CHPPC Module 22, Section 4.4: The Comfort Care Pavilion: Palliative & Hospice Units
MODULE 22: THE HOSPITAL ECOSYSTEM

Section 4.4: The Comfort Care Pavilion: Palliative & Hospice Units

Master the most profound and compassionate application of pharmacology, where your expertise is dedicated entirely to alleviating suffering and maximizing quality of life at its most critical stage.

SECTION 4.4

The Comfort Care Pavilion: Palliative & Hospice Units

Where the goal of care is quality of life.

4.4.1 The “Why”: Shifting the Goal of Care from Curative to Comfort-Focused

In every section of this course thus far, the implicit goal of our pharmacotherapy has been to extend life—to cure the infection, to stabilize the heart, to control the cancer. The Comfort Care Pavilion operates under a different, and arguably more profound, philosophy. The “Why” of palliative and hospice care is to make a deliberate and compassionate pivot away from life-prolonging or curative interventions and toward a singular focus on maximizing comfort and quality of life. This is not giving up. It is a fundamental redefinition of what it means to “win.” Winning is no longer measured in weeks or months gained, but in the quality of the moments that remain. It’s about ensuring a patient’s final days, weeks, or months are lived with dignity, free from pain, and aligned with their personal values.

This philosophical shift has massive implications for the pharmacist. The traditional risk-benefit analysis that governs our practice is turned on its head. Long-term side effects of a medication become irrelevant. The risk of addiction to opioids in a terminally ill patient with severe pain is a moot point. The need for a “perfect” blood pressure or blood glucose level is abandoned in favor of simply avoiding symptomatic hypo- or hyperglycemia. Your role is to de-prescribe any medication that is not directly contributing to the patient’s comfort and to aggressively prescribe and titrate medications that are. You become a specialist not in treating disease, but in treating suffering. It is one of the most challenging, and ultimately rewarding, roles in all of pharmacy.

Palliative Care vs. Hospice: A Critical Distinction

These terms are often used interchangeably, but they are not the same. Understanding the difference is crucial for any healthcare professional.

Feature Palliative Care Hospice Care
Timing Can begin at any stage of a serious illness, from diagnosis onward. Begins after treatment for the disease is stopped and when a physician certifies the patient has 6 months or less to live if the disease runs its natural course.
Treatment Goal To relieve symptoms and stress of a serious illness. Can be provided alongside curative treatment. Focuses exclusively on comfort and quality of life. Curative treatment is stopped.
Example Patient A patient with metastatic cancer receiving chemotherapy who also has a palliative care team involved to manage their pain and nausea. The same patient who, after several lines of chemotherapy, decides to stop treatment to focus on comfort for their final months.
Pharmacist’s Focus Integrative symptom management; managing side effects of curative therapies; helping with complex decision-making. Aggressive symptom management; aggressive de-prescribing of all non-essential medications; providing comfort at the end of life.

4.4.2 The Pharmacist’s Role: The Symptom Management Expert

Mastering the compassionate use of pharmacology to alleviate suffering.

Retail Pharmacist Analogy: The Ultimate MTM Consultant for Quality of Life

You have a long-time patient with multiple, complex chronic conditions. For years, your focus during MTM sessions has been on hitting guideline-directed targets: A1c < 7%, blood pressure < 130/80, LDL cholesterol as low as possible. You have added drugs, titrated doses, and pushed for adherence to achieve these long-term goals. One day, the patient comes to you and says, "I'm tired. The side effects are wearing me out. I don't care about my A1c in 10 years; I just want to feel good today."

This is the moment you transform into a palliative care pharmacist. Your goals instantly shift. You work with the provider to de-prescribe the statin that’s causing muscle aches. You relax the A1c goal to < 8.5% to avoid hypoglycemia, maybe stopping their glyburide. You focus on simplifying the regimen to a once-daily schedule. You have stopped treating the numbers and started treating the person. You are now managing the patient's medications with the sole goal of improving their daily quality of life. This is the exact mindset that governs every decision in the Comfort Care Pavilion.

Mastery 1: The Art of End-of-Life Pain Management

Pain is one of the most common and feared symptoms at the end of life. Your ability to aggressively and effectively manage pain is perhaps your most important contribution to the hospice and palliative care team. This requires a mastery of opioid pharmacology and a willingness to use doses that might seem astronomical in any other setting.

The Principle of Double Effect

This is a critical ethical concept. The “double effect” doctrine states that it is ethically permissible to perform an action (e.g., giving a high dose of morphine) that has a good intended effect (relieving severe pain) even if it has a known, but unintended, bad effect (potentially hastening death through respiratory depression). The intent is what matters. In end-of-life care, the primary intent is always to relieve suffering. You must be comfortable with this principle to be an effective comfort care pharmacist.

The Opioid Conversion Masterclass

You will be constantly converting patients from one opioid to another or from one route to another. You must be an expert in equianalgesic dosing. A common scenario is converting a patient from a short-acting oral opioid to a long-acting formulation or a continuous IV/subcutaneous infusion for better baseline pain control.

