Study guide
Palliative Care, Advance Care Planning, Pain Management & End-of-Life
AANPCB Adult-Gerontology Primary Care Nurse Practitioner A-GNP
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1 Exam Structure, APRN Foundations & Geriatric Assessment
A-GNP Exam Logistics, Blueprint & Scoring Structure APRN Scope of Practice, Consensus Model & Interprofessional Collaboration Comprehensive Health History & Subjective Assessment Across Adult Lifespan Comprehensive Physical Examination & Clinical Assessment Skills
2 Health Assessment, Diagnostic Reasoning & Clinical Procedures
Diagnostic Reasoning, Test Interpretation & Clinical Decision-Making Screening Guidelines & Evidence-Based Health Promotion (USPSTF) Comprehensive Geriatric Assessment (CGA), Frailty & Function In-Office Clinical Procedures, ECG Interpretation & Minor Surgical Skills
3 Cardiovascular & Peripheral Vascular Disorders
Essential Hypertension & Hypertensive Urgency/Emergency Management Coronary Artery Disease, Acute Coronary Syndromes & Post-MI Care Heart Failure (HFrEF & HFpEF) Diagnosis, Staging & 4-Pillar GDMT Arrhythmias (Atrial Fibrillation), Valvular Heart Disease & PAD
4 Respiratory, HEENT & Dermatological Disorders
Asthma Management across the Adult Lifespan (GINA Guidelines) Chronic Obstructive Pulmonary Disease (COPD) Staging & Management (GOLD Guidelines) Community-Acquired Pneumonia & Lower Respiratory Tract Infections Common HEENT Disorders: Otitis, Sinusitis, Pharyngitis, Glaucoma & Macular Degeneration
5 Endocrine, Metabolic & Renal/Genitourinary Disorders
Type 2 Diabetes Mellitus Management Thyroid Disorders: Hypothyroidism, Hyperthyroidism & Subclinical Disease Chronic Kidney Disease (CKD) Staging & Diabetic/Hypertensive Nephropathy Genitourinary Disorders: BPH, Urinary Incontinence, UTIs & Prostatitis
6 Gastrointestinal, Hematologic & Immunologic Disorders
Upper Gastrointestinal Disorders: Dyspepsia, GERD, PUD & H. pylori Lower Gastrointestinal Disorders: IBS, IBD, Diverticulitis & Colorectal Screening Liver, Biliary & Pancreatic Disorders: NAFLD/MASLD, Cirrhosis & Cholecystitis Hematologic & Immunologic Disorders: Anemias, Anticoagulation & Immunizations
7 Neurological, Cognitive & Psychiatric Disorders
Cognitive Assessment: Delirium, Dementia & Mild Cognitive Impairment Neurological Disorders: Stroke, TIA, Parkinson's Disease & Headache Syndromes Major Depressive Disorder & Anxiety Disorders in Adults & Older Adults Sleep Disorders, Insomnia & Restless Legs Syndrome
8 Geriatric Syndromes, Polypharmacy & Deprescribing
The Beers Criteria & STOPP/START Criteria for Potentially Inappropriate Medication Use Polypharmacy Management, Pharmacokinetics/Pharmacodynamics in Aging & Deprescribing Protocols Fall Risk Assessment (CDC STEADI), Gait/Balance & Mobility Impairments Pressure Injury Prevention/Staging, Urinary/Fecal Incontinence & Frailty Assessment
9 APRN Professional Practice, Ethics, Quality & Healthcare Policy
Musculoskeletal Disorders: Osteoarthritis, Osteoporosis, Gout & Back Pain Dermatological Disorders: Lesions, Skin Cancers, Infections & Rash Evaluation Palliative Care, Advance Care Planning, Pain Management & End-of-Life APRN Professional Practice, Quality Improvement, Ethics & Healthcare Policy
Palliative Care, Advance Care Planning, Pain Management & End-of-Life
Key Takeaways Explain This Topic AI
Palliative care provides interdisciplinary symptom management concurrently with disease-modifying therapies at any stage of serious illness, whereas Hospice care requires a terminal prognosis <=6 months and foregoes curative interventions.
