Palliative care for adults in the ED: Concepts, presenting complaints, and symptom management

INTRODUCTION — Patients with chronic, severe, or life-threatening conditions who would benefit from palliative interventions present to the emergency department (ED) every day. Whenever possible, emergency clinicians should engage such patients and their families in conversations about palliative care and hospice services. Early referral from the ED to palliative medicine or, when indicated, to hospice can improve both quality and quantity of life. Such practice is in keeping with the recommendations of the American College of Emergency Physicians (ACEP) [1].

This topic provides the emergency clinician with the basic concepts and terminology of palliative care and guidance for the assessment and initial management of common symptoms. Guidance for emergency clinicians who must determine goals of care, communicate difficult news, or assist dying patients is provided separately. (See "Palliative care for adults in the ED: Goals of care, communication, consultation, and patient death".)

More detailed discussions of palliative medicine practice outside the ED are found separately and include the following topics:

●General concepts and patient assessment (see "Approach to symptom assessment in palliative care" and "Overview of comprehensive patient assessment in palliative care" and "Benefits, services, and models of subspecialty palliative care" and "Palliative care and hospice outside of the United States")

●Symptom management (see "Pain control in the critically ill adult patient" and "Assessment and management of dyspnea in palliative care" and "Palliative sedation" and "Overview of managing common non-pain symptoms in palliative care" and "Palliative care: The last hours and days of life")

BASIC TERMINOLOGY AND CONCEPTS

Why the integration of palliative care in the ED is important — Many patients seek care in the ED for acute crises related to chronic, life-threatening illnesses [2-13]. Such visits tend to increase as a patient’s clinical status deteriorates and they approach the end of life [4,5,8,11,14]. In addition, most hospitalizations are initiated from the ED, and decisions about life-sustaining interventions (eg, initiation of mechanical ventilation) are often made there, establishing a trajectory of subsequent in-hospital care [2,15-18]. For many patients and families, these decisions must be made rapidly in the face of an uncertain prognosis. Even for patients who can be stabilized and possibly discharged from the ED but who have needs best met through palliative care interventions, emergency clinicians have an opportunity to encourage the patient, their family, and primary care clinicians to have follow-up discussions about goals of care.

Early integration of palliative care, whether provided primarily through ED providers or secondarily by palliative care consult services, can substantially improve patient care. Moreover, by implementing palliative care principles or involving palliative care clinicians early in decision-making, emergency clinicians can help patients and families make decisions with the best available information and support. Thus, it is important that emergency clinicians have an understanding of the basic concepts of palliative care and training in the relevant aspects of providing such care, such as communication with seriously ill patients and their families [5,8,18-22].

Early integration of palliative care is associated with better patient quality of life, better understanding and communication about illness, improved access to home care and to emotional and spiritual supports, increased patient wellbeing and dignity, improved care at the time of death, and decreased symptom burden [23-28]. Studies show that inpatient palliative care consultation reduces length of stay and cost per episode of care, primarily by reducing the use of unnecessary tests and nonbeneficial treatments; and, in some cases, it may prolong life [29-31]. (See "Benefits, services, and models of subspecialty palliative care", section on 'Rationale for palliative care'.)

While the impact of palliative care provided in the ED has not been studied extensively, the successes of palliative care in the inpatient setting lead us to believe that ED-based palliative care has the potential to accomplish important goals, including better alignment of clinical care with patient wishes, better communication during transitions across clinical settings, and increased patient and family satisfaction [2,23,27,32].

For the busy ED setting, it is important that EDs, in partnership with their hospice and palliative care teams, establish effective and simple operational aids to improve access and referrals to needed palliative care services, such as automated trigger alerts and referral prompts in the electronic health records [33-38].

Palliative care definitions and principles

Palliative care practice scope and distinction from hospice — The Center to Advance Palliative Care (CAPC) defines palliative care as "Specialized medical care for people with serious illnesses…focused on providing patients with relief from the symptoms, pain, and stress of a serious illness—whatever the diagnosis. The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a team of doctors, nurses, and other specialists who work together with a patient’s other doctors to provide an extra layer of support. It is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment" [39].

Palliative care aims to improve the quality of life of patients (and their families) facing the problems associated with a life-threatening illness [15,19,40,41]. A list of palliative care terms and their definitions can be found in the table (table 1).

Palliative care is not synonymous with end-of-life care or hospice care. The two are distinguished as follows:

●Hospice programs in the United States deliver palliative care to patients at the end of life, when the focus is on comfort rather than curing an illness, and when the patient has decided they do not wish to return to the hospital. In the United States, patients need to have an estimated life expectancy of six months or less to be eligible for hospice benefits.

