anxiety and agitation 1, 5
- Anticholinergics (glycopyrrolate, scopolamine) for secretions 2
- Antiemetics for nausea 5
- Medications for pruritus, delirium, and other distressing symptoms 5
- Supplemental oxygen if it provides comfort 2, 5
The American Academy of Hospice and Palliative Medicine emphasizes that palliative treatments aimed at managing pain, dyspnea, anxiety, and other distressing symptoms should continue and are often enhanced as death approaches. 2, 3
The Doctrine of Double Effect
The American College of Chest Physicians endorses using the "doctrine of double effect" for end-stage patients, which morally justifies medications that relieve suffering (the intended good effect) even if they theoretically might hasten death (the unintended effect). 1 The intent is symptom relief, not death—this makes aggressive symptom management ethically and legally appropriate. 1
What Changes at PPS 20%
What you discontinue are treatments that:
- Prolong life without improving comfort
- Are burdensome (frequent blood draws, aggressive interventions)
- No longer align with comfort-focused goals 1, 2
What you maintain or intensify are treatments that:
Palliative Sedation for Refractory Symptoms
For patients at PPS 20% with intolerable symptoms despite optimal palliative care, continuous palliative sedation may be appropriate. 1 This is reserved for patients with terminal illness and life expectancy of weeks or less who suffer refractory physical or psychological symptoms after careful attention to all dimensions of suffering. 1 This represents intensification of comfort measures, not withdrawal.
Common Pitfall to Avoid
The most dangerous misconception is equating "hospice" or "comfort measures only" with medication withdrawal. 1, 2 The NCCN Guidelines and American College of Chest Physicians both emphasize that hospice patients are not required to withdraw all medical treatments—they focus on comfort-oriented care rather than curative treatments. 2 At PPS 20%, patients require more aggressive symptom management, not less. 3
The ACC/AHA guidelines for heart failure patients specifically state that greater attention and research need to be devoted to the provision of comfort measures in the final days of life, including relief of pain and dyspnea, with physicians becoming familiar with prescribing anxiolytics, sleeping medications, and narcotics to ease distress. 1