- Hospice eligibility (prognosis)
- A prognosis of 6 months or less if the disease runs its normal course, certified by two physicians (or one plus the hospice medical director).
- Hospice vs. palliative care
- Palliative care = any stage, with curative treatment, no prognosis limit. Hospice = ≤6-month prognosis, comfort-focused, curative treatment of the terminal illness forgone.
- Palliative Performance Scale (PPS)
- Rates function 100% (well) to 0% (death) in 10% steps using ambulation, activity, self-care, intake, and consciousness. Lower/falling PPS = shorter prognosis.
- Karnofsky threshold for hospice
- A Karnofsky Performance Status ≤50% (needs considerable assistance) is a common functional threshold supporting hospice eligibility.
- FAST scale (dementia)
- Functional Assessment Staging. Stage 7 = advanced dementia; FAST 7c (nonambulatory) plus a serious comorbidity supports hospice eligibility.
- End-stage heart failure (hospice)
- NYHA Class IV (symptoms at rest), optimally treated, often EF ≤20%, with refractory symptoms.
- End-stage COPD (hospice)
- Disabling dyspnea at rest, disease progression (ED visits/hospitalizations), hypoxemia/hypercarbia, cor pulmonale, and unintentional weight loss.
- ESRD (hospice)
- Discontinuing or not pursuing dialysis, with creatinine clearance under 10 mL/min (under 15 with comorbidity).
- End-stage liver disease (hospice)
- INR over 1.5 and albumin under 2.5, plus ascites, SBP, hepatorenal syndrome, encephalopathy, or recurrent variceal bleeding; not a transplant candidate.
- ALS (hospice)
- Rapid progression with critically impaired breathing capacity or critical nutritional impairment.
- Goals of care
- The patient's and family's values and priorities for treatment; they anchor the plan of care and shared decision making.
- Shared decision making
- A collaborative process where the clinician shares medical information and the patient/family share values, reaching a care decision together.
- Plan of care
- An individualized, interdisciplinary plan addressing physical, psychosocial, and spiritual needs; under Medicare it is reviewed at least every 15 days.
- Indicators of imminent death
- Decreasing intake/wakefulness, cool mottled extremities, weak/irregular pulse, falling BP, low urine output, Cheyne-Stokes breathing, death rattle, terminal restlessness.
- Terminal surge of energy
- A transient rally — brief alertness or energy days before death — that should not be mistaken for recovery.
- Cheyne-Stokes respirations
- A pattern of crescendo-decrescendo breathing alternating with apneic pauses, common in the actively dying patient.
- Mottling
- Bluish-purple skin discoloration of the extremities from poor perfusion; a sign of approaching death.
- Continuum of care
- Coordinating care as the patient moves across settings/levels (home, inpatient, respite) to match changing needs.
- Prognostication
- Estimating life expectancy using functional scales (PPS, KPS), disease-specific criteria, and the trajectory of decline.
- Levels of hospice care (4)
- Routine home care, continuous home care, general inpatient (GIP), and inpatient respite care.
- Routine home care
- The default, most common hospice level — care delivered wherever the patient lives, with scheduled interdisciplinary-team visits.
- Continuous home care
- Crisis-level care at home (≥8 hours in 24, mostly nursing) to manage an acute symptom and avoid hospitalization.
- General inpatient care (GIP)
- Short-term inpatient care for symptoms that cannot be controlled in other settings.
- Inpatient respite care
- Short-term inpatient care (up to 5 consecutive days) to give the family caregiver a break.
- Medicare hospice benefit periods
- Two 90-day periods, then unlimited 60-day periods, each requiring recertification of terminal illness (face-to-face for later periods).
- Hospice election statement
- The document by which a patient chooses the Medicare hospice benefit and comfort-focused care for the terminal illness.
- Self-determined life closure
- Supporting the patient's right to define a meaningful, dignified end of life consistent with their values.
- Functional decline as a signal
- The direction and speed of decline (a falling PPS/KPS) often predicts prognosis better than a single static score.
- Hospice recertification
- Periodic re-certification that the patient still has a ≤6-month prognosis, required to continue the benefit; later periods require a face-to-face encounter.
- WHO analgesic ladder
- Step 1: non-opioid (acetaminophen/NSAID). Step 2: weak opioid + non-opioid. Step 3: strong opioid + non-opioid. ± adjuvant at any step; move up if uncontrolled.
