Palliative care refers to the comprehensive care of patients and families who are living with serious illness. It focuses on providing patients with relief from the symptoms and stress of serious illness. The goal is to improve the quality of life for both the patient and the family. Palliative care is appropriate at any stage of illness and should be provided simultaneously with other medical treatments, including disease-modifying and life-prolonging therapies. Palliative care is provided by interprofessional teams, including physicians, nurse practitioners, physician assistants, nurses, social workers, case managers, and chaplains.
Seriously ill patients are frequently hospitalized, and thus all hospitalists—as frontline physicians who coordinate care for these patients—are key members of the interprofessional team who provide primary or generalist palliative care. In addition, in hospitals where palliative care consultation services are available, hospitalists are optimally positioned to refer to and collaborate with these specialty palliative care consultants. In hospitals where no or limited specialty palliative care services are available, hospitalists have an even more central role in providing palliative care. Hospitalists also have a key role in leading and contributing to systems and quality improvement efforts related to palliative care.
Key roles for hospitalists involved in palliative care are (1) leading discussions of goals of care and advance care planning, including completing appropriate documentation of patients’ wishes; (2) screening and implementing treatment for common physical symptoms, including pain, nausea and vomiting, dyspnea, anxiety, depression, confusion and delirium, and constipation; and (3) referring patients to community services to provide support around serious illness after hospital discharge, including hospice and community palliative care services when available. A complete list of core competencies for hospitalists in palliative care follows.
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Hospitalists should be able to:
Define palliative care, including primary (or generalist) and specialty palliative care, and explain effective strategies for describing the benefits of palliative care to colleagues, specialists, patients, and families.
Explain the role of palliative care throughout the course of illness, how it can be provided alongside all other appropriate medical treatments, and appropriate referral to local resources that provide palliative care in the hospital and community.
Recognize when specialty palliative care consultation, when it is available, should be sought for refractory or complex patient or family palliative care needs.
Identify the factors that contribute to prognosis in common serious illnesses (eg, cancer, congestive heart failure, chronic obstructive pulmonary disease, end stage renal disease, dementia, and multimorbidity), including how to identify patients who may benefit from palliative care and how to broadly estimate prognosis (eg, months to years, weeks to months, days to weeks, hours to days).
Describe signs and symptoms of the last 24 hours of life and how to discuss these observations with families.
Describe data on efficacy and burdens of life support interventions in seriously ill patients, such as tube feeding in advanced dementia and cardiopulmonary resuscitation.
Explain the ethical principles involved with caring for patients at the end of life, including the right of competent patients or their surrogates to refuse medical treatments, including life-sustaining therapies, and the principle of “double effect.”
Describe specific legal considerations related to surrogate decision-making and advance planning in the state in which the hospitalist practices.
Describe the purpose and mechanics of advance directives, including physician or medical orders for life-sustaining treatment (POLST/MOLST) forms available in the state in which the hospitalist practices, durable medical power of attorney forms, and other declarations of patient wishes and treatment preferences.
Describe the basic tenets of hospice care and the Medicare hospice benefit and explain the process of initiating direct referrals to these programs in various settings (ie, home, skilled nursing facility, inpatient).
Describe the role of the hospitalist after a patient dies in the hospital, including pronouncing of death, completing the death certificate, requesting an autopsy, notifying the family and primary care physician, contacting the organ donor network, and providing the family with hospital contact information for questions and bereavement resources.
Hospitalists should be able to:
Perform a comprehensive patient assessment to screen patients for palliative care needs, including (1) pain and other common symptoms (eg, nausea and vomiting, dyspnea, anxiety, depression, confusion and delirium, constipation); (2) psychosocial and spiritual support of the patient and family; (3) advance care planning communication about prognosis and goals of care; and (4) needs for support on hospital discharge or bereavement.
Work in interdisciplinary teams, including nursing, social work, case management, therapy, and spiritual care, to formulate specific patient-centered palliative care plans to address identified patient and family needs.
Build therapeutic relationships with seriously ill patients and their families as a basis of support for coping and creating collaborative patient- and family-centered care plans.
In seriously ill and/or actively dying patients, provide first-line treatment for common symptoms such as nausea and vomiting, dyspnea, anxiety, depression, confusion and delirium, and constipation.
Provide counseling on advance care planning, advance care directives, POLST/MOLST forms, and code status, including the outcomes of cardiopulmonary resusitation and other life-sustaining interventions in seriously ill patients.
Lead culturally sensitive communications about prognosis and goals of care among patients, families, and other members of the healthcare team, including family meetings and discussions in urgent situations to ensure that patients receive treatments that match their goals.
Coordinate goals of care and treatment plan among the treatment team, including primary care physicians and inpatient and outpatient specialty consultants.
Consult specialty palliative care and/or hospital ethics service when there is conflict among patients, families, and/or healthcare providers regarding the appropriate healthcare agent for decision-making and provision of life-sustaining interventions.
Identify when hospice may be the appropriate care model given a patient’s prognosis and goals of care, and describe the hospice care philosophy and care model to a patient and family.
Implement protocols and multidisciplinary care plans to ensure patient comfort and adequate family support when life-prolonging measures such as mechanical ventilation, vasopressor support, or other intensive care measures are withdrawn or withheld.
Ensure that the hospital palliative care plan is honored upon discharge, including communicating this plan with primary care and other outpatient providers and establishing home supportive services if needed.
Implement best practices for self-care and coping with the stress of caring for the seriously ill.
Hospitalists should be able to:
Appreciate that palliative care is appropriate at any stage of a serious illness and that it should be provided to all seriously ill patients.
Appreciate that hospitalists have a key role in ensuring that the palliative care needs of seriously ill patients are addressed.
Recognize the importance of empathic communication, building a therapeutic relationship with patients and families, and developing patient- and family-centered treatment plans.
Recognize the impact that social, cultural, and spiritual factors have on preferences for care in the setting of serious illness.
Appreciate the roles of, and collaboration with, other members of the healthcare team, including nursing and social services, pharmacy, psychology, and spiritual care, in providing palliative care.
Lead, coordinate, and/or participate in quality improvement initiatives to improve the care of seriously ill patients, such as symptom identification and management systems and improved advance care planning and goals of care approaches.
Lead, coordinate, and/or participate in efforts to establish or support existing multidisciplinary palliative care teams.