●Palliative care aims to relieve suffering in all stages of disease for patients with serious illness, and it is not limited to end-of-life care. Palliative care is appropriately offered to patients at any time along the trajectory of any serious illness, concurrent with curative, restorative, and any life-prolonging therapies.

These issues, including the different sites where palliative care is delivered, are discussed in detail elsewhere. (See "Benefits, services, and models of subspecialty palliative care", section on 'Definitions'.)

High-income countries generally have greater integration of subspecialty palliative care and hospice care into the health care system, although community hospitals may lack ready access to such resources. Among low-income countries, palliative care is only rarely available. (See "Palliative care and hospice outside of the United States".)

Palliative care subspecialty services can be provided in the hospital, ambulatory setting, nursing home, or home. In addition, palliative care for homeless persons has become an important objective. (See "Benefits, services, and models of subspecialty palliative care", section on 'Models of palliative care delivery' and "Palliative care: Nursing home" and "Palliative care delivery in the home" and "Palliative care for adults experiencing homelessness".)

Primary versus subspecialty palliative care — Subspecialty (or "secondary") palliative care is delivered by palliative medicine specialists who work alongside a patient’s primary care clinician. However, for most patients with a serious life-threatening illness, basic palliative care needs, such as pain and symptom control, can be met by clinicians who did not complete advanced training in palliative medicine. This is sometimes termed "primary" or "basic" palliative care. (See "Primary palliative care".)

All patients should receive primary palliative care when needed; only those patients with difficult-to-manage symptoms or complex psychosocial circumstances or who require frequent and intense follow-up should be referred to a palliative care subspecialist (table 2). Indications for referral are reviewed separately. (See "Palliative care for adults in the ED: Goals of care, communication, consultation, and patient death", section on 'Palliative consultation, hospice referral, and patient disposition'.)

Palliative care skills expected of emergency clinicians — The Model of the Clinical Practice of Emergency Medicine includes health care coordination at the end of life and palliative care (including coordination with hospice) as essential skills for emergency physicians [42]. Management of the routine palliative care needs of patients, such as breaking bad news, symptom management, and functional assessments, is also included.

According to American College of Emergency Physicians (ACEP), the core topics of palliative care relevant to emergency medicine training fall under three domains (table 3) [43]:

●Recognition of palliative care and hospice needs in patients

●Primary-level provider skills in palliative care

●Understanding of how palliative care can be implemented in the ED

CONDITIONS COMMONLY MANAGED IN THE ED THAT BENEFIT FROM PALLIATIVE CARE — Little evidence is available to quantify the number and types of patients with palliative care needs who present for care in the ED [44]. However, we know that ED visits increase as a serious illness progresses, regardless of the underlying disease, and as patients approach the end of life [5,8,14,44-46]. One-third of ED deaths may be due to the effects of underlying chronic disease, and many older adults with chronic illnesses die in the ED [12]. In one study, over one-half of 4518 decedents 65 years or older during a 15-year period were found to have visited the ED in the last month of life, and 75 percent visited during the last six months, many repeatedly [14]. Patients receiving palliative care are less likely than those not receiving palliative care to visit the ED in the last month of life [47]. (See "Benefits, services, and models of subspecialty palliative care", section on 'Rationale for palliative care'.)

Patients with the following conditions may be appropriate for palliative care in the ED:

●Older adults with dementia or multimorbidity – Frail older adults with advanced dementia or multiple morbidities and those transferred from long-term care facilities with acute or precipitous decline, unstable vital signs, and unclear goals of care constitute a substantial proportion of the patients in many EDs. These patients may benefit from an interdisciplinary palliative care team approach that includes consideration of the risks and benefits of interventions, assessment of the goals of care, and advance care planning [17,48-51]. (See "Care of patients with advanced dementia" and "Frailty" and "Palliative care: Nursing home" and "Multiple chronic conditions".)

●Advanced malignancy – Malignancy, especially metastatic disease, often places a high symptom burden on patients [11,29,52-58]. Early integration of palliative care concurrent with active treatment is recommended for all patients with advanced cancer [59]. (See "Benefits, services, and models of subspecialty palliative care", section on 'Rationale for palliative care'.)

●Severe or incurable neurologic conditions – Devastating acute neurologic events, such as stroke and intracranial bleeds, are common reasons to initiate conversations in the ED about goals of care and life-sustaining treatment [18]. Irreversible hypoxic brain injury and neurodegenerative conditions that diminish quality of life, such as advanced multiple sclerosis, amyotrophic lateral sclerosis, or Parkinson disease, may prompt conversations about goals of care, particularly when invasive interventions are contemplated. (See "Palliative approach to Parkinson disease and parkinsonian disorders" and "Symptom-based management of amyotrophic lateral sclerosis" and "Spontaneous intracerebral hemorrhage: Acute treatment and prognosis" and "Overview of ischemic stroke prognosis in adults".)