- By mouth, by the clock, by the ladder
- WHO principles: prefer the oral route, give persistent pain around-the-clock (not just PRN), and follow the ladder by severity.
- Opioid ceiling dose
- Pure mu-agonist opioids (morphine, hydromorphone, oxycodone, fentanyl) have no ceiling dose — titrate to effect with acceptable side effects.
- Breakthrough (rescue) dose
- About 10–20% of the total 24-hour opioid dose, given PRN with an immediate-release form; frequent use means raise the scheduled baseline.
- Around-the-clock (ATC) dosing
- Scheduled dosing for persistent pain to keep a steady analgesic level, with PRN rescue doses for breakthrough flares.
- Equianalgesia
- Using an equianalgesic table to convert doses between opioids or routes so the new regimen gives comparable pain relief.
- Incomplete cross-tolerance
- When rotating to a NEW opioid, reduce the calculated equianalgesic dose by about 25–50% because tolerance does not fully transfer.
- Morphine PO to IV ratio
- Roughly 3:1 — oral morphine 30 mg is about equal to IV/subcutaneous morphine 10 mg.
- Methadone caution
- Methadone has a long, variable half-life and non-linear potency; it requires specialist dosing and is not converted with a simple ratio.
- Opioid rotation
- Switching to a different opioid to improve the balance of analgesia and side effects (e.g., for neurotoxicity or poor control).
- Adjuvant analgesics
- Drugs not primarily analgesic that relieve specific pain types — anticonvulsants, antidepressants, corticosteroids, bisphosphonates.
- Neuropathic pain agents
- Gabapentin/pregabalin, TCAs (amitriptyline, nortriptyline), and SNRIs (duloxetine) for burning, shooting, or tingling nerve pain.
- Bone pain treatment
- NSAIDs, corticosteroids (dexamethasone), bisphosphonates, and palliative radiation for painful bony metastases.
- Tolerance
- Needing a higher dose to achieve the same effect — a normal, expected pharmacologic response, not addiction.
- Physical dependence
- Withdrawal symptoms on abrupt cessation or with an antagonist — expected and physiologic; managed by tapering, not addiction.
- Addiction
- Compulsive use, loss of control, and continued use despite harm — a behavioral disease, uncommon when opioids treat pain.
- Pseudoaddiction
- Drug-seeking behavior driven by UNDER-treated pain that resolves once analgesia is adequate — not true addiction.
- Total pain
- Cicely Saunders' concept that suffering is physical, psychological, social, and spiritual; all four must be addressed.
- Nociceptive pain
- Pain from tissue damage — somatic (well-localized, aching) or visceral (deep, cramping, poorly localized).
- Pain assessment in nonverbal patients
- Use behavioral indicators — facial grimacing, restlessness, guarding, moaning, vocalizations — and validated observational scales.
- Opioid-induced constipation prophylaxis
- Start a stimulant laxative (senna ± docusate) with the first opioid dose; the body never develops tolerance to constipation.
- Naloxone in palliative pain
- Reserve for true opioid-induced respiratory depression; dilute and titrate in small aliquots to avoid precipitating severe pain and withdrawal.
- Myoclonus from opioids
- Dose-related neurotoxicity (jerking movements); consider opioid rotation, hydration, or dose reduction.
- Non-pharmacologic pain measures
- Positioning, heat/cold, massage, relaxation, distraction, and palliative procedures (radiation, nerve blocks).
- Complementary therapies
- Reiki, hypnosis, acupressure, massage, music therapy, and pet therapy used alongside (not instead of) medical management.
- Fear and pain
- Anxiety, depression, cultural, and spiritual factors can amplify the perceived intensity of pain — part of total pain.
- Fentanyl patch caveat
- Transdermal fentanyl is for stable, opioid-tolerant patients; it has a delayed onset/offset and is unsuitable for rapid titration of unstable pain.
- Corticosteroids as adjuvants
- Dexamethasone can relieve pain from nerve compression, raised intracranial pressure, and bowel obstruction, and also boost appetite and reduce nausea.
- Proportionate dosing
- Give the dose needed to control the symptom; escalating an opioid to relieve pain near death is appropriate, guided by double effect.
- First-line for dyspnea
- Low-dose opioids reduce the sensation of breathlessness (air hunger). Oxygen only if hypoxic; a fan to the face helps even without hypoxia.
