Clinical Guides for Hospices

What is dyspnea in hospice care?
Dyspnea is the medical term for shortness of breath, breathlessness, or "air hunger." It's one of the most common and distressing symptoms in advanced illness, and hospice teams treat it as a patient-reported experience rather than a lab value.

Does low oxygen saturation always mean a patient is having trouble breathing?
No. Dyspnea and oxygen saturation don't always match — a patient can feel very breathless with a normal pulse-ox reading, or have low oxygen and appear comfortable. Hospice care prioritizes the patient's symptoms and visible distress over the oxygen number.

How do hospice teams treat breathlessness?

1. Assess distress — ask the patient directly, or watch for signs like agitation, labored breathing, or a fearful expression if they can't communicate.
2. Identify possible causes — bronchospasm, fluid overload, infection, anxiety, or disease progression.
3. Start comfort measures first — positioning, a fan on the face, a calm environment, and reduced stimulation.
4. Add medication or oxygen if needed — opioids for persistent air hunger; oxygen only for symptomatic low oxygen or clear comfort benefit.
5. Reassess regularly — the plan changes as the patient's strength and abilities decline.

Do opioids help with shortness of breath?
Yes. For persistent or distressing dyspnea, low-dose opioids are a standard, evidence-based hospice treatment — they ease the brain's perception of air hunger, not just pain. They can be used well before end-of-life and are titrated individually.

Is oxygen always the right treatment?
No. Oxygen helps when there's symptomatic low blood oxygen or clear patient-reported comfort. Without that, it may add equipment burden without added relief — so hospice teams reassess its ongoing value rather than using it automatically.

What can a caregiver do at home during an episode?
Stay calm and close, help the patient sit upright, point a fan at their face, reduce noise/activity, use paced breathing if the patient can participate, give PRN meds as prescribed, and call hospice if symptoms are new, worsening, or frightening.

Why do inhalers or nebulizers sometimes get changed later in hospice?
Because using a metered-dose or dry-powder inhaler correctly requires coordination and inspiratory strength that decline with illness. Hospice pharmacists reassess whether a device, route, or medication still provides real benefit versus burden — and simplify or switch as needed.

Who decides the treatment plan?
The hospice interdisciplinary team — nurses, prescribers, and pharmacists — working with the patient and family, guided by symptoms, response to treatment, and the patient's goals of care.

Chronic cough in hospice patients — whether productive or non-productive — significantly affects quality of life and caregiver burden. This guide provides a clinical framework for assessing cough in end-of-life care, differentiating productive from non-productive presentations, and developing a treatment plan using both pharmacological and non-pharmacological interventions. Covers commonly used agents including opioids for cough suppression, expectorants, and nebulized therapies available through the BetterRX formulary.

Thyroid medications present a common clinical question in hospice: should they be continued, dose-adjusted, or deprescribed? This guide helps patients and families understand how thyroid therapy is reconsidered when hospice care begins, including the rationale for continuing or stopping thyroid medications based on the patient's comfort goals and prognosis. Designed to support family conversations during the hospice admission medication review process.

Diabetes medications are among the most commonly deprescribed drug classes when patients transition to hospice care. Tight glycemic control that was appropriate for prevention of long-term complications may cause dangerous hypoglycemia in patients who are eating less, losing weight, and nearing end of life. This guide provides hospice clinicians with a systematic framework for assessing which diabetes medications to continue, reduce, or discontinue — and how to monitor patients safely during the transition period.

Patients and families often have concerns — and sometimes fears — about starting or changing opioid pain medications. This guide addresses the most common questions directly: how opioids work for pain management in hospice, the difference between dependence and addiction in the context of palliative care, what to expect when opioid therapy begins, signs that the current dose is working, and when to contact the hospice team about pain that isn't controlled.

Modifying opioid therapy or transitioning a patient from one opioid to another requires precise equianalgesic dosing to avoid undertreating pain or inadvertently causing harm. This guide provides hospice clinicians with practical conversion tables and step-by-step calculation methodology for the most common opioid transitions encountered in end-of-life care, including oral morphine equivalents, methadone conversions, and fentanyl patch dosing. Includes clinical notes on incomplete cross-tolerance and dose reduction guidance.

Patients admitted to hospice who are currently managed on buprenorphine for pain or opioid use disorder (OUD) present unique clinical challenges. This guide addresses how to manage symptom control in buprenorphine-maintained patients, including dosing considerations, rotation strategies, and the pharmacological factors that make buprenorphine distinct from full opioid agonists. Designed for hospice nurses and prescribers navigating increasingly common clinical scenarios at admission.