●Resuscitations and cardiac arrest – In cases where the prognosis for a survivor of sudden cardiac arrest is poor (eg, prolonged cardiopulmonary resuscitation [CPR] for non-shockable arrhythmia), involvement of palliative care may be appropriate to support families who are faced with surrogate decision-making [7,13,60,61]. (See "Prognosis and outcomes following sudden cardiac arrest in adults".)

●Organ failure – Patients with end-stage heart failure, chronic obstructive pulmonary disease (COPD), or liver or kidney disease often benefit from palliative care management [62-64]. However, the trajectory of functional decline in these patients is often erratic and unpredictable. Many patients remain in a chronic state of poor or declining health punctuated by intermittent exacerbations and hospitalizations but interspersed with temporary periods of improvement or relative stability. This "entry-reentry" pattern of dying associated with decompensated heart failure, liver failure, and COPD often hinders recognition of patient decline and many patients who would benefit are not referred for palliative care [49,64]. (See "Palliative care for patients with end-stage liver disease", section on 'Disease trajectory and estimating prognosis' and "Palliative care for patients with advanced heart failure: Indications and systems of care", section on 'Challenges to accurate prognostication' and "Palliative care for adults with nonmalignant chronic lung disease", section on 'Disease trajectory'.)

The acute exacerbations of chronic disease commonly encountered in the ED can make prognostication difficult. However, palliative care involvement is often appropriate and useful for patients with severe chronic disease requiring interventions to sustain life, such as mechanical ventilation, hemodialysis, or vasopressor infusions. The emergency clinician should consider the burdens and benefits of procedures and interventions (including hospital admission) and, if time permits, discuss these decisions with patients and surrogates in the context of the patient’s goals of care [12,65,66].

●Trauma – Trauma can lead to sudden and devastating functional decline or death and palliative care support is often needed for trauma patients. Such support can entail not only pain and symptom management, but many other aspects of care including advance care planning, complex decision-making, and difficult communications (eg, breaking bad news and death disclosure). While studies report that early palliative care intervention for geriatric trauma patients is associated with cost savings and decreased length of stay, the evidence is not sufficiently strong to justify routine consultation [67]. (See "Geriatric trauma: Initial evaluation and management".)

REASONS FOR ED PRESENTATION OF PATIENTS WITH KNOWN ADVANCED ILLNESS — Patients with serious life-threatening illness present to the ED with many symptoms and needs that may be amenable to palliative interventions, including the following [11,26,28,41,49,53,55,68-71]:

●New or exacerbation of chronic symptoms (eg, pain, dyspnea, constipation, nausea and vomiting, weakness)

●Reduced performance status; worsening frailty; worsening dementia

●Altered mentation (eg, delirium)

●Psychological distress

●Social problems (eg, lack of a caregiver, caregiver distress, poor coordination of care)

●Financial, employment, or housing concerns

●Questions about prognosis and treatment options

Understanding these reasons helps the clinician address immediate patient needs and possibly prevent future ED visits. Such understanding may also enable the ED team to connect the patient and family with appropriate support systems and community-based services [23,26,65,72].

Efforts are ongoing to develop decision support tools to help ED clinicians identify patients who may benefit from palliative care interventions and facilitate early referral to appropriate services [73-76]. As an example, the Palliative Care and Rapid Emergency Screening (P-CaRES) instrument is being used to create alerts in some electronic health records [73,75,76].

Reasons why hospice patients are sent to the ED — Emergency clinicians are often uncertain about the appropriate level of care for patients transferred to the ED from hospice. A caregiver call for an ambulance or arrival in the ED of a patient under hospice care does not necessarily mean that the patient wants to revoke hospice care [41]. Therefore, it is important that the clinician perform a careful history and discuss with the patient, their caregivers, and hospice staff what triggered the ED visit. Common triggers are listed in the table (table 4) [15,41].

Many hospices provide patients with a folder containing important contact information and any advance directives (eg, a do not resuscitate order) and instruct the patient and their family to bring this to the ED in case of an emergency. Some electronic medical records have designated sections for such information.

Management of hospice patients in the ED — The following table lists some important strategies for how to manage a patient under hospice care who presents to the ED (table 5) [77,78].

SYMPTOM ASSESSMENT AND MANAGEMENT — Patients with serious illness can have a number of burdensome symptoms. Pain, dyspnea, and fatigue are the most common [53,58,70,79-82]. To determine appropriate treatment, the emergency clinician must first determine the underlying cause. As an example, a patient with advanced lung cancer may have increasing dyspnea from unrelated causes, such as pneumonia or pulmonary embolus. EM clinicians must guard against assuming that the chief complaint stems from an exacerbation of a chronic palliative issue; potentially reversible, new causes should be investigated as indicated.