- Dyspnea is subjective
- Like pain, dyspnea is what the patient says it is; a normal pulse oximetry reading does not rule it out.
- Death rattle
- Noisy breathing from pooled secretions in the actively dying patient — usually more distressing to family than to the patient.
- Death rattle management
- Reposition and give an antimuscarinic (glycopyrrolate, scopolamine, atropine, hyoscyamine). Avoid deep suctioning. Reassure the family.
- Terminal delirium
- Acute, fluctuating confusion common near death; assess reversible causes (meds, infection, pain, retention, hypoxia, metabolic).
- Hyperactive delirium treatment
- Haloperidol is first-line for agitation, plus non-pharmacologic measures — reorientation, calm environment, family presence.
- Nausea: CTZ cause
- Chemoreceptor trigger zone nausea (opioids, metabolic) responds to haloperidol, metoclopramide, or ondansetron.
- Nausea: gastric stasis
- Treat with the prokinetic metoclopramide to improve gastric emptying.
- Nausea: vestibular/motion
- Treat with antihistamines or anticholinergics (scopolamine, meclizine).
- Bowel obstruction symptoms
- Octreotide, anticholinergics, and corticosteroids reduce secretions and colic when surgery is not appropriate.
- Constipation management
- Stimulant ± osmotic laxative; avoid bulk-forming fiber in opioid-induced constipation. PAMORAs (methylnaltrexone) for refractory cases.
- Rule out before laxative escalation
- Always exclude fecal impaction and bowel obstruction before increasing laxatives.
- Anorexia-cachexia
- A natural part of advanced dying; artificial nutrition/hydration usually does not prolong life or improve comfort and can worsen symptoms.
- Family teaching on decreased intake
- Reassure family that reduced appetite and intake are normal at the end of life; offer small amounts of preferred food for pleasure.
- Fatigue
- The most common symptom in advanced illness; treat reversible contributors (anemia, depression, meds) and pace activities.
- Terminal restlessness
- Agitation in the actively dying; rule out reversible causes (pain, retention, dyspnea) then treat for comfort, sometimes with sedatives.
- Pruritus
- Itching from opioids, cholestasis, or uremia; treat the cause and use antihistamines or, for cholestatic itch, other agents.
- Urinary retention
- Can cause agitation/restlessness in a dying patient; assess the bladder and consider catheterization for comfort.
- Pressure injury prevention
- Reposition, protect skin, and manage moisture; near death the goal shifts to comfort rather than aggressive turning if it causes distress.
- Mouth care
- Frequent moisturizing and oral care relieve dry mouth in patients with low intake and mouth breathing — a key comfort measure.
- Seizures at end of life
- Benzodiazepines (e.g., rectal or buccal midazolam/lorazepam) are used when the oral route is lost.
- Hiccups (intractable)
- Persistent hiccups may respond to chlorpromazine, baclofen, or metoclopramide; treat reversible causes.
- Spiritual distress
- Suffering related to meaning, hope, or faith; distinct from depression — involve chaplaincy and use a spiritual assessment.
- Anxiety near death
- Benzodiazepines for acute anxiety; address fears and unmet psychosocial/spiritual needs alongside medication.
- Hemorrhage (terminal)
- A catastrophic bleed; have dark towels and a fast-acting sedative ready, stay with the patient, and support the family.
- Edema and ascites
- Manage for comfort — positioning, gentle diuretics if helpful, and avoiding over-hydration that worsens fluid overload.
- Hearing preserved late
- Hearing is thought to remain until close to death; encourage family to keep talking to the patient.
- Opioids for cough
- Opioids can suppress a distressing dry cough in advanced illness when other measures fail.
- Oxygen at end of life
- Oxygen relieves dyspnea only when the patient is hypoxic; for non-hypoxic air hunger, airflow and opioids are more effective.
- Advance directive
- A legal document — a living will (treatment preferences) plus a durable power of attorney (names a health care surrogate) — for future incapacity.
- Living will
- A written statement of a person's treatment preferences if they lose decision-making capacity.
- Durable power of attorney for health care
- A document naming a surrogate (proxy) to make medical decisions if the patient cannot.
- POLST / MOLST
- Portable, actionable medical orders signed by a clinician for a seriously ill patient — code status, intubation, nutrition — that travel across settings.
