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California Continuing Medical Education
CALIFORNIA MEDICAL LICENSURE PROGRAM
MANDATORY TRAINING REQUIRED FOR CALIFORNIA LICENSE RENEWAL
• 15 CREDITS (Meets the 12-Hour Requirement for Pain Management and Treatment of the Terminally Ill)
Need to complete the DEA’s new one-time MATE requirement? See inside for more details.
InforMed is Accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
CME FOR:
AMA PRA CATEGORY 1 CREDITS ™ MIPS MOC STATE LICENSURE
COMPLETE ENCLOSED PROGRAM TO SATISFY ANY OR ALL OF THESE REQUIREMENTS
AVAILABLE ONLINE AT: CA.CME.EDU
CALIFORNIA PHYSICIAN
MANDATORY CME REQUIREMENT FOR NEW CALIFORNIA PHYSICIAN S Complete one-time requirement within the minimum established time period.
Dear Colleagues,
This is a courtesy reminder that new licensees must meet the one-time California requirement for 12 credit hours of pain management and the treatment of terminally ill patients. Effective January 1, 2019, the course must also include information on the risks of addiction associated with Schedule II controlled substances. The InforMed California Medical Licensure Program is designed to help you fulfill your mandatory CME requirement. Successful completion of the program satisfies California’s 12 credit hour pain management requirement, including the risks of addiction associated with Schedule II controlled substances. In addition, all hours count towards the 50 credit hours of approved CME required during each biennial renewal cycle.
Thank you for choosing InforMed as your CME provider. We strive to create a high-quality, streamlined, and efficient program for our colleagues. Please contact us with any questions, concerns, or suggestions.
Best Regards,
The lnforMed CME Team
Required CME on Pain Management and the Appropriate Treatment of the Terminally Ill The board mandates 12 credit hours be earned in pain management/terminally ill patients, including the risks of addiction associated with Schedule II controlled substances, for physicians before their second renewal of the medical license, or four years from the date of their initial license, whichever occurs first. This is a one-time requirement for all physicians (excluding pathologists and radiologists). These hours count toward the total hours required during the biennium. What does that mean for you? You must earn the mandatory 12 credit hours in pain management and the appropriate treatment of terminally ill and dying patients before your second renewal, or four years from the date of your initial license, whichever occurs first.
Medical Board of California | 2005 Evergreen Street, Suite 1200 Sacramento, CA 95815 | 1-800-633-2322
We are a nationally accredited CME provider. For all board-related inquiries please contact:
1-800-237-6999
BOOK CODE: MDCA1525
BOOK.CME.EDU
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What’s Inside
01
PALLIATIVE CARE AND PAIN MANAGEMENT AT THE END OF LIFE COURSE ONE | 15 CREDITS SATISFIES THE REQUIREMENT FOR TWELVE (12) CREDIT HOURS IN PAIN MANAGEMENT AND THE TREATMENT OF TERMINALLY ILL AND DYING PATIENTS This course is designed to bridge the gap in knowledge of palliative care by providing an overview of the concept of palliative care and a discussion of the benefits and barriers to optimum palliative care at the end of life. Central to this discussion is an emphasis on the importance of talking to patients about the value of palliative care, of clearly presenting the prognosis and appropriate treatment options and goals, and of ensuring that advance planning is completed. The majority of the course focuses on the assessment and management of the most common end-of-life symptoms, with particular attention to pain, the most prevalent, as well as the most distressing, physical symptom. Psychosocial and spiritual needs of the patient and family are also discussed. Palliative care presents unique challenges for some patient populations, most notably older patients, children/adolescents, and patients receiving critical care. An overview of the most important issues specific to these settings is provided.
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LEARNER RECORDS: ANSWER SHEET & EVALUATION REQUIRED TO RECEIVE CREDIT
Need to complete the DEA’s new requirement under the Medication Access and Training Expansion (MATE) Act?
InforMed has the solution. Scan the QR code or go to https://uqr.to/deamate to get started. Effective June 27, 2023 , renewing DEA-registered practitioners must complete 8 hours of one-time training on the treatment and management of patients with opioid or substance use disorders. Get the training you need in a self-paced, convenient format with a course specifically designed for physicians to meet the Drug Enforcement Administration (DEA)’s new requirement under the Medication Access and Training Expansion (MATE) Act.
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MOC/MIPS CREDIT INFORMATION
Participants can earn MOC points equivalent to the amount of CME credits claimed for designated activities. InforMed currently reports to the following specialty boards: ABA, ABIM, ABS, ABPath and ABP. To be awarded MOC points, you must obtain a passing score, complete the corresponding activity evaluation, and provide required information necessary for reporting.
