Citations

Donation after circulatory death (DCD) has become a key avenue for expanding the organ donor pool. Many DCD protocols include premortem intravenous heparin to reduce microthrombus formation and preserve graft viability. This presents the plausible risk of premortem bleeding from an intervention that offers no direct therapeutic benefit to the donor. Ethical concerns and moral distress can arise when potential donors have a catastrophic intracranial hemorrhage with ongoing physiological concern for bleeding risk that is not survivable, but do not currently meet brain death criteria. While prior analyses describe premortem interventions in DCD in conceptual or protocol-driven terms, this case report considers the ethical concerns inherent in premortem heparin administration and illustrates how multidisciplinary teams can operationalize ethical safeguards, including transparent communication, attention to surrogate understanding, and separation of end-of-life decisions from donation-related interventions, to mitigate concerns and minimize moral distress. These issues are directly relevant to palliative care clinicians, who frequently support families during end-of-life crises and when there is consideration for organ donation. Through a multidisciplinary and ethically guided approach, this case illustrates how collaborative decision-making and transparent communication can uphold both donor dignity and transplant integrity.

Survivors of human trafficking experience profound trauma with long-lasting psychological, physical, and social consequences that can complicate medical care, particularly in the context of serious illness. This case highlights the palliative care approach to a 38-year-old woman with metastatic cervical cancer and a history of trafficking-related trauma. The clinical team encountered nuanced challenges, including disrupted trust, limited social support, high symptom burden, and distress related to bodily autonomy. A trauma-informed, multidisciplinary team—comprised of palliative care, gynecological oncology, psychiatry, and social work—prioritized safety, choice, and trust-building to align care with the patient’s values and goals. Despite significant health inequities and psychosocial vulnerabilities, individualized care planning and intentional communication supported dignity, symptom control, and emotional safety during a prolonged hospitalization. This case illustrates the ethical and relational dimensions of caring for survivors of trafficking and underscores the importance of trauma-informed care principles, cultural humility, and interdisciplinary collaboration in palliative settings.

In this letter, the authors evaluate the potential of suzetrigine, a newly U.S. Food and Drug Administration-approved selective NaV1.8 sodium channel inhibitor, as a novel nonopioid alternative for managing moderate-to-severe pain. By targeting peripheral sensory neurons and avoiding the central nervous system, suzetrigine offers a favorable safety profile that bypasses typical opioid-related risks such as respiratory depression, sedation, and tolerance. While clinical trials demonstrate its noninferiority to hydrocodone/acetaminophen in acute postsurgical settings, the authors highlight significant barriers to its use in palliative and hospice care. These limitations include a lack of evidence in patients with serious illness, a current safety restriction of 14 days of use, and a high cost of approximately $15.50 per tablet. Consequently, while suzetrigine represents a significant pharmacological advancement, its current utility is likely limited to short-term acute pain crises until further data support its long-term application in serious illness management.

Stiff Person Syndrome (SPS) is a rare, progressive autoimmune neurological disorder characterized by painful spasms, muscle rigidity, and heightened sensitivity to external stimuli. Management often relies on therapies that fall outside standard hospice formularies, creating challenges in end-of-life care for affected individuals. We present the case of a 57-year-old woman with metastatic colorectal cancer and SPS whose primary concern in transitioning to hospice was the risk of symptom destabilization if standard neurological treatments, including intravenous immunoglobulin and intrathecal baclofen, were discontinued. Through close interdisciplinary collaboration among palliative care, neurology, and the hospice team, an individualized plan of care was developed that preserved access to symptom-modifying treatments while aligning with the hospice philosophy. Environmental and pharmacologic strategies—including diazepam, levetiracetam, and anticipatory planning—were employed to address evolving symptoms, resulting in effective symptom control and avoidance of hospital readmission. This case highlights the need for flexible, patient-centered approaches in hospice care for rare neurological conditions like SPS. Continuation of disease-specific therapies for symptom palliation can be ethically and clinically appropriate when integrated with clear goals of care. Adaptable interdisciplinary models are essential to attend to quality of life and support care that is in alignment with patient values at the end of life.

Airway obstruction is a distressing and potentially life-threatening complication in patients with advanced head and neck cancers, particularly squamous cell carcinoma (SCC) of the pharynx. This case highlights the clinical, ethical, and interdisciplinary complexities involved in managing airway compromise in the context of progressive disease and limited treatment options. A 75-year-old man with recurrent SCC of the soft palate, nasopharynx, oropharynx, and hypopharynx, recently initiated on pembrolizumab and radiation therapy, presented with dysphagia, stridor, and intermittent tumor bleeding. Imaging revealed a large pharyngeal mass causing critical airway narrowing. Plans for tracheostomy to manage anticipated radiation-induced edema were aborted following the patient’s acute neurological deterioration, with imaging confirming bilateral carotid artery occlusions and a new stroke. With poor prognosis and elevated risk of carotid blowout syndrome (CBS), further disease-directed treatments were deemed inappropriate. A multidisciplinary team, including palliative care, oncology, and ENT, facilitated a transition to comfort-focused care, emphasizing symptom control, airway management, and emotional support. The patient was transferred to inpatient hospice for end-of-life care. This case underscores the multifactorial nature of airway obstruction in advanced pharyngeal SCC, including tumor burden, treatment-related edema, and vascular complications. It highlights the importance of risk stratification for tracheostomy, especially in the setting of stroke, bleeding risk, and impending CBS. Symptom management was pivotal in maintaining comfort. Nonpharmacologic strategies and psychosocial-spiritual support further contributed to comprehensive end-of-life care. Individualized, multidisciplinary, and patient-centered approaches are essential when curative therapies are no longer appropriate in advanced head and neck cancer. Prioritizing comfort, clear communication, and integrative symptom management can optimize quality of life and support dignity at the end of life.