- Advance directive vs. POLST
- An advance directive guides future care; a POLST is an immediately actionable clinician order for current care.
- Patient Self-Determination Act
- Requires facilities to ask patients about advance directives and inform them of their right to accept or refuse treatment.
- Medicare Hospice Benefit coverage
- Covers care related to the terminal diagnosis — IDT visits, medications, DME/supplies — and bereavement support for up to 13 months after death.
- Bereavement services
- Grief support the hospice provides to the family for up to 13 months after the patient's death.
- Anticipatory grief
- Grief experienced before the death by patient and family as they anticipate the loss; a normal response.
- Complicated / prolonged grief
- Persistent, impairing grief lasting well beyond the expected period; a clinical concern warranting referral.
- Grief vs. mourning vs. bereavement
- Grief = internal response to loss; mourning = outward/cultural expression; bereavement = the state of having lost someone.
- Kübler-Ross stages
- Denial, anger, bargaining, depression, acceptance — DESCRIPTIVE, not linear, universal, or required; a framework, not a checklist.
- SPIKES protocol
- Breaking bad news: Setting, Perception, Invitation, Knowledge, Empathy, Strategy/Summary.
- NURSE statements
- Empathic responses to emotion: Name, Understand, Respect, Support, Explore.
- Ask-tell-ask
- Assess what the patient knows/wants, give information in small chunks, then check understanding.
- Family meeting
- A structured conversation to share information and align goals of care among patient, family, and the team.
- Cultural humility
- An ongoing stance of openness and self-reflection — ask rather than assume about beliefs on disclosure, decisions, and rituals.
- FICA spiritual assessment
- Faith, Importance, Community, and Address in care — a tool to explore a patient's spirituality.
- Respond to emotion before information
- When a patient expresses strong emotion, address it (empathy) before giving more medical information.
- Allowing silence
- Pausing after bad news or emotion gives the patient space to process and respond.
- Caregiver self-care
- Promoting rest, support, and respite for family caregivers to prevent burnout and sustain caregiving.
- Caregiver teaching
- Train caregivers in medication administration, symptom recognition, what to expect when dying, DME use, and whom to call.
- Safe controlled-substance storage
- Teach families secure storage and proper disposal of opioids to prevent diversion and accidental harm.
- Demystifying opioids
- Address family fears that opioids cause addiction or hasten death; correct misconceptions so pain is treated adequately.
- Post-mortem care
- Respectful care of the body after death, honoring cultural/religious practices, and supporting the family's presence and rituals.
- Support at time of death
- Being present, explaining what is happening, normalizing the process, and supporting the family through the moment of death.
- Patient safety in the home
- Assess environmental, physical, and socioemotional risks — fall hazards, medication safety, caregiver capacity.
- Disclosure preferences
- Some cultures favor protecting the patient from a terminal diagnosis; clarify who should receive information and how.
- Hope reframing
- Help patients shift hope from cure to achievable goals — comfort, time with family, dignity, life closure.
- Autonomy
- The ethical principle respecting a patient's right to self-determination and informed choices about their own care.
- Beneficence
- The ethical duty to act for the patient's good.
- Nonmaleficence
- The ethical duty to do no harm.
- Justice
- The ethical principle of fairness in the distribution of care and resources.
- Fidelity and veracity
- Fidelity = keeping commitments to the patient; veracity = truth-telling.
- Principle of double effect
- An act with a good intended effect (relief of suffering) is permissible despite a foreseen, unintended harm if intent is good, dose proportionate, and harm not the means.
- Palliative sedation
- Titrating sedation to relieve refractory, intolerable symptoms in an imminently dying patient; the intent is symptom relief — ethically and legally accepted.
- Euthanasia
- Intentionally causing a patient's death — distinct from palliative sedation in both intent and act.
- Physician-assisted dying
- A clinician provides the means for a patient to end their own life; distinct from euthanasia and from palliative sedation.
- Interdisciplinary team (IDT)
- Nurse, physician/medical director, social worker, chaplain, hospice aide, bereavement counselor, and volunteers — with patient and family at the center.
- IDT plan-of-care review
- Medicare requires the interdisciplinary team to review and update the plan of care at least every 15 days.
- National Consensus Project
- The NCP Clinical Practice Guidelines for Quality Palliative Care — the national standards for palliative care practice.
- Medicare Conditions of Participation
- Federal requirements a hospice must meet to receive Medicare payment, covering the IDT, plan of care, and quality.
- Certification of terminal illness
- Physician certification that the patient has a ≤6-month prognosis; required at admission and at each benefit period.
- Face-to-face encounter
- A required visit by a physician or nurse practitioner before the third and later hospice benefit periods to recertify eligibility.
- HIPAA
- The federal law protecting the privacy and security of patients' health information.
- OSHA
- The federal agency setting workplace-safety standards, including bloodborne-pathogen and hazard protections for nurses.
- Professional boundaries
- Maintaining a therapeutic, not personal, relationship with patients and families to protect both parties.
- Compassion fatigue
- Emotional and physical exhaustion from caring for the suffering, reducing empathy over time; an occupational risk in hospice.
- Burnout
- Chronic work-related exhaustion, cynicism, and reduced efficacy; mitigated by boundaries, support, and self-care.
- Moral distress
- The distress that arises when a nurse knows the right action but is constrained from taking it.
- Vicarious / secondary traumatic stress
- Stress from repeated exposure to others' trauma and suffering; addressed through debriefing and peer support.
- Nurse self-care strategies
- Reflective practice, debriefing, boundaries, peer support, and resilience practices — explicitly part of the Practice Issues domain.
- Quality assessment / performance improvement
- Hospices must run a data-driven QAPI program to monitor and improve care quality and safety.
- Controlled-substance handling
- Follow DEA and facility rules for prescribing, counting, wasting, and disposing of opioids and other controlled drugs.
- Eligibility for admission
- Verify the patient meets hospice criteria — a ≤6-month prognosis and election of comfort-focused care — before admission.
- Preceptor / mentor role
- Contributing to the professional development of peers and students as an educator, preceptor, or mentor.
- Trends affecting hospice
- Staying current on legislation, policy, reimbursement, and health-care delivery changes that affect hospice and palliative care.
- National hospice standards
- Recognized standards and guidelines (NHPCO, NCP) that define quality hospice and palliative nursing practice.
- End-stage cancer (hospice)
- Metastatic or locally advanced disease with declining function (PPS ≤ 50%) and a clinical course consistent with a ≤6-month prognosis.
- Stroke/coma (hospice)
- Poor functional status (PPS ≤ 40%), inability to maintain hydration/nutrition, and post-stroke complications support eligibility.
- Dementia hospice — comorbidities
- FAST 7c plus a recent serious comorbidity (aspiration pneumonia, pyelonephritis, sepsis, stage 3–4 ulcers, or weight loss) strengthens eligibility.
- Karnofsky Performance Status (KPS)
- Rates function 100% (normal) to 0% (dead) in 10% steps; KPS ≤ 50% is a common functional threshold for hospice.
- Comprehensive palliative assessment
- Covers physical, functional, psychological, social, spiritual, and cultural domains plus goals of care — not just the disease.
- Reassessment frequency
- Symptoms and function are reassessed regularly and whenever the condition changes, so the plan of care keeps pace with decline.
- Local Coverage Determinations (LCDs)
- Medicare disease-specific guidelines (cardiac, pulmonary, dementia, etc.) used to support hospice prognosis and eligibility.
- Functional vs. disease criteria
- Prognosis combines a functional scale (PPS/KPS), disease-specific criteria, and the trajectory of decline — never a single number.
- Edmonton Symptom Assessment System (ESAS)
- A validated tool scoring nine common symptoms 0–10 (pain, tiredness, nausea, depression, anxiety, drowsiness, appetite, wellbeing, dyspnea).
- Setting of care
- Hospice/palliative care is delivered wherever the patient lives — home, assisted living, nursing facility, or inpatient unit.
- Disenrollment / live discharge
- A patient may revoke the hospice benefit (e.g., to pursue curative care) or be discharged if no longer terminally ill, and may re-elect later.
- Pediatric concurrent care
- Under the ACA, children on Medicaid/CHIP may receive hospice AND curative treatment at the same time (concurrent care).
- Spiritual & psychosocial screen
- Early screening for spiritual distress, depression, anxiety, and social needs guides referrals to chaplaincy and social work.
- Risk for falls / safety
- Assess fall risk, home hazards, and caregiver ability as part of planning, balancing safety against the patient's goals.
- Trajectory of dying
- Common illness trajectories — rapid (cancer), intermittent decline (organ failure), and prolonged dwindling (frailty/dementia).
- Oral morphine to oral oxycodone
- Roughly 1.5:1 — oral morphine 30 mg ≈ oral oxycodone 20 mg (ratios vary by reference; verify locally).
- Oral morphine to oral hydromorphone
- Roughly 5:1 — oral morphine 30 mg ≈ oral hydromorphone 6–7.5 mg (potent; small numbers).
- Hydromorphone PO to IV
- Roughly 5:1 — oral hydromorphone is about one-fifth as potent as IV; convert carefully because the drug is potent.
- Calculating a basal + rescue regimen
- Total the 24-hour requirement, divide for the scheduled dose, and set the breakthrough dose at ~10–20% of the 24-hour total.
- WHO ladder — adjuvant at every step
- Adjuvants (steroids, anticonvulsants, antidepressants, bisphosphonates) can be added at ANY step, not only at the top.
- Visceral pain
- Deep, cramping, poorly localized pain from organs (e.g., bowel obstruction, hepatic capsule); opioids ± antispasmodics/steroids.
- Somatic pain
- Well-localized, aching pain from skin, muscle, or bone; responds to opioids, NSAIDs, and acetaminophen.
- Numeric & faces pain scales
- Self-report scales (0–10 numeric, Wong-Baker FACES) are the gold standard when the patient can communicate.
- PAINAD scale
- A behavioral pain scale for advanced dementia scoring breathing, vocalization, facial expression, body language, and consolability.
- Acetaminophen ceiling
- Acetaminophen has analgesic benefit but a dose ceiling (hepatotoxicity); useful as a non-opioid co-analgesic.
- NSAID cautions
- GI bleeding, renal impairment, and fluid retention limit NSAIDs, especially in the frail and renally impaired.
- Transdermal fentanyl dosing
- For STABLE, opioid-tolerant pain only; ~12 hours to onset and offset — never use for rapid titration of unstable pain.
- Subcutaneous route
- When oral and IV access are lost, subcutaneous infusion/injection delivers opioids and other comfort meds at home.
- Methadone NMDA effect
- Methadone's NMDA-antagonist action helps neuropathic pain but its variable, long half-life makes dosing specialist-only.
- Tramadol caution
- Lowers the seizure threshold and carries serotonin-syndrome risk; a weak opioid with a dose ceiling — limited in severe pain.
- Meperidine avoided
- Avoid meperidine (Demerol) in palliative care — its metabolite normeperidine accumulates and causes neurotoxicity/seizures.
- Patient-controlled analgesia (PCA)
- Lets the patient self-administer rescue doses within set limits; useful for rapidly changing or severe pain.
- Neuraxial / interventional analgesia
- Epidural/intrathecal opioids, nerve blocks, and palliative radiation for pain refractory to systemic medication.
- Constipation prophylaxis is mandatory
- Because tolerance to opioid constipation never develops, a bowel regimen is started prophylactically with every opioid.
- Opioid-induced neurotoxicity (OIN)
- Myoclonus, hyperalgesia, delirium, and seizures from metabolite accumulation; treat with rotation, hydration, or dose reduction.
- Reassess pain after each change
- After any dose change or new analgesic, reassess pain and function to confirm benefit and detect toxicity.
- Cultural and spiritual factors in pain
- Beliefs about pain, stoicism, and the meaning of suffering shape reporting and acceptance of treatment.
- Goal of pain control
- Acceptable comfort at rest and with activity, balanced against tolerable side effects — defined with the patient.
- Steroid-responsive pain
- Pain from nerve/cord compression, raised intracranial pressure, capsular stretch, or bowel obstruction often responds to dexamethasone.
- Dyspnea ladder
- Treat reversible causes; use low-dose opioids first-line, a fan to the face, positioning, and benzodiazepines for associated anxiety.
- Opioid for dyspnea (opioid-naive)
- Start a low dose of an immediate-release opioid (e.g., morphine 2.5–5 mg PO) and titrate to comfort.
- Nausea — choose the antiemetic by cause
- Match the drug to the pathway: CTZ (haloperidol), gut/stasis (metoclopramide), vestibular (anticholinergic/antihistamine), cortical (benzodiazepine).