Dyspnea — Control of dyspnea begins with the identification and treatment of any underlying cause whenever possible. While treating any reversible cause, and in cases where such treatment is not possible, it is important to palliate the sensation of dyspnea. Adjunct treatment with opioids and other appropriate palliative measures are provided as needed. (See "Approach to the adult with dyspnea in the emergency department".)

A common obstacle to the use of opioids for the palliative management of dyspnea is a fear of respiratory depression or worsening of oxygenation, especially in hypoxic patients. This fear has been shown to be largely unfounded, with studies and meta-analyses demonstrating significant improvement of dyspnea with titrated administration of opioids and no evidence of decreases in oxygen saturation or clinically significant respiratory depression, even in patients with hypoxia [83-85].

Tailoring dyspnea management to the goals of care is important. As an example, for a dying patient, diagnostic tests themselves may be burdensome and the use of simple, noninvasive tests (eg, pulse oximetry, plain chest radiograph) are strongly preferred, if needed.

The palliative management of dyspnea is reviewed in detail separately; key points for ED management are found below. (See "Assessment and management of dyspnea in palliative care".)

Opioid therapy — Opioids are the drugs of choice for palliation of dyspnea.

●Initial dose – In the opioid-naïve patient, low doses of oral (5 to 10 mg) or parenteral morphine (2 to 5 mg intravenously [IV]) provide relief for most patients. When dyspnea is acute and severe, parenteral is the route of choice (morphine 2 mg IV every 5 to 10 minutes until symptoms are relieved).

●Redosing intervals – Based on opioid pharmacokinetics, when symptoms (eg, dyspnea or pain) are severe and uncontrolled, opioids can be redosed at 5 to 15 minutes for an IV opioid and 60 minutes for an oral opioid.

●Patients already taking opioids – Many patients are already taking opioids, often for cancer-related pain. For such patients, 50 percent of the usual dose they receive for breakthrough pain may be used to treat dyspnea. As an example, if the patient takes morphine 100 mg orally every 12 hours, an appropriate dose for breakthrough pain is 10 percent of the total daily dose of 200 mg, or 20 mg. Thus, for dyspnea, a dose of 10 mg would be used for acute dyspnea (50 percent of the pain breakthrough dose). In patients with a prognosis of days to weeks, the US National Cancer Consensus Guidelines recommend increasing the total daily dose by 25 percent [86].

●Monitoring – Patients being treated for dyspnea with opioids in appropriate doses do not typically experience respiratory depression. However, all patients should be monitored for side effects, including sedation, confusion, and suppression of respiratory drive. Monitoring should include capnography and frequent in-person checks when indicated. Frequent checks enable clinicians to determine the effectiveness of therapy and titrate doses appropriately. (See "Carbon dioxide monitoring (capnography)".)

●Morphine allergy – For patients with a morphine allergy or unacceptable side effects (eg, nausea; hypotension from histamine release), oxycodone or hydromorphone may be used. The initial dose of oxycodone is 5 mg orally every one hour as needed; for hydromorphone, it is 0.2 mg every 5 to 10 minutes given IV or subcutaneously as needed.

Other interventions

●Benzodiazepines – Dyspnea is often accompanied by anxiety, which may tempt the clinician to administer benzodiazepines. When the clinician has a high degree of clinical certainty that anxiety started before the episode of dyspnea, benzodiazepines may be given. However, benzodiazepines are not first-line agents for the treatment of dyspnea because they may increase morbidity and mortality [87-89].

●Adjunct interventions (eg, fan) – Some patients feel better having a fan blowing cool air toward their face or sleeping in a seated position or one with the head and chest elevated.

●Supplemental oxygen – Supplemental oxygen is a standard therapy for symptomatic management of patients who are hypoxemic on room air; however, the presence of hypoxemia does not reliably predict symptomatic benefit from oxygen therapy.

●Noninvasive ventilation – Noninvasive ventilation may be considered as a palliative measure in dying patients who have severe dyspnea. If a trial of noninvasive ventilation is considered, it is essential to establish in advance clear goals for the intervention, a timeframe for reevaluation, and markers of success or lack thereof. Patients and families should understand that the dying process may be prolonged by the use of noninvasive ventilation. (See "Assessment and management of dyspnea in palliative care", section on 'Limited role for noninvasive ventilation'.)

●Secretion management – Excessive secretions may contribute to aspiration or dyspnea. Anticholinergic medications are useful in some instances (table 6). (See "Swallowing disorders and aspiration in palliative care: Assessment and strategies for management", section on 'Secretion management'.)