Advance Care Planning utilizes Durable Power of Attorney for Healthcare for surrogate designation, Living Wills for general treatment preferences, and POLST/MOLST for actionable, portable medical orders signed by a clinician.
Management of refractory dyspnea in palliative/end-of-life care centers on low-dose oral or IV opioids (e.g., morphine) to reduce breathlessness perception, alongside non-pharmacologic interventions like a cool fan blowing air across the face.
Chronic pain pharmacotherapy in older adults emphasizes starting low and going slow, using topical NSAIDs or acetaminophen first line, while requiring a mandatory bowel regimen (a scheduled stimulant laxative such as senna) whenever initiating opioid therapy.
End-of-life terminal phase care involves managing noisy respiratory secretions ('death rattle') with sublingual atropine or transdermal hyoscine/scopolamine, addressing delirium with low-dose haloperidol, and supporting family bereavement.
Last updated: October 2026
- Palliative Care, Advance Care Planning, Pain Management & End-of-Life
- 1. Palliative Care vs. Hospice Care Delivery Models
Optimizing quality of life and relieving suffering in serious illness requires understanding the distinctions between palliative and hospice care delivery models.
Palliative Care Definition & Scope
Palliative care is specialized, interdisciplinary medical care focused on providing relief from the symptoms, pain, and stress of a serious, life-limiting illness (advanced heart failure, ESRD, COPD, ALS, metastatic cancer). The primary goal is improving quality of life for both patient and family.
Key Feature : Palliative care is appropriate at any age and at any stage of a serious illness. It is delivered concurrently with disease-modifying, curative, or life-prolonging therapies (such as chemotherapy, radiation, hemodialysis, LVADs, or heart failure titrations). It is not dependent on prognosis.
Hospice Care Parameters & Eligibility
Hospice care is a specific delivery model and Medicare benefit structure for patients in the terminal phase of illness.
Eligibility Criteria : Requires two physicians (or attending APRN and hospice medical director) to certify a terminal prognosis with life expectancy <=6 months if the disease runs its normal course.
Care Philosophy : Patients and surrogates elect to shift goals entirely to comfort, voluntarily foregoing curative and disease-modifying treatments . Care is delivered by an interdisciplinary team in home, assisted living, nursing facility, or inpatient hospice.
- 2. Advance Care Planning & Legal-Ethical Instruments
- Advance Directive Documents
Durable Power of Attorney for Healthcare (DPOA-HC) / Healthcare Proxy : Designates a surrogate decision-maker authorized to make medical decisions if the patient loses capacity. It is the most adaptable advance directive for real-time decision-making in unforeseen clinical scenarios.
Living Will : Written document specifying instructions regarding which life-sustaining medical treatments (CPR, mechanical ventilation, artificial nutrition/hydration, hemodialysis) should be withheld or withdrawn under specific conditions (terminal illness, persistent vegetative state).
POLST / MOLST (Physician Orders for Life-Sustaining Treatment) :
Actionable medical orders signed by a licensed clinician (NP, PA, MD) and patient/surrogate.
Portable across care settings : Immediately actionable by Emergency Medical Services (EMS) in home, transport, ED, or nursing facility. Dictates specific orders for CPR status, medical intervention level (Full vs. Selective vs. Comfort-Focused), and artificial nutrition.
Standards for Surrogate Decision-Making
Substituted Judgment Standard (Primary) : The surrogate must make the decision the patient would have made based on prior expressed wishes, values, and statements.
Best Interest Standard (Secondary) : Used only when patient wishes are completely unknown; surrogate decides what a reasonable person would choose as most beneficial.
- 3. Comprehensive Palliative Symptom Management
- Refractory Dyspnea Management
Dyspnea is a subjective, distressing experience of air hunger common in advanced cardiopulmonary disease and terminal cancer.
First-Line Pharmacotherapy : Low-dose systemic opioids (oral morphine 2.5–5 mg PO Q3–4H PRN, or low-dose IV morphine) are the gold standard for managing severe refractory dyspnea. Opioids blunt central dyspnea perception, reduce respiratory drive sensitivity to hypercapnia, and decrease pulmonary vascular congestion and anxiety.