- Ondansetron use
- A 5-HT3 antagonist useful for chemotherapy/radiation-related nausea; may worsen constipation.
- Malignant bowel obstruction (inoperable)
- Manage medically with octreotide, anticholinergics, antiemetics, and corticosteroids; a venting gastrostomy if needed.
- Diarrhea
- Treat the cause; loperamide for symptom control; review laxatives and rule out overflow around an impaction.
- Anorexia-cachexia — drug options
- Corticosteroids (short-term) or megestrol may transiently improve appetite; neither reverses cachexia or prolongs life.
- Artificial nutrition near death
- Tube feeding/IV fluids generally do not prolong life or improve comfort at the very end and can worsen secretions and edema.
- Delirium — assess first
- Screen for and treat reversible causes (medications, infection, pain, urinary retention, hypoxia, metabolic) before sedating.
- Hypoactive delirium
- Quiet, withdrawn confusion that is easily missed; manage reversible causes and minimize deliriogenic drugs.
- Secretions — early use of anticholinergics
- Antimuscarinics work best when started early, before large volumes pool; they dry new secretions but not existing pooled fluid.
- Repositioning for secretions
- Turning the patient to a lateral or semi-prone position helps drain pooled secretions and reduce the death rattle.
- Fever and infection at end of life
- Treat for comfort (antipyretics, cooling); antibiotics are used only when they improve comfort, consistent with goals of care.
- Insomnia
- Address pain, anxiety, and environment first; use sleep aids judiciously, as they can worsen confusion in the frail.
- Depression vs. anticipatory grief
- Persistent hopelessness, worthlessness, and anhedonia suggest depression (treatable), distinct from normal anticipatory grief.
- Cancer-related fatigue
- The most common and distressing symptom; treat reversible causes, pace activity, and consider a psychostimulant in selected patients.
- Lymphedema
- Manage with skin care, compression, and gentle exercise; treat associated discomfort and infection risk.
- Wound and odor management
- Topical metronidazole, charcoal dressings, and odor control improve comfort and dignity with malodorous fungating wounds.
- Mucositis / stomatitis
- Painful oral inflammation from cancer therapy; manage with oral care, topical analgesics, and systemic analgesia.
- Hypercalcemia of malignancy
- Confusion, constipation, nausea, polyuria, and weakness; treat with hydration and bisphosphonates if consistent with goals.
- Spinal cord compression
- An oncologic emergency — back pain with weakness/sensory loss; give dexamethasone urgently and consider radiation.
- Superior vena cava syndrome
- Facial/arm swelling and dyspnea from SVC obstruction; treat with steroids, head elevation, and oncologic therapy or stenting.
- Restlessness — rule out retention/impaction
- A full bladder or impacted stool is a common, reversible cause of terminal restlessness — check before sedating.
- Comfort as the unit of measure
- Near death, interventions (turning, vitals, labs) are continued only if they add comfort, not by routine.
- DNR / code status
- A DNR/AND order directs that CPR not be attempted; clarify it is separate from, and does not stop, comfort care.
- Allow Natural Death (AND)
- Preferred framing over 'DNR' — emphasizes allowing a natural death and continuing comfort, not withdrawing care.
- Surrogate decision-maker hierarchy
- If no health-care proxy is named, most states follow a statutory order (spouse, adult child, parent, sibling) for the surrogate.
- Substituted judgment
- The surrogate decides as the patient WOULD have decided, based on the patient's known values — not on the surrogate's own wishes.
- Best-interest standard
- Used when the patient's wishes are unknown — decisions are made in the patient's overall best interest.
- Capacity vs. competence
- Capacity is a clinical, decision-specific judgment; competence is a legal determination by a court.
- Health literacy
- Tailor teaching to the patient's literacy — plain language, teach-back, and written/visual aids improve understanding.
- Teach-back method
- Ask the patient/caregiver to restate instructions in their own words to confirm understanding.
- Disclosure across cultures
- Some families prefer to shield the patient from a terminal diagnosis; clarify the patient's own disclosure wishes respectfully.
- Advocacy role
- Representing and protecting the patient's preferences, dignity, and access to needed care across the team and system.
- Children and grief
- Support children's grief with honest, age-appropriate language; avoid euphemisms like 'gone to sleep.'
- Bereavement risk assessment
- Identify family at higher risk for complicated grief (sudden loss, prior losses, poor support) for targeted follow-up.