Pain

Determining the causes of pain — It is important for the emergency clinician to conduct a careful pain history, identify all the sources of pain, and determine (even hypothetically) the underlying pathophysiology prior to administering potentially risky medications (eg, opioids). It is important to distinguish between those sources of pain that may respond to opioids and those sources that are opioid-resistant (eg, musculoskeletal or whole-body pain). Typically, we recommend that ED providers elicit a description of the pain, including onset, provocative and palliative factors, quality, radiation, site, and time course (OPQRST approach), as well as conduct a careful physical examination and review of the medical record.

Pain is a common symptom in palliative care patients, and the etiology may be multifactorial. In the setting of cancer, pain can be due to tumor burden or can represent a complication of treatment. When pain is disease related, causes may include:

●Direct invasion of a pain-sensitive structure (eg, bone) by the neoplasm

●Injury to or invasion of a component of the nervous system

●Obstruction of a hollow viscus

●Distention of organ capsules

●Distortion or occlusion of blood vessels

●Infiltration of adjacent soft tissues

In patients with noncancer conditions, pain stems primarily from secondary complications due to progression of disease or acute trauma. Causes may include:

●Wounds

●Edema

●Vascular insufficiency

●Fracture

However, not all pain in patients with serious illness is disease-related. Many patients develop chronic musculoskeletal pain, often stemming from immobility, for which opioid therapy may or may not be beneficial. Patients with nausea, vomiting, or swallowing difficulties may experience pain (and possibly opioid withdrawal symptoms) due to inability to take their usual pain medications.

Some patients with advanced illnesses such as dementia or decompensated heart failure may experience pain from complications not usually associated with pain. Pain may also be due to edema, wounds, or other secondary complications of the primary illness. Patients with dementia or other cognitive dysfunction may have pain that manifests as increased agitation, labored breathing, grimacing, tachycardia, diaphoresis, or other nonspecific symptoms and signs. (See "Assessment of cancer pain" and "Palliative care for patients with advanced heart failure: Decision support and management of symptoms", section on 'Pain' and "Care of patients with advanced dementia", section on 'Pain and symptom management' and "Approach to symptom assessment in palliative care", section on 'Patients unable to self-report'.)

Assessment of pain is challenging in patients with profound cognitive impairment, and several disease-specific tools to assess pain and discomfort in advanced dementia are available. Pain Assessment in Advanced Dementia (PAINAD), a relatively easy-to-use instrument developed for this purpose, is reproduced in the table (table 7).

Managing an acute pain crisis — The approach and interventions described below are for the management of patients whose main reason for presenting to the ED is an acute pain crisis. The management of other severe or complex pain syndromes is discussed separately:

●Cancer-related pain (see "Cancer pain management with opioids: Optimizing analgesia" and "Cancer pain management: Role of adjuvant analgesics (coanalgesics)" and "Cancer pain management: Use of acetaminophen and nonsteroidal anti-inflammatory drugs")

●Non-cancer-related pain (see "Use of opioids in the management of chronic non-cancer pain" and "Approach to the management of chronic non-cancer pain in adults")

●Pain assessment and management in patients with dementia (see "Treatment of chronic non-cancer pain in older adults")

The term "breakthrough pain" refers to a severe acute pain that occurs on a background of chronic pain (usually cancer pain) that was previously adequately controlled by an opioid regimen. The baseline pain management plan may need to be modified for patients experiencing breakthrough pain.

Three broad categories of analgesic medications are available to manage acute pain crises: opioids, nonopioid analgesics (including acetaminophen and the nonsteroidal antiinflammatory drugs [NSAIDs]), and the so-called adjuvant analgesics (which comprise numerous agents in diverse classes). Opioid analgesics are the mainstay of the treatment of moderate to severe pain in patients with advanced illness. While opioids treat all kinds of pain, complex pain syndromes (ie, pain syndromes that have characteristics of multiple pain types) are often better treated with opioid-adjuvant combinations. (See "Cancer pain management with opioids: Optimizing analgesia" and "Cancer pain management: Role of adjuvant analgesics (coanalgesics)".)

In complex cases, palliative care consultation can be helpful. (See "Palliative care for adults in the ED: Goals of care, communication, consultation, and patient death", section on 'Palliative consultation, hospice referral, and patient disposition'.)

Management of an acute pain crisis includes the following steps [87]:

●Obtain a pain history including past and present opioid use – Obtain a history of the patient’s pain and the treatments used, including past and present use of opioids. Often, patients with pain are already taking opioids for cancer-related pain. Ask what opioids have been taken and in what amounts. The exact dose is needed to gauge the equivalent parenteral or oral dose of an opioid given in the ED. Patients who have not been taking opioids routinely should be treated as opioid naïve and should not be given a long-acting opioid.