Oxygen Therapy : Supplemental O2 is indicated only if documented hypoxemia (SpO2 <90%) is present. Non-hypoxic dyspneic patients derive equal relief from room air delivered via nasal cannula.
Non-Pharmacological : Directing a cool breeze from a handheld fan across the face (trigeminal nerve distribution) and head elevation.
Etiology-Targeted Antiemetic Selection
Gastric Stasis / Delayed Emptying : Prokinetics ( metoclopramide 5–10 mg PO TID ).
Chemotherapy / Toxin / Uremia : Serotonin antagonists ( ondansetron 4–8 mg PO/IV ) or central D2 antagonists ( haloperidol 0.5–2 mg PO/IV ).
Bowel Obstruction / Visceral Secretions : Anticholinergics ( scopolamine patch ) or somatostatin analogs ( octreotide ).
- 4. Geriatric Pain Management & Opioid Prescribing
- WHO Pain Ladder & Pharmacotherapy Rules
Step 1 (Mild Pain 1–3) : Non-opioid analgesics ( acetaminophen , topical NSAIDs) +/- adjuvants (gabapentin for neuropathic pain).
Step 2 (Moderate Pain 4–6) : Low-dose strong opioids + non-opioids.
Step 3 (Severe Pain 7–10) : Strong opioids (morphine, oxycodone, hydromorphone, fentanyl) titrated to comfort.
Safety Rules & Beers Criteria 2023
Acetaminophen : First-line for mild-to-moderate musculoskeletal pain. Max dose 2,000–3,000 mg/day in older adults.
Oral NSAIDs : Avoid chronic use due to high risks of GI bleeding, renal failure, fluid retention, and heart failure exacerbation. Topical diclofenac gel is preferred for localized joint pain.
Renal Impairment Caution : Morphine and meperidine produce active neurotoxic metabolites cleared by kidneys. In severe renal failure ( eGFR <30 mL/min ), morphine accumulates, causing severe sedation, respiratory depression, and myoclonus. Hydromorphone or Fentanyl are safer choices.
Mandatory Bowel Regimen : Opioid-induced constipation is universal and non-tolerated (tolerance never develops). A prophylactic bowel regimen consisting of a scheduled stimulant laxative (senna 1–2 tabs daily) or polyethylene glycol (Miralax) must be initiated concurrently at the time of the first opioid prescription .
- 5. Active Dying Phase & End-of-Life Interventions
- Clinical Indicators of Active Dying
Recognizing the final 24 to 72 hours of life includes observing bedbound status, profound somnolence, diminished food/fluid intake, peripheral cyanosis and mottling of extremities, Cheyne-Stokes breathing, and oliguria.
End-of-Life Symptom Management
Noisy Respiratory Secretions ("Death Rattle") : Caused by relaxation of hypopharyngeal muscles and inability to swallow secretions. Reassure family. Reposition patient to side-lying or elevate head of bed. Pharmacotherapy includes sublingual anticholinergic drops ( sublingual atropine 1% ophthalmic solution 1–2 drops Q2–4H PRN ) or transdermal scopolamine patch. Avoid deep oral suctioning , which causes severe distress and reflex secretion production.
Terminal Delirium & Agitation : Restlessness or agitation during active dying. Evaluate for urinary retention or fecal impaction. Pharmacotherapy includes low-dose haloperidol (0.5–2 mg IV/SC/PO) or sublingual lorazepam.
Palliative & End-of-Life Matrix
- Domain Key Clinical Marker First-Line Intervention Critical Caution
- Hospice Benefit Terminal prognosis <= 6 months Interdisciplinary comfort care Foregoes curative treatments
POLST Orders Actionable medical order across settings Dictates EMS CPR/intubation care Must be signed by clinician
Refractory Dyspnea Subjective breathlessness at end of life Low-dose morphine + facial cool fan O2 beneficial only if SpO2 <90%
Opioid Prescribing Moderate-to-severe pain management Hydromorphone/Fentanyl in CKD MANDATORY concurrent scheduled senna