Palliative care, hospice and end-of-life ethics in cancer pain

Hospice needs a certified prognosis of 6 months or less and can be revoked; palliative sedation is a last resort for refractory physical symptoms, never to cause death; and confusion with bone metastases may be hypercalcemia needing antiresorptive therapy.

1. Hospice requires a 6-month prognosis. Medicare hospice requires Part A entitlement and written certification, renewed for each election period, of a life expectancy of 6 months or less if the terminal illness runs its normal course ¹.
2. Election waives curative coverage, and is revocable. During the election the patient waives Medicare payment for treatment of the terminal condition outside the hospice, and may revoke the election at any time ¹.
3. Palliative sedation is a last resort. It may be offered for severe pain or other symptoms unresponsive to aggressive, symptom-specific palliation, only in the final stages of terminal illness, after multidisciplinary palliative consultation and informed consent, with documentation ².
4. Sedation is not for existential suffering. It must never be used to intentionally cause death; existential suffering is addressed with social, psychological or spiritual support ².
5. The AMA opposes physician-assisted suicide. Physicians should instead respond aggressively to end-of-life needs, including comfort care and adequate pain control ³.
6. Surrogates use the patient's own values. Decisions for patients without capacity follow substituted judgment from advance directives and known values; best interest applies only when preferences are unknown ⁴.

Confusion, constipation and polyuria in a patient with bone metastases may be hypercalcemia of malignancy, the most common metabolic complication of cancer; denosumab or an intravenous bisphosphonate is strongly recommended ⁵.

• Hospice election periods are an initial 90 days, a second 90 days, then an unlimited number of 60-day periods, each needing certification ¹.
• Certification must include clinical information and a brief physician narrative supporting the prognosis ¹.
• The rationale for symptom management and sedation should be documented in the record ².
• For hypercalcemia of malignancy, denosumab is suggested over an intravenous bisphosphonate; severe cases may add calcitonin initially ⁵.
• Glucocorticoids are suggested mainly for hypercalcemia from tumors with high calcitriol levels ⁵.
• Treating the primary malignancy is instrumental for controlling hypercalcemia and preventing its recurrence ⁵.
• Certification rests on the physician's clinical judgment about the normal course of the illness ¹.
• A revocation is filed as a signed statement whose effective date cannot precede the date it is made ¹.

• Believing a hospice election cannot be revoked ¹.
• Offering palliative sedation for fear or loss of control with controlled symptoms ².
• Using the best-interest standard when the patient's wishes are known ⁴.
• Blaming confusion with bone metastases on opioids without checking the calcium ⁵.