●Select a medication and dose – Whether to use an opioid and which to use depends upon several considerations, including the following:

•Severity of pain

•Current analgesic regimen

•Presence of clinically significant liver or kidney dysfunction (avoid morphine)

•Presence of tolerance to opioids (indicates need for higher starting doses)

•Ability to swallow

•Presence of side effects (eg, delirium)

In patients not previously taking opioids, morphine is generally the drug of choice. Some patients may benefit from a shorter-acting opioid (eg, fentanyl). This includes patients with moderate to severe kidney or liver dysfunction or with reversible conditions where pain is expected to be relieved within hours to days (eg, bladder obstruction, bone metastases amenable to radiotherapy).

For opioid-naïve patients, the dosing outlined in the following table is appropriate (table 8). The table includes oral and parenteral medications.

For patients already taking opioids for chronic pain who have developed some degree of tolerance, a typical opioid dose chosen for the treatment of acute breakthrough pain is 5 to 20 percent of the total basal daily requirement of opioid. The dose should account for all opioids taken in a 24-hour period. Dosing is calculated as follows (see "Cancer pain management with opioids: Optimizing analgesia", section on 'Management of breakthrough pain'):

•Determine all the opioids used by the patient in the most recent 24-hour period

•Convert the doses for all opioids to their oral morphine equivalent

•Add together the oral morphine equivalent doses for all the opioids taken in the 24-hour period

•Calculate 5 to 20 percent of the total oral morphine equivalent dose (usual starting dose is 10 percent)

•Administer equianalgesic dose of chosen opioid

If a patient has developed tolerance to or unacceptable side effects from a particular opioid, it is prudent to change to a different opioid. The development of significant side effects such as myoclonus or delirium require that a different opioid be used. When doing so, the clinician should use an equianalgesic dosing table (table 9) to help avoid under- and over-dosing.

●Adjust dosing based on age, impaired liver or kidney function, and use of other sedating medications – Opioid dosing needs to be modified for patients at the extremes of age (table 10) and those with liver or kidney dysfunction. A good rule of thumb for liver dysfunction is to give one-half of the dose at twice the interval. Suggested initial doses for a variety of analgesics in patients with chronic liver disease are outlined in the table (table 11). (See "Management of pain in patients with advanced chronic liver disease or cirrhosis".)

In patients with acute or chronic kidney injury, avoid opioids that are renally excreted, including morphine, or use them with caution; hydromorphone or fentanyl may be preferred in such patients. Some opioids, such as hydromorphone, are dosed according to creatinine clearance (calculator 1 and calculator 2) [90]. This is discussed in greater detail separately. (See "Cancer pain management with opioids: Optimizing analgesia", section on 'Patients with kidney impairment' and "Calculation of the creatinine clearance".)

●Select a route of administration – IV administration of opioids is preferred for controlling severe nociceptive pain that is new or escalating.

While most patients present to the ED with an acute pain crisis requiring treatment with parenteral opioids, they often remain in the ED pending final disposition after pain is controlled. Ongoing mild or moderate pain generally can be managed with oral medication, provided the patient is able to swallow. Similarly, if a patient comes to the ED for an unrelated need (eg, a blood transfusion) and develops a mild to moderate exacerbation of chronic pain, the patient's rescue regimen for breakthrough pain using oral opioids can be used.

●Perform pain reassessment – Timely reassessment is essential to achieve adequate pain control safely. Although challenging in a busy ED, reassessment at 10 to 15 minutes is important, as the peak effect of IV morphine is seen at approximately 15 minutes and further doses may still be needed. The approach to escalating opioids in a patient receiving chronic opioid therapy is discussed separately. (See "Management of acute pain in the patient chronically using opioids for non-cancer pain", section on 'Opioids for acute pain'.)

●Ensure appropriate chronic pain management – Once the acute pain crisis has been successfully managed, an appropriate longer-term plan for analgesia must be put in place. Such a plan may involve simple modifications to an existing plan or require major changes and consultation with appropriate specialists, including palliative medicine. Long-term analgesia is discussed separately. (See "Overview of cancer pain syndromes", section on 'Chronic pain syndromes' and "Cancer pain management with opioids: Optimizing analgesia" and "Cancer pain management: Role of adjuvant analgesics (coanalgesics)" and "Approach to the management of chronic non-cancer pain in adults".)

Managing opioid side effects and toxicity

●Somnolence/respiratory depression – Opioid therapy can cause somnolence. This occurs most often when treatment is started or doses are increased. Most patients develop tolerance to this side effect within days to weeks. Respiratory depression is rarely a problem in palliative care patients who have opioid tolerance, provided that dosing is not excessive. This does not apply to patients with histories of neurodegenerative disease or hypoventilatory respiratory failure; such patients should not take opioids unless the patient and family have accepted the risks of respiratory failure. (See "Prevention and management of side effects in patients receiving opioids for chronic pain", section on 'Somnolence and mental clouding'.)

