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Palliative care

Copyright © 2006 Society of Hospital Medicine

Palliative care refers to a collaborative, comprehensive, interdisciplinary approach to improve the quality of life of patients living with debilitating, chronic or terminal illness. Palliative care is appropriate at any stage of illness and should be provided simultaneously with all other medical treatments. This approach includes the prevention and relief of suffering by means of early identification, assessment, and treatment of pain and other distressing symptoms such as dyspnea, nausea, fatigue, anxiety and depression; and attention to the physical, psychosocial and spiritual needs of patients and their families.

Hospitalists provide palliative care in multiple realms including 1) patients dying in the hospital; 2) patients discharged to home or another institution for end‐of‐life care; 3) patients with newly diagnosed life‐threatening illness; 4) patients requiring complex inpatient symptom management interventions; 5) patients for whom it is appropriate to shift the goal of care away from disease cure or stabilization and toward the maximization of comfort; and 6) patients with serious, chronic illness such as heart failure, COPD, liver disease, dementia, and cancer. Hospitalists lead, coordinate, and participate in initiatives to improve the identification and treatment of patients and families in need of palliative care.

KNOWLEDGE

Hospitalists should be able to:

  • Determine effective management strategies for patients requiring palliative care.

  • Describe potential adverse effects from medications and procedures directed at palliation.

  • Formulate strategies for prevention and treatment of complications of palliative care interventions.

  • Assess the impact of interventions including feeding tubes, parenteral nutrition, mechanical ventilation, and intravenous fluids on patient comfort and prognosis.

  • Describe the concept of double effect with respect to palliative care intervention.

  • Name the basic tenets of hospice care and the Medicare hospice benefit.

  • Identify indicators of clinical stability that allow for safe transitions of care and continuity after discharge.

  • Explain the role of palliative care throughout the course of illness and how it can be provided alongside all other appropriate medical treatments.

  • Describe signs and symptoms of the last 24 hours of life and how to discuss these observations with families.

  • Describe the responsibilities of the hospitalist after a patient dies, including pronouncing a person dead, completing the death certificate, requesting an autopsy, notifying family and PCP, and contacting the organ donor network.

SKILLS

Hospitalists should be able to:

  • Obtain a thorough and relevant history, review the medical record, and perform a comprehensive physical examination to identify symptoms, co‐morbidities, medications or social influences that impact the palliative care plan.

  • Direct individual patient's palliative care delivery from admission to discharge.

  • Formulate a communication plan for delivering prognostic information.

  • Conduct effective and compassionate family meetings.

  • Formulate specific patient centered palliative care plans that include pain management; integration of psychiatric, social, spiritual and other support services; and discharge planning.

  • Recognize and address the psychosocial effects of complex, acute life threatening illness in hospitalized patients.

  • Assess and respond to patient's symptoms, which may include pain, dyspnea, nausea, constipation, fatigue, anorexia, anxiety, depression and delirium.

  • Anticipate adverse effects and double effect from interventions and initiate measures to minimize such problems.

  • Communicate effectively with patients and families about patient's values and goals of care.

  • Communicate effectively with patients and families about hospice and know how to refer a patient to hospice.

  • Respond to patient requests for assisted suicide and identify and address other important ethical issues.

ATTITUDES

Hospitalists should be able to:

  • Convey diagnosis, prognosis, treatment and support options available for patients and families in a clear, concise, compassionate, culturally sensitive and timely manner.

  • Determine patient and family understanding of severity of illness, prognosis and their role in determining the goals of their care.

  • Promote the ethical imperative of frequent pain assessment and adequate control.

  • Appreciate that all pain is subjective and acknowledge patient's self reports of pain.

  • Discuss with patients and families goals for pain management strategies and functional status and set targets for pain control.

  • Appreciate that good palliative care for patients with certain conditions often involves the use of therapies typically thought of as curative.

  • Conduct meetings with patients and families to establish goals of care that reflect the patient's wishes.

  • Determine existence of advance directives and provide patients and families with resources to understand and execute such directives.

  • Advocate incorporation of patient wishes into care plans.

  • Recognize the need for frequent family meetings.

  • Address resuscitation status and patient preferences for care early during hospital stay.

  • Maintain rapport with patients and families and a consistent approach to management during transfers of care.

  • Recognize impact of cultural and spiritual factors to the provision of palliative care.

  • Appreciate the role of other members of the healthcare team including nursing and social services, pharmacy, psychology and pastoral care in providing comprehensive palliative care, and work closely with these team members in caring for patients with serious, chronic and terminal illnesses and their families.

  • Provide reassurance to patients and families that clinical providers will be available to provide ongoing care and relief of symptoms.

  • Formulate a comprehensive discharge plan that will empower the patient, family and subsequent providers to anticipate and manage changing symptoms, emergency situations, and increasing dependency.

  • Lead, coordinate or participate in efforts to establish or improve palliative care in the hospital, which may include establishing a palliative care consultation service.

  • Consider palliative care issues at hospital management and committee meetings.

  • Engage providers and administrators in the study of local palliative care delivery to include efficacy of pain assessment and intervention, patient and family satisfaction with care delivery, impact on hospital occupancy and costs, and fulfilled expectations of referring and collaborating providers and services.

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