Table 1. MOC Recognition Statements Successful completion of certain enclosed CME activities, which includes participation in the evaluation component, enables the participant to earn up to the amounts and credit types shown in Table 2 below. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.
Board Programs
American Board of Anesthesiology’s redesigned Maintenance of Certification in Anesthesiology TM (MOCA®) program, known as MOCA 2.0®
ABA
ABIM
American Board of Internal Medicine’s Maintenance of Certification (MOC) program
ABS
American Board of Surgery’s Continuous Certification program
ABPath
American Board of Pathology’s Continuing Certification program
Table 2. Credits and Type Awarded
AMA PRA Category 1 Credits T M
Activity Title
ABA
ABIM
ABS
ABPath
15 AMA PRA Category 1 Credits TM
15 Credits LL
15 Credits MK
15 Credits SA
15 Credits LL
Palliative Care and Pain Management at the End of Life
Legend: LL = Lifelong Learning, MK = Medical Knowledge, SA = Self-Assessment, LL+SA = Lifelong Learning & Self-Assessment, PS = Patient Safety
DATA REPORTING: Federal, State, and Regulatory Agencies require disclosure of data reporting to all course participants. InforMed abides by each entity’s requirements for data reporting to attest compliance on your behalf. Reported data is governed by each entity’s confidentiality policy. To report compliance on your behalf, it’s mandatory that you must achieve a passing score and accurately fill out the learner information, activity and program evaluation, and the 90-day follow-up survey. Failure to accurately provide this information may result in your data being non-reportable and subject to actions by these entities.
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How to complete
Please read these instructions before proceeding. Read and study the enclosed courses and answer the final examination questions. To receive credit for your courses, you must provide your customer information and complete the mandatory evaluation. We offer two ways for you to complete. Choose an option below to receive credit and your certificate of completion.
ONLINE
FASTEST AND EASIEST!
• Go to BOOK.CME.EDU and enter code MDCA1525 in the book code box, then click GO. • Proceed to your exam. If you already have an account, sign in with your username and password. If you do not have an account, you’ll be able to create one now. • Follow the online instructions to complete your final examination. Complete the purchase process to receive course credit and your certificate of completion. Please remember to complete the online evaluation.
Enter book code
MDCA1525
GO
IF YOU’RE ONLY COMPLETING CERTAIN COURSES IN THIS BOOK: • Go to BOOK.CME.EDU and enter the code that corresponds to the course below, then click GO. Each course will need to be completed individually, and the specified course price will apply.
Complete the answer sheet and evaluation found in the back of this book. Include your payment information and email address. Mail to: InforMed, PO Box 997432, Sacramento, CA 95899
BY MAIL
Mailed completions will be processed within 2 business days of receipt, and certificates emailed to the address provided. Submissions without a valid email address will be mailed to the postal address provided.
Program Options
Price
Option
Code
Credits
$135
Palliative Care and Pain Management at the End of Life
MDCA1525 15 Credit Hours
Note: Prices are subject to change
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___________________________________________ Palliative Care and Pain Management at the End of Life MDCA1525 — 15 CREDIT HOURS R elease D ate : 11/01/24 E xpiration D ate : 10/31/27
Palliative Care and Pain Management at the End of Life In addition to receiving AMA PRA Category 1 Credit TM , physicians participating in Maintenance of Certification will receive the following points appropriate to their certifying board: 15 ABIM MOC Points, 15 ABS MOC Points, 15 ABA MOCA Points, 15 ABPath CC Points.
8. Assess pain accurately through use of clinical tools and other strategies. 9. Select appropriate pharmacologic and/or non- pharmacologic therapies to manage pain in patients during the end-of-life period. 10. Assess and manage the most common symptoms (other than pain) experienced by patients during the end-of-life period. 11. Evaluate the psychosocial needs of patients at the end of life and their families and provide appropri- ate treatment or referral. 12. Recognize and address the spiritual needs of patients at the end of life and provide appropriate treatment or referral. 13. Develop a strategy for providing care to patients and their families over the last days and hours of life. 14. Support appropriate grief and mourning. 15. Explain the specific challenges and ethical consid- erations in delivering optimum palliative care to older patients, children, and patients in critical care settings. Faculty John M. Leonard, MD , Professor of Medicine Emeritus, Vanderbilt University School of Medicine, completed his post- graduate clinical training at the Yale and Vanderbilt University Medical Centers before joining the Vanderbilt faculty in 1974. He is a clinician-educator and for many years served as director of residency training and student educational programs for the Vanderbilt University Department of Medicine. Over a career span of 40 years, Dr. Leonard conducted an active practice of general internal medicine and an inpatient consulting practice of infectious diseases. Faculty Disclosure Contributing faculty, John M. Leonard, MD, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
HOW TO RECEIVE CREDIT
• Read the enclosed course. • Complete the final examination questions at the end. A score of 70% is required. • Return your customer information/answer sheet, evaluation, and payment to InforMed by mail or complete online at BOOK.CME.EDU.
