Brought to you by the

Massachusetts Medical Society and its

Committee on Geriatric Medicine
What is palliative care?

Care focused on helping support and guide patients who have life
limiting and serious illnesses, as well as their families and caregivers

Palliative care:
• is for people with life limiting and serious conditions
• addresses physical, emotional, spiritual and psychosocial distress
• is usually provided by a team of doctors, nurses, and social
workers, and sometimes includes physical therapists, nutritionists,
chaplains, or other professionals
• seeks to improve quality of life for the ill person and his or her
family
• matches patient values and preferences to achievable health care
goals in order to develop and direct an individualized plan of care
Palliative care

Became a specialty in 2006

Grew out of hospice

Focuses on three domains:

• pain and symptom management (includes, but is not limited to,
nausea, delirium, constipation, dyspnea, anorexia)
• psychosocial and spiritual support
• advance care planning
Palliative care

• can be helpful for patients of ALL ages:

o at the time of diagnosis of a serious illness
o in concurrence with curative treatments for life-limiting
problems
o living with chronic diseases
o nearing the end of life

Palliative care can be provided in any setting

• very common in larger hospitals and some smaller ones
• outpatient ambulatory centers such as pain and symptom
management centers
• nursing facilities
• at home (near the end of life, hospice is most commonly used)
The role of primary care in palliative care

• much symptom and pain management is already being addressed

• educate patients and families about palliative care
• assist patients and families with advance care planning

When the patient’s needs exceed the PCP’s capabilities

• know how to get extra support and help
• cultivate a clinical relationship with a palliative care team or
provider who can offer consultation or care management support
• know the resources in your community
• provide materials in hand or on-line resources to patients
• recognize many PCP practices do not have resources for spiritual
and psychosocial support
What is Hospice?

• a Medicare benefit since 1986

• designed for those with less than 6 months to live should the
disease run its natural course
• a specific form of palliative care supplied by an agency
• the most widespread, developed way to provide palliative care for
patients at or approaching the end of life
• provided typically in home but also available at nursing homes,
hospitals, or at a hospice residence
• can reduce the risk of depression in a spouse even when provided
to the loved one a few days before death
• reduces the risk of the widow or widower from dying prematurely
Hospice and Palliative Care Both:

• provide support to caregivers

• use an interdisciplinary team approach
• focus on pain management, psychosocial and spiritual support
and advance care planning
• can be provided in any setting

Additionally, hospice
• is similar to a traditional visiting nurse but has enhanced services
to support patients with less than 6 months prognosis
• strives to keep patients home or in their current setting as they
decline
• is for individuals with care goals focused on comfort
• provides bereavement services for 13 months post death
Hospice and Palliative Care:
Palliative Care Hospice Care
 Meant for those with serious  A type of palliative care for those
illness; not limited by life with six months or less of life
expectancy expectancy; can be extended past
six months, with certain criteria
met
 Individuals may still receive  Individuals no longer receive
curative/disease modifying curative treatment; the focus
treatments becomes care that improves
quality of life
 Eligible patients have a serious,  Eligible patients have up to a 6
life-limiting illness, including month prognosis; can return to
ALS, cancer, congestive heart curative or disease modifying
failure, kidney failure, liver failure, care trajectory as a primary goal
COPD, dementia, and Parkinson’s but would typically then leave
hospice.
 Offered in any setting although  Offered in any setting
most commonly offered in the
hospital setting
Advance Care Planning:

• allows patients to express their goals and values

• communicates those goals and values to clinicians and family
• designates a health care proxy in the event of incapacity

An advance directive
• a document that specifies wishes for future care
• appoints a health care proxy
• may include medical orders (DNR/comfort care form or MOLST)
Advantages of Advance Care Planning:

• prevents over-treatment and under-treatment

• assures the patient’s wishes are known in the event of loss of
capacity to make decisions
• prepares the groundwork for future decision-making

Advance care planning components:

Health Care Proxy
• the only officially recognized Advance Directive in Massachusetts
• denotes health decisions in the event of incapacity
• communicates patients’ life-sustaining treatment preferences
• medical orders if appropriate
• Out-of-hospital DNR
• MOLST
Communicating with Patients About Palliative Care

Talking to patients about palliative care can be difficult, especially

when patients do not understand what palliative or hospice care
entail or know the differences between the two.

Determine if the patient has made advance care plans. If not:

• elicit and prioritize goals of care
• translate goals into a plan for care

Patients and families of patients considering hospice care need

additional support, as they are dealing with many challenging
decisions. Both palliative care and hospice care provide aggressive
care aimed at optimizing symptom management.
Communicating with Patients About Palliative Care

When planning the conversation, make sure to:

• determine what the patient and family understand about their
illness or disease trajectory
• realize how well the patient and family are able to understand
• allow enough time for a thorough discussion
• be aware of who else will be present at the meeting
• remember most patients and families want honest, objective
information
• encourage patients to designate a health care proxy
• a health care proxy form and instructions can be found at
www.massmed.org/proxy
Maintain An Inclusive Environment

• different cultures and religions deal with death and illness in

different ways
• consider incorporating a chaplain or other religious figure into the
care team
• be aware that some cultures take a community-based approach to
decision making (family-inclusive decision making)
• consider hiring a translator who is familiar with medical
terminology if language is a barrier
• avoid using a family member as a translator; they might be
unfamiliar with medical terms, may translate incorrectly, or may
leave out information to ‘protect’ the patient
• always offer silent listening and empathetic responses to emotions
Resources for Physicians

• Communicating Difficult News: A presentation from the

Massachusetts Medical Society’s conference on palliative care;
how to provide information and comfort to patients and families
• Making Health Care Decisions for Others: A presentation from the
Albert Einstein College of Medicine that advises physicians on
how to work with health care proxies and surrogates (pdf)
• CAPC Fast Facts and Tools for Providers:
• VITAL Talk: Nonprofit agency providing interactive clinician and
faculty development courses to improve communication skills on
an individual and institutional level
• Dying In America: The latest report on end of life information from
the Institute of Medicine
Resources for Patients

• The Conversation Project: This website includes a starter kit for

beginning a conversation on values with loved ones
• IOM Report – The Conversation: This website includes a myriad of
resources and decision tools for patients and their families
• Medline Plus: This page answers common questions about
palliative care for patients and families that need more clarification
• End of Life: A resource from the National Institute on Aging to
guide caregivers through the end of life process
• Get Palliative Care: This website is a resource on palliative care,
with more information on the process and a directory of palliative
care centers by state
• Hospice and Palliative Care Federation of MA: This website
provides more details on palliative and hospice care, as well as a
directory of hospice care centers
Resources for Patients

• Planning Ahead: What Are Your Choices: – this downloadable

brochure describes end of life planning steps across the lifespan