Somnolence may be the first sign of opioid toxicity. Somnolence itself is not an indication to reverse the effects of an opioid. However, in rare cases, when there is significant respiratory compromise with a threat of respiratory arrest, administration of a short-acting opioid antagonist (ie, naloxone) may be warranted. The decision to give naloxone to an opioid-dependent palliative care patient requires careful thought and often discussion with the family, as pain can be severely exacerbated by opioid reversal. Often a patient's respiratory function can be supported without opioid reversal by using noninvasive measures, including intermittent physical stimulation. (See "Prevention and management of side effects in patients receiving opioids for chronic pain", section on 'Respiratory depression'.)

Guidance for using naloxone in these circumstances includes the following:

•Naloxone should be reserved for symptomatic respiratory depression, which typically means the patient is unarousable and has significant, ongoing hypoventilation. Given the risks of withdrawal and pain crisis from naloxone, its use is relatively contraindicated in palliative care patients in pain crisis.

•If naloxone is deemed necessary, use the smallest dose of diluted naloxone possible and proceed in a stepwise fashion. Dilute 0.4 mg of naloxone in 10 mL of saline and give 0.5 to 1 mL of this diluted mixture IV every five minutes until respiratory depression has resolved. The goal of reversal is NOT a fully awake and alert patient, but rather resolution of hypoventilation and a normal respiratory rate. Clinicians should be prepared to manage rebound pain and nausea/vomiting. (See "Acute opioid intoxication in adults", section on 'Basic measures and antidotal therapy'.)

●Constipation – All opioids cause constipation, and patients taking opioids should take a daily laxative bowel regimen (eg, senna, polyethylene glycol). For patients with opioid-induced constipation despite a prophylactic regimen, options include a rectal therapy (eg, a suppository containing bisacodyl or glycerin) or an osmotic laxative (such as polyethylene glycol, magnesium hydroxide, or magnesium citrate), as long as there is no evidence of bowel obstruction (table 12). (See "Prevention and management of side effects in patients receiving opioids for chronic pain", section on 'Prevention'.)

For refractory opioid-induced constipation, peripherally acting mu-opioid receptor antagonists (PAMORAs; eg, methylnaltrexone) are effective; these agents should be avoided in the presence of bowel obstruction. There are no widely accepted guidelines on when to try a PAMORA, and the decision may include factors as varied as the patient’s level of constipation-associated distress, psychological reaction to the possibility of another over-the-counter strategy, and extent of insurance coverage for the cost of prescription medications. Generally, these agents are well tolerated. Side effects include diarrhea and cramping. Docusate provides minimal benefit and is not recommended. (See "Prevention and management of side effects in patients receiving opioids for chronic pain", section on 'Management of refractory opioid-induced constipation'.)

Overcome barriers to opioids in seriously ill patients — Clinician fears of causing addiction or death are common barriers to effective analgesia, particularly with opioids. While opioid safety is important, clinicians must distinguish among addiction, pseudoaddiction, and tolerance [21,56].

Patients taking opioids for chronic malignant pain may develop tolerance over time and require increasing doses. This is not addiction. Addiction (substance use disorder) is defined as aberrant drug-taking behavior characterized by craving, loss of control, compulsive use, and continued use despite harm. At the end of life, addiction is rarely ever a reason for withholding treatment of terminal pain with opioids. (See "Cancer pain management: General principles and risk management for patients receiving opioids", section on 'Risk assessment and management for patients receiving opioids'.)

The term "pseudoaddiction" describes a situation in which a patient’s legitimate chronic pain condition is undertreated with pain medication, leading the patient to act in a way that resembles addictive behavior (requesting extra medications and demanding attention); such patients are often labeled as demonstrating "drug-seeking behaviors." (See "Approach to symptom assessment in palliative care", section on 'Pain'.)

Patients with serious illness or a terminal condition with a high pain burden and an underlying substance use disorder may have complex pain management needs. High doses of opioids may be required. A team-based approach with early engagement of palliative medicine and pain management specialists helps to optimize management.

Other symptoms — Management of other common symptoms in palliative care patients is addressed separately:

●Delirium and agitation (table 13). (See "Palliative sedation" and "Overview of managing common non-pain symptoms in palliative care", section on 'Delirium' and "Palliative care: The last hours and days of life", section on 'Delirium' and "Palliative care: The last hours and days of life", section on 'Anxiety and agitation'.)

●Nausea and vomiting – Palliative care patients may experience nausea and vomiting from a wide variety of conditions, many of which require specific therapy, as summarized in the following table (table 14). This is reviewed separately. (See "Assessment and management of nausea and vomiting in palliative care".)

●Pruritus and sweating. (See "Overview of pruritus in palliative care".)