Audience This course is designed for all members of the interprofessional team, including physicians, physician assistants, nurse practitio- ners, nurses, pharmacists, pharmacy technicians, social workers, marriage and family therapists, and other members seeking to enhance their knowledge of palliative care. Course Objective The purpose of this course is to provide an overview of the concept of palliative care as distinct from hospice care, including a discussion of challenges, benefits, and strategies for optimal palliative care and symptom management at the end of life. Learning Objectives Upon completion of this course, you should be able to: 1. Describe how the definition of palliative care has evolved. 2. Define the structure of palliative care delivery, including models of care and the interdisciplinary healthcare team. 3. List the benefits of palliative care at the end of life. 4. Anticipate the barriers to optimum delivery of pal- liative care through hospice. 5. Effectively engage the components of communica- tion and decision making for end-of-life care. 6. Identify the common concerns and symptoms at the end of life for patients with life-limiting dis- eases. 7. Discuss the barriers to effective relief of pain at the end of life.
Mention of commercial products does not indicate endorsement.
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Division Planners John V. Jurica, MD, MPHMary Franks, MSN, APRN, FNP-C Senior Director of Development and Academic Affairs Sarah Campbell Division Planners/Director Disclosure The division planners and director have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned. Accreditations & Approvals In support of improving patient care, NetCE is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. Designations of Credit NetCE designates this enduring material for a maximum of 15 AMA PRA Category 1 Credit(s) ™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Successful completion of this CME activity, which includes participation in the evaluation component, enables the par- ticipant to earn up to 15 MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equiva- lent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit partici- pant completion information to ACCME for the purpose of granting ABIM MOC credit. Completion of this course consti- tutes permission to share the completion data with ACCME. Successful completion of this CME activity, which includes participation in the evaluation component, enables the learner to earn credit toward the CME and Self-Assessment require- ments of the American Board of Surgery’s Continuous Certifi- cation program. It is the CME activity provider’s responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.
This activity has been approved for the American Board of Anesthesiology’s ® (ABA) requirements for Part II: Lifelong Learning and Self-Assessment of the American Board of Anes- thesiology’s (ABA) redesigned Maintenance of Certification in Anesthesiology Program ® (MOCA ® ), known as MOCA 2.0 ® . Please consult the ABA website, www.theABA.org, for a list of all MOCA 2.0 requirements. Maintenance of Certification in Anesthesiology Program ® and MOCA ® are registered cer- tification marks of the American Board of Anesthesiology ® . MOCA 2.0 ® is a trademark of the American Board of Anes- thesiology ® . This activity has been designated for 15 Lifelong Learning (Part II) credits for the American Board of Pathology Continu- ing Certification Program. Through an agreement between the Accreditation Council for Continuing Medical Education and the Royal College of Physicians and Surgeons of Canada, medical practitioners participating in the Royal College MOC Program may record completion of accredited activities registered under the ACC- ME’s “CME in Support of MOC” program in Section 3 of the Royal College’s MOC Program. Special Approvals This activity is designed to comply with the requirements of California Assembly Bill 1195, Cultural and Linguistic Compe- tency, and California Assembly Bill 241, Implicit Bias. About the Sponsor The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare. Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice. Disclosure Statement It is the policy of NetCE not to accept commercial support. Fur- thermore, commercial interests are prohibited from distributing or providing access to this activity to learners.
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This course is designed to bridge the gap in knowledge of palliative care by providing an overview of the concept of palliative care and associated clinical issues and a discussion of the benefits and barriers to optimum palliative care at the end of life. Central to this discussion is an emphasis on the importance of talking to patients about the value of palliative care, of clearly presenting the prognosis and appropriate treat- ment options and goals, and of ensuring that advance planning is completed. Much of the course focuses on the assessment and management of the most common end-of-life needs, with particular attention to pain, the most prevalent, as well as the most distressing, physical symptom. Psychosocial and spiritