HeyHippocratesCancer pain, opioid rotation, goals of care — a colleague who cites every call.
Clinical decision support that reasons like a palliative physician while you decide: titrate and rotate the opioid safely, prevent its side effects, relieve refractory dyspnea, and lead the goals-of-care conversation — with the decision rule and exactly what would change it. Built for verified physicians.
Watch it think — in palliative care.
Two worked examples, reasoned the way it answers: the relevant clinical checks run, the answer is cited, the decision rule is explicit, and what is missing is flagged.
Severe cancer pain uncontrolled on scheduled morphine, now with confusion and myoclonus — the move?
Confusion and myoclonus on morphine point to opioid neurotoxicity from accumulating metabolites, worsened by renal impairment or dehydration. Rotate to a different opioid at an equianalgesic dose, then reduce that dose by about a quarter to a third for incomplete cross-tolerance, and hydrate. Set the breakthrough dose at roughly ten percent of the 24-hour total, given as needed. Reassess frequently, and always start a prophylactic bowel regimen. Escalating the same opioid would deepen the toxicity.
Decision ruleOpioid neurotoxicity (confusion, myoclonus) → rotate to another opioid at equianalgesic dose, reduce ~25–33% for incomplete cross-tolerance, hydrate, check renal function; breakthrough ~10% of 24-h total; prophylactic bowel regimen.
Not established from this alone — the renal function, the current regimen and the pain type change the rotation and the dose.
Advanced disease with declining function; the family wants "everything done" but the prognosis is short — the conversation?
Hold a structured goals-of-care conversation rather than offering a menu of procedures. Ask permission to talk about what lies ahead, assess what the patient and family already understand, and share the prognosis honestly using ask-tell-ask, allowing for emotion. Explore what matters most — function, time, place, relationships — then make a recommendation aligned to those values, framing code status and hospice within it. "Everything" usually means everything that helps; name the trade-offs and document the plan.
Decision ruleGoals-of-care talk → ask permission + assess understanding + share prognosis honestly (ask-tell-ask, allow emotion) → elicit values → recommend care aligned to values (not a menu); frame code status and hospice within the goals; document.
Not established from this alone — the patient values, the prognosis and the understanding change the recommendation.
Illustrative simulations. The physician always decides.
The answers palliative care physicians actually look up.
The exact questions your field searches for — answered in the format the knowledge base speaks: the answer, the decision rule, what's missing, and the source.
Cancer pain — how do I dose and rotate opioids safely?
Follow the WHO analgesic ladder, moving to a strong opioid for moderate-to-severe cancer pain, titrated against effect. Give scheduled around-the-clock dosing plus a breakthrough dose of about ten percent of the 24-hour total. When toxicity, poor response or renal impairment demands a change, rotate to another opioid at the equianalgesic dose and cut it by a quarter to a third for incomplete cross-tolerance. Add adjuvants for neuropathic or bone pain, and start a bowel regimen from the first dose.WHO · EAPC
Decision ruleWHO ladder → strong opioid for moderate-severe cancer pain, titrate; scheduled dosing + breakthrough ~10% of 24-h total; rotate at equianalgesic dose minus 25–33% for cross-tolerance; adjuvants for neuropathic/bone pain; always a bowel regimen.
Missing data: the pain mechanism, the renal function and prior opioids change the drug and the dose.
Opioid side effects — how do I prevent and manage them?
Anticipate the side effects rather than reacting to them. Constipation is universal and does not wane, so start a stimulant laxative with every opioid, adding a peripherally acting mu-antagonist for refractory opioid-induced constipation. Nausea is common early and usually settles; treat it and reassess. Sedation and mild confusion often ease with time, but new confusion, myoclonus or hallucination signals neurotoxicity and prompts a dose reduction or opioid rotation. Respiratory depression is rare when opioids are titrated to pain.palliative pharmacology
Decision ruleProphylactic stimulant laxative with every opioid (peripheral mu-antagonist if refractory); treat early nausea and reassess; sedation eases; new confusion/myoclonus/hallucination = neurotoxicity → reduce or rotate; respiratory depression rare when titrated to pain.
Missing data: the specific side effect, the renal function and the regimen change the management.
Refractory breathlessness at the end of life — what actually helps?
Once reversible causes are treated, a low-dose systemic opioid is the first-line treatment for refractory breathlessness, titrated gently. Add non-pharmacologic measures — a fan or airflow to the face, positioning, pacing and breathing techniques — which have real effect. Reserve benzodiazepines for the anxiety that accompanies dyspnea, not as first-line, and use oxygen only when the patient is hypoxemic, since it does not help breathlessness in the non-hypoxemic. Reassess and titrate to comfort.ATS · palliative
Decision ruleTreat reversible causes → low-dose systemic opioid first-line for refractory dyspnea, titrate; non-pharmacologic (fan/airflow, positioning, breathing); benzodiazepine only for accompanying anxiety; oxygen only if hypoxemic; titrate to comfort.
Missing data: the reversible causes, the oxygenation and the anxiety change the treatment.
The goals-of-care conversation — how do I structure it?
Prepare and hold the conversation deliberately. Ask permission, assess understanding, then share the prognosis honestly with ask-tell-ask, giving a headline and pausing for emotion before detail. Elicit what matters most — the values, hopes and fears — and reflect them back. Make a clear recommendation aligned to those values rather than listing interventions, and place code status and hospice within that recommendation. Close by summarizing the plan and documenting it for the team.VitalTalk · serious illness
Decision rulePrepare → ask permission + assess understanding → share prognosis (ask-tell-ask, headline then pause for emotion) → elicit values → recommend aligned to values (not a menu) → frame code status/hospice → summarize + document.
Missing data: the understanding, the values and the emotional readiness change the pacing and the plan.
What it knows in palliative care
Your whole practice, one specialist brain — grounded in specialist-written, cited knowledge.
A generalist palliative-care colleague across pain, non-pain symptoms, the last days, goals of care, prognostication and hospice — cited, non-directive, always with the decision rule.
Deep specialist agents for cancer pain and symptom management, communication and goals of care, end-of-life and hospice care, and non-cancer palliative care — each its own specialist voice and knowledge base — plus your own uploaded materials.
Why not just use OpenEvidence or ChatGPT?
A large language model answers any clinical question with total confidence and no idea whether it is right. A search engine finds papers. HeyHippocrates reasons inside your specialty from a knowledge base a specialist in your field wrote and signed, and tells you the decision rule and what is missing.
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Questions palliative care physicians ask
It reasons in the frameworks you use — the WHO ladder, opioid rotation and breakthrough dosing, the dyspnea approach and the goals-of-care structure — and always shows the reasoning, the decision rule and what would change it. The decision always stays your call.
Both. Fellows use it to pressure-test a plan and learn the decision rule; attendings use it as a fast, cited second opinion on consults and at the bedside. Access is gated to verified physicians.
Cancer pain and symptom management, communication and goals of care, end-of-life and hospice care, and non-cancer palliative care each have their own deep specialist agent on the Pro plan, on top of the full palliative-care scope on Basic.
No. It is physician-facing clinical decision support — a cited thinking partner. It does not diagnose, does not treat, and gives no patient-facing advice. The decision always stays with you.
Every answer is grounded only in specialist-written, cited palliative-care knowledge — traceable to a named source — and always states the decision rule plus what data is missing, instead of a confident guess.