●Cough and hemoptysis. (See "Palliative care: Overview of cough, stridor, and hemoptysis in adults".)

●Secretions – Excessive secretions can lead to aspiration and contribute to dyspnea. Anticholinergic medications are useful in some instances (table 6). (See "Swallowing disorders and aspiration in palliative care: Assessment and strategies for management", section on 'Secretion management'.)

●Constipation and malignant bowel obstruction. (See "Overview of managing common non-pain symptoms in palliative care", section on 'Constipation' and "Palliative care of bowel obstruction in cancer patients".)

●Chronic wounds, including malodorous or bleeding malignancy-related wounds. (See "Basic principles of wound management" and "Overview of treatment of chronic wounds".)

●Acute urinary retention. (See "Acute urinary retention".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Palliative care".)

SUMMARY AND RECOMMENDATIONS

●Palliative care in ED – Many patients seek care in the emergency department (ED) for acute crises related to chronic, life-threatening illnesses, especially as clinical status deteriorates and they approach the end of life. Most hospitalizations are initiated from the ED, and decisions about life-sustaining interventions (eg, initiation of mechanical ventilation) are often made there, establishing a trajectory of subsequent in-hospital care. Early involvement of palliative care, whether provided primarily through ED providers or secondarily by palliative care consult services, can substantially improve patient care. Palliative care skills relevant to emergency care are listed in the following tables (table 3 and table 2). (See 'Why the integration of palliative care in the ED is important' above.)

●Concepts and terminology – A list of palliative care terms relevant to emergency care and their definitions are found in the table (table 1). One important distinction is that palliative care is not synonymous with end-of-life care or hospice care. Hospice programs deliver care to patients at the end of life, when the focus is on comfort rather than curing an illness, and when the patient has decided they do not wish to return to the hospital. Palliative care aims to relieve suffering in all stages of disease for patients with serious illness, and it is not limited to end-of-life care.

●Common presentations – Patients with serious life-threatening illness often present to the ED with symptoms and needs amenable to palliative interventions. Such problems include symptom management (particularly dyspnea, pain, and fatigue), worsening frailty, altered mentation, social problems, and questions about prognosis or treatment (table 4). (See 'Reasons why hospice patients are sent to the ED' above and 'Symptom assessment and management' above.)

●Dyspnea management – Opioids are the drugs of choice for dyspnea in the setting of advanced illness. In the opioid-naïve patient, low doses of oral (5 to 10 mg) or parenteral morphine (2 to 5 mg intravenously [IV]) provide relief for most patients. When dyspnea is severe and uncontrolled, opioids can be redosed at 5 to 15 minutes for an IV opioid and 60 minutes for an oral opioid. Additional details about opioid treatment (eg, managing patients already taking opioids) and adjunct therapies are provided in the text. (See 'Dyspnea' above.)

●Pain assessment – Often, a careful pain history is needed to determine the source. The clinician should inquire about all relevant factors (the OPQRST template is useful: onset, provocative and palliative factors, quality, radiation, site, and time course) and any past or present opioid use. Disease-related pain may be due to one or more of the following causes:

•Direct invasion of a pain-sensitive structure (eg, bone) by a neoplasm

•Injury to or invasion of a component of the nervous system

•Obstruction of a hollow viscus

•Distention of organ capsules

•Distortion or occlusion of blood vessels

•Infiltration of adjacent soft tissues

Other causes include worsening of chronic musculoskeletal pain. Patients with dementia or other cognitive dysfunction may have pain that manifests as increased agitation, labored breathing, grimacing, tachycardia, and diaphoresis. However, these symptoms and signs are not specific for pain. Pain Assessment in Advanced Dementia (PAINAD), a relatively easy-to-use instrument developed for this purpose, is reproduced in the table (table 7).

●Pain management – In patients with acute, disease-related pain, morphine is generally the drug of choice, unless there is a history of adverse reactions or comorbidities that affect selection (eg, impaired kidney function).

Dosing depends on whether the patient is opioid naïve or opioid tolerant. For opioid-naïve patients, the dosing outlined in the following table is appropriate (table 8).

For patients already receiving opioids for chronic pain who are opioid tolerant (total daily oral morphine equivalent dose generally >60 mg per day), a typical opioid dose for treating acute breakthrough pain is 5 to 20 percent of the total daily oral morphine equivalent. The equivalent should account for all opioids taken in a 24-hour period.

Frequent reassessment of pain is important. Additional information, such as dosing for patients with impaired kidney or liver function, is provided above. (See 'Managing an acute pain crisis' above and 'Managing opioid side effects and toxicity' above.)

●Other symptoms – See-links to topics that discuss the management of other symptoms common in palliative care patients (eg, nausea, agitation, pruritus) are provided above. (See 'Other symptoms' above.)