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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.