- Dual process model of grief
- Healthy grieving oscillates between loss-oriented and restoration-oriented coping over time.
- Continuing bonds
- Maintaining a healthy ongoing connection to the deceased (memories, rituals) is part of normal grieving, not pathology.
- Legacy and dignity work
- Helping patients create legacy (letters, recordings, life review) supports meaning and dignity near the end of life.
- Resources & referrals
- Connect families to community resources — financial, respite, equipment, support groups, spiritual care.
- What to expect when dying
- Teach families the signs of approaching death so changes feel anticipated rather than alarming.
- Caregiver burden
- Assess and address the physical, emotional, and financial strain on caregivers as part of the unit of care.
- Goals-of-care conversation
- Elicit the patient's values, hopes, and fears, then align recommendations and treatment with them.
- Respect for autonomy in teaching
- Provide balanced information so the patient/family can make informed choices; do not coerce a decision.
- Spiritual care vs. religion
- Spirituality (meaning, hope, connection) is broader than religion and applies even to non-religious patients.
- Family presence at death
- Facilitate and support family presence, normalize the process, and honor their cultural and religious rituals.
- Documentation of preferences
- Record advance directives, code status, and goals so they travel with the patient and guide all team members.
- Empathic communication
- Acknowledge emotion, allow silence, and respond to feelings before adding more medical detail.
- Four classic conditions of double effect
- (1) the act is good/neutral, (2) intent is the good effect, (3) the bad effect is not the means, (4) proportionality.
- Proportionate (palliative) sedation
- Sedation is titrated to the lowest level that relieves the refractory symptom — only as deep as needed for comfort.
- Refractory symptom
- A symptom that cannot be adequately controlled despite aggressive, tolerable treatment — the threshold for palliative sedation.
- Withholding vs. withdrawing treatment
- Ethically equivalent — there is no moral difference between not starting and stopping a treatment that no longer serves goals.
- VSED
- Voluntarily stopping eating and drinking — a capacitated patient's legal choice; the team provides comfort care and support.
- Medical aid in dying (MAID)
- Legal only in some states under strict criteria; distinct from euthanasia (patient self-administers); know your jurisdiction's law.
- Conscientious objection
- A nurse may decline to participate in certain acts on moral grounds but must not abandon the patient and must ensure continuity.
- Nonabandonment
- Nurses do not abandon patients who express a wish to hasten death — they assess suffering and engage the team.
- Ethics consultation
- A resource to help resolve value conflicts and complex end-of-life decisions among patient, family, and team.
- Informed consent
- Voluntary agreement to treatment after disclosure of risks, benefits, and alternatives by a capacitated patient.
- Confidentiality limits
- Protect health information; disclose only with consent or where law requires (e.g., safety, mandated reporting).
- Role of the hospice nurse on the IDT
- Provides direct care, coordinates the plan, communicates observations, and educates patient, family, and team.
- Medical director role
- Certifies terminal illness, oversees the medical component of care, and supports the IDT.
- Volunteers in hospice
- Medicare requires hospices to use trained volunteers (≥5% of patient-care hours) for companionship and support.
- HPNA
- The Hospice and Palliative Nurses Association — the professional organization providing standards and education for the specialty.
- HPCC
- The Hospice and Palliative Credentialing Center — the body that administers the CHPN and related certifications.
- Scope and standards of practice
- HPNA/ANA standards defining competent hospice and palliative nursing practice and professional responsibilities.
- Evidence-based practice
- Integrating best evidence, clinical expertise, and patient values to guide hospice and palliative interventions.
- Quality measures (HQRP)
- The Hospice Quality Reporting Program — outcome and experience measures hospices report to Medicare.
- Resilience and self-care
- Building resilience through reflection, debriefing, boundaries, and support sustains the nurse and prevents burnout.
- Grief support for staff
- Team debriefing and remembrance practices help staff process cumulative loss and prevent compassion fatigue.
- Delegation and supervision
- Delegate appropriately to aides/LPNs within scope while retaining accountability for assessment and the plan of care.
- Cultural & spiritual competence
- Practicing with humility and respect for diverse beliefs about death, decision-making, and rituals.
- Advocacy at the system level
- Influencing policy, access, and resources to improve hospice and palliative care beyond the individual patient.
