Download Guidelines on Palliative Care Services Palliative care—including

Guidelines on Palliative Care Services
Palliative care—including management of pain and symptoms and access to
supportive services such as mental health care, professional chaplaincy, and social work—
should be integrated into treatment and care plans in all care settings for all patients,
including patients near the end of life. This integration should begin upon admission
through upfront screening for palliative care needs and should be maintained through all
care transitions. This is an ethical imperative for health care institutions and an ethics
education priority. Palliative care services should also encompass the support of loved
ones involved in the care of dying patients and address their grief and bereavement.
Palliative care is an interdisciplinary specialty that involves physicians, nurses, mental
health professionals, social workers, chaplains, and other professionals. There are models for
delivering palliative care in hospitals and nursing homes, through home care agencies and other
outpatient settings, and through hospices that deliver pre-hospice palliative care and the wellestablished hospice model. Materials on these models are now readily available, as are
standards for assessing the quality of an institution’s palliative care services. The web-based
research and educational resources included in the Bibliography feature many tools for
developing, assessing, and improving palliative care services.
The integration of pain and symptom management into care near the end of life in
U.S. health care institutions is a work in progress. The benefits of the full integration of
palliative care into health care from diagnosis onward are quantifiable for patients and for
institutions. However, some professionals may still incorrectly associate palliative care solely
with situations in which therapeutic interventions have ceased. They may be unsure when to call
for a palliative care consultation or how to collaborate with specialists in palliative medicine
and nursing. Palliative care services may not be fully reimbursable and may require institutional
investment.
All health care institutions should integrate pain and symptom management into patient
care. Health care institutions that care for persons near the end of life must do so.
As seriously ill patients are likely to experience pain and symptoms and have other
palliative care needs, institutions that provide care to seriously ill patients should:
1. Invest in palliative care services appropriate for the needs of their patient
population.
An institution should identify palliative care models appropriate for their patient
population and care setting. Necessary investments may include training for all clinical staff
in the fundamentals of palliative medicine, the recruitment of a team of palliative care
specialists, and collaboration between institutions, such as a hospice program and a nursing
home.
2. Regularly review and improve existing institutional processes by which professionals,
patients, and loved ones gain access to pain and symptom management services, including
but not limited to palliative care consultations.
An institution should seek to learn how its palliative care service is perceived by
professionals and other staff in all patient care settings within the institution, including those
that provide care to patients facing decisions about life-sustaining treatment or who are near
the end of life. These settings include ICUs and medical and surgical units serving adult and
pediatric patients, the emergency department, and also outpatient facilities for patients
undergoing dialysis, chemotherapy, and other life-sustaining treatments. Learning about
clinical perceptions of palliative care and how accessible an institution’s palliative care
services are to patients in different care settings helps identify any structural barriers to
access. Coupling quality improvement measures with palliative care education and training
opportunities may increase knowledge of pain and symptom management and encourage a
shared vision of good care.
3. Use system-generated data to identify gaps in access to palliative care.
Systemic approaches to improving palliative care use data to identify patients diagnosed
with conditions indicating an ongoing need for palliative care, and to train the professionals
responsible for these patients’ care to assess and address palliative care needs. Data
suggesting gaps in access to palliative care provide evidence that institutions should review
their performance in palliative care and check for discrepancies in access across groups.
4. Ensure that access to palliative care is maintained during care transitions.
Ensuring access to palliative care is particularly important during transitions, including
transfers of responsibility for patient care between professionals (hand-offs). Shift changes
should include a review of each patient’s pain, symptoms, medications, and other palliative
care needs and the completion or updating of any medical orders prior to a hand-off to
incoming staff.
Transfers between care settings should include a review of palliative care needs and the
completion or updating of any medical orders and prescriptions that will accompany the
patient to his or her destination prior to initiating transfer. Transfers between care settings
(including between a medical unit and a hospice unit in the same facility) should include
contact between the responsible professional in the patient’s current care setting and the
professional who will be responsible for palliative care at the patient’s destination to ensure
that all ordered medications will be available at the destination. In particular, the
discharging health care professional should ensure that the patient is provided with an
adequate supply of all necessary medications and with prescriptions and other
documentation required to support the safe and effective use of all prescribed medications.
5. Establish policies and processes to assure access to mental health services, social
services, and chaplaincy for patients and loved ones when decisions about life-sustaining
treatment and end-of-life care are being made
Clinical practice guidelines for palliative care encourage institutions to recognize the
interdisciplinary nature of palliative care and to involve specialties beyond medicine and
nursing in providing it. An institution’s policy and processes should support access to
mental health services, spiritual care services, and social services for patients facing
decisions to forgo life-sustaining treatment and patients approaching the end of life, and for
surrogates and loved ones involved in a patient’s care. The integration of screening tools
into admission processes and other interviews with patients can help ensure this access by
eliciting patient concerns and promoting referrals as needed. For example, a “spiritual
screen” is a short set of questions designed to help physicians and nurses quickly identify
and make referrals for patients whose suffering may have a spiritual or religious dimension
that a board-certified chaplain may be able to address if desired by the patient. By
providing the responsible professional with a way to elicit more information about the
patient’s concerns, the planned use of screening tools can also facilitate communication
between the responsible professional and other team members who may be able to provide
support during decision-making and end-of-life care.
6. Promote collaboration among palliative care providers across care settings.
Patients forgoing life-sustaining treatment or nearing the end of life may need to receive
palliative care as they move across settings that include hospitals, hospices, and nursing
homes and other types of long-term care facilities, as well as home. Hospital-based palliative
care professionals may be best situated to promote ongoing collaboration among
professionals and staff who are involved in the delivery of palliative care in a community
with the goal of identifying common concerns, developing knowledge and skills, and
improving care and continuity of care across settings. Opportunities for collaboration may
include ethics education, interdisciplinary grand rounds and other continuing education
programs, and projects to explore ways for professionals at different institutions to work
together.
Adapted from: N Berlinger, B Jennings, and SM Wolf, The Hastings Center Guidelines for
Decisions on Life-Sustaining Treatment and Care Near the End of Life: Revised and Expanded
Second Edition (Oxford University Press, 2013): Part II, Section 6B, “Guidelines for
Institutional Policy: Guidelines on Palliative Care Services,” 116-19. Publisher’s permission
secured.