Patients and family caregivers frequently struggle to understand the difference between scheduled medications and PRN (as-needed) medications — a distinction that is fundamental to effective hospice symptom management. This guide explains when to give scheduled medications, how to recognize when a PRN dose is needed, how to track medications given, and when to contact the hospice team. Designed to reduce caregiver anxiety and improve medication adherence in the home hospice setting.

Beginning the deprescribing conversation with patients and families is often more difficult than the clinical decision itself. This guide provides hospice clinicians with a framework for initiating the deprescribing conversation compassionately and effectively — including language for explaining why certain medications are no longer appropriate, how to respond to family concerns about "giving up," and how to document the shared decision-making process in a way that supports clinical continuity and regulatory compliance.

Cholinesterase inhibitors and NMDA antagonists used for dementia management are among the most frequently continued — and most appropriately discontinued — medications in hospice care. This guide helps hospice clinicians evaluate whether continuing dementia medications aligns with a patient's comfort-focused goals of care, including a review of the evidence base for these medications in advanced dementia, the clinical timeline for symptom changes after discontinuation, and guidance for family conversations about stopping dementia medications.

Inhalers and respiratory medications are frequently continued in hospice even when patients can no longer use them effectively — or when the underlying condition no longer warrants aggressive management. This guide provides a clinical framework for evaluating respiratory medications in the hospice setting, including criteria for continuing bronchodilators for dyspnea relief vs. discontinuing preventive therapies, and guidance for transitioning to alternative symptom management routes when inhaled delivery is no longer feasible.

Anticoagulants present a nuanced deprescribing challenge in hospice — the risk-benefit calculation shifts substantially at end of life, but blanket discontinuation is not always appropriate. This guide provides hospice clinicians with a structured approach to evaluating anticoagulant therapy at hospice admission and on an ongoing basis, including indications where continuation may remain appropriate (mechanical heart valves, high-risk atrial fibrillation), management of anticoagulant reversal, and monitoring considerations for patients in whom anticoagulants are discontinued.

Transdermal fentanyl is one of the most commonly used long-acting opioid formulations in hospice care, but its 72-hour dosing cycle, delayed onset, and temperature-sensitive absorption create clinical management challenges. This guide covers patient selection criteria, dose initiation and titration, heat exposure warnings, rotation site guidance, and safe disposal requirements for used patches — a critical compliance and safety consideration for hospice organizations.

Methadone is a medication with a long history — originally developed for pain management and later used in opioid use disorder treatment — that is now recognized as an effective option for refractory pain in hospice and palliative care. This patient guide explains what methadone is, why it may be recommended for certain hospice patients, how it differs from other opioids, what monitoring is involved, and important drug interaction and safety information for patients and caregivers.

As hospice patients decline, oral medication administration often becomes difficult or impossible due to dysphagia, altered consciousness, or refusal to swallow. This guide introduces patients and caregivers to the alternative medication delivery routes commonly used in hospice — including sublingual, buccal, rectal, transdermal, and subcutaneous routes — and explains what to expect when the care team recommends transitioning away from oral medications. Designed to reduce fear and improve caregiver confidence when oral routes are no longer appropriate.

Feelings of sadness, grief, and depression are normal and expected responses to a life-limiting illness — and they are also treatable. This guide helps hospice patients and families distinguish between normal grief and clinical depression, understand how depression is managed in the hospice setting (including both pharmacological and non-pharmacological approaches), and know when and how to communicate emotional distress to the hospice care team. Designed to reduce stigma and improve symptom reporting for psychological distress.

Anticoagulant medications ("blood thinners") are among the most common medications reconsidered when a patient begins hospice care. This guide helps patients and families understand what anticoagulants do, why their benefits and risks change in the context of end-of-life care, and how the hospice team will discuss continuing or stopping these medications. Provides plain-language guidance on what to watch for if anticoagulants are discontinued and when to contact the care team.

Starting hospice care often means changes to a patient's medication routine that can feel confusing or even alarming. This guide helps patients and families understand how hospice medication management works — why some medications are continued, why others may be stopped, how comfort-focused prescribing differs from curative care, and what to do if symptoms are not well controlled. Designed to be shared directly with patients and caregivers during the hospice admission process.

Pain is one of the most common and feared symptoms experienced by hospice patients. This guide provides a plain-language overview of how opioid therapy is used in hospice care — including why opioids are considered the standard of care for moderate-to-severe pain at end of life, how doses are determined and adjusted, and how the hospice team monitors for both effectiveness and side effects. Addresses common family concerns about opioid use and provides clear guidance on when and how to reach the hospice team.

Inhalers and respiratory medications are frequently used prior to hospice admission, but their effectiveness and appropriateness at end of life varies significantly. This guide helps patients and families understand how respiratory medications are reviewed when hospice care begins, how to use inhalers correctly if continued, and what alternatives may be recommended if inhaled therapy becomes difficult. Covers the four key factors that determine whether inhaled medications are reaching their target — and what to do when they aren't.

Many patients and families want to prepare as well as possible for end of life — and having clear, honest information helps. This guide covers the physical and emotional changes that typically occur in the final days and hours of life, how symptoms will be managed, what the care team's role is during this time, and what families can expect during and after death. Designed to reduce fear, improve family preparedness, and support the hospice team's communication with families during one of the most significant transitions of the care journey.

Weight loss and decreased appetite are among the most distressing changes families observe in hospice patients — and among the most commonly misunderstood. This guide explains the physiological reasons why hospice patients lose interest in food and fluids at end of life, addresses common family concerns about hunger and dehydration, and provides evidence-based guidance on nutrition and hydration decisions in hospice care. Helps families understand that decreased oral intake is a natural part of the dying process rather than a cause of decline.

Methadone is a synthetically derived Schedule II controlled substance with a unique pharmacokinetic profile that makes it both highly effective and potentially dangerous when not managed carefully. This clinical guide covers methadone's mechanism of action, its use in hospice for refractory pain management, QTc monitoring considerations, drug interaction risks, and safe prescribing practices. Intended for hospice prescribers and clinical pharmacists managing patients with complex pain syndromes.

Neuropathic pain — arising from peripheral or central nervous system damage — requires a different pharmacological approach than nociceptive pain and often responds poorly to opioids alone. This guide covers the primary and adjuvant agents used for neuropathic pain management in hospice, including gabapentinoids, TCAs, SNRIs, and topical agents, with dosing considerations, monitoring guidance, and formulary-aligned prescribing recommendations for the hospice setting.

Opioids are the most utilized analgesics in hospice and palliative care, but non-opioid therapies play an important complementary role — particularly for bone pain, inflammatory pain, and neuropathic components. This guide covers the evidence base and practical use of NSAIDs, acetaminophen, corticosteroids, ketamine, lidocaine, and other non-opioid analgesics in the hospice setting, with guidance on patient selection and formulary considerations.

A quality, comprehensive pain assessment is the foundation of effective pain management in hospice. This guide outlines validated pain assessment tools appropriate for hospice patients across cognitive levels — including verbal, observational, and behavioral scales — and provides a framework for documenting pain assessments in a way that supports both clinical decision-making and regulatory compliance. Includes guidance on reassessment frequency following medication changes and for rapidly changing clinical presentations.

Proper drug deposition with inhaled medications depends on four factors: inhalation flow, correct inhaler technique, aerosol velocity, and drug particle size. When any of these are compromised — as is common in debilitated hospice patients — therapy is ineffective and patients may be receiving medications that provide no comfort benefit. This guide helps hospice clinicians assess inhaler use effectiveness, identify patients who can no longer benefit from inhaled therapy, and make evidence-based decisions about transitioning to alternative delivery routes.

For hospice patients with difficulty swallowing whole or halved sucralfate tablets — a frequent challenge with oral mucositis, dysphagia, or altered consciousness — a sucralfate slurry preparation offers a practical alternative. This guide provides step-by-step instructions for preparing a sucralfate slurry just prior to administration, including mixing ratios, appropriate uses, and stability considerations. A frequently referenced clinical tool for hospice nurses managing patients with head and neck cancers or esophageal complications.

Hepatic encephalopathy (HE) is a common neuropsychiatric complication of liver failure and frequently presents in hospice patients with hepatic diagnoses. This guide covers the clinical spectrum of HE presentations in the hospice setting, treatment approaches including lactulose and rifaximin, and the unique considerations for managing altered cognition and agitation in patients with end-stage liver disease. Includes guidance on medication safety in hepatic impairment — a critical formulary consideration given altered drug metabolism.