Equianalgesic Opioid Dosing Table (Revisited for Hospice)
Opioid Approx. Equianalgesic IV/IM/SC Dose Approx. Equianalgesic Oral Dose Your Hospice & Palliative Care Pearls
Morphine10 mg30 mgThe gold standard. Often used for continuous infusions. Use with caution in severe renal failure due to accumulation of the active M6G metabolite.
Hydromorphone (Dilaudid)1.5 mg7.5 mgPotent and versatile. A preferred agent in renal failure as it has no active metabolites. Excellent for continuous infusions and IV pushes.
OxycodoneN/A20 mgExcellent oral agent. Long-acting formulations (OxyContin) are a mainstay for providing a stable baseline of pain control.
Fentanyl0.1 mg (100 mcg)N/A (Transdermal)Transdermal patches are for stable, chronic pain in opioid-tolerant patients ONLY. Never use a patch for acute pain or in an opioid-naïve patient. Fentanyl IV drips are used for severe, acute pain.
MethadoneHighly Variable (Requires Specialist Consultation)An exceptional drug for complex pain (especially neuropathic pain) but extremely dangerous to convert to/from due to its long, unpredictable half-life and complex pharmacology (NMDA antagonist). All methadone conversions should be done by or in consultation with a pain/palliative specialist.
Case Study: Converting to a Continuous Hydromorphone Infusion

Scenario: A 68-year-old woman with metastatic pancreatic cancer is admitted to the inpatient hospice unit for intractable pain. Over the last 24 hours at home, she has been taking oral hydromorphone 4 mg tablets, and her pain diary shows she took 15 doses. Her pain is still 8/10. The team wants to switch her to a continuous subcutaneous infusion for better pain control.

Your Step-by-Step Calculation and Recommendation:

  1. Calculate the total 24-hour oral dose: 15 doses * 4 mg/dose = 60 mg of oral hydromorphone/24 hours.
  2. Convert the total oral dose to an equivalent parenteral (IV/SC) dose: The oral:IV ratio for hydromorphone is 5:1.
    $$Parenteral Dose = \frac{Oral Dose}{5} = \frac{60 mg}{5} = 12 mg \text{ IV/SC hydromorphone per 24 hours}$$
  3. Calculate the basal rate for the continuous infusion:
    $$Basal Rate = \frac{Total 24h Dose}{24 hours} = \frac{12 mg}{24 h} = 0.5 mg/hour$$
  4. Calculate a breakthrough (demand) dose: The breakthrough dose should be approximately 50-100% of the hourly basal rate, available every 15-30 minutes. Let’s choose 100%. The breakthrough dose would be 0.5 mg.
  5. Make Your Recommendation: “The patient has been using 60 mg of oral hydromorphone per day. To convert this to a continuous subcutaneous infusion, I recommend the following:
    • Start a continuous infusion of hydromorphone at 0.5 mg/hour.
    • For breakthrough pain, order hydromorphone 0.5 mg IV/SC every 15 minutes as needed.
    • We must also start a scheduled stimulant bowel regimen, like senna and bisacodyl, immediately.”

Mastery 2: The Symptom Management Toolkit

Beyond pain, you will be responsible for managing a host of other distressing symptoms. Your goal is to use your pharmacology knowledge to select the right tool for the right job, always with the patient’s comfort as the primary outcome.

Symptom The “Why” / Common Causes The Pharmacist’s Go-To Agents Your Clinical Pearls
Nausea & Vomiting Opioids, chemotherapy, bowel obstruction, brain metastases, anxiety. • Haloperidol: Excellent for opioid-induced and metabolic causes.
• Ondansetron: Best for chemotherapy/radiation-induced.
• Prochlorperazine: Good all-purpose antiemetic.
• Metoclopramide: Good for gastroparesis, but avoid in bowel obstruction.		 You must match the drug to the mechanism. For opioid-induced nausea, targeting dopamine with haloperidol is often more effective than targeting serotonin with ondansetron. Don’t be afraid to use multiple agents with different mechanisms for refractory nausea.
Agitation / Delirium (“Terminal Restlessness”) Uncontrolled pain, metabolic abnormalities, medications, impending death. • Haloperidol: First-line for hyperactive delirium with psychotic features.
• Lorazepam: Best for anxiety-driven agitation or paradoxical reactions to haloperidol. Can worsen delirium in some patients.
• Chlorpromazine: A potent, sedating option for severe, refractory agitation at the end of life.		 This is one of the most distressing symptoms for families. The goal is calm, not coma. Always look for and treat reversible causes (like a full bladder) first. Start low and titrate gently.
Dyspnea (“Air Hunger”) Advanced COPD, heart failure, cancer, anxiety. • Low-Dose Opioids (Morphine, Hydromorphone): These are the mainstay of therapy. They do not improve oxygenation but reduce the brain’s perception of breathlessness.
• Benzodiazepines: To treat the anxiety component that often accompanies dyspnea.		 This is an evidence-based practice that often requires significant family education. You must explain that the goal is to relieve the sensation of suffocation. Doses are typically very low (e.g., Morphine 2.5-5 mg PO).
Excessive Secretions (“Death Rattle”) Patient is too weak to clear their own oral and airway secretions. Anticholinergics:
• Glycopyrrolate (IV/SC): Doesn’t cross the blood-brain barrier, so less central confusion.
• Atropine 1% eye drops: Given sublingually (0.25-0.5mL).
• Scopolamine Patch: Slower onset, but provides a long duration of action.		 This symptom is often more distressing for the family than the patient. The goal is to dry up the secretions. Glycopyrrolate is often the preferred agent due to its favorable side effect profile. Repositioning the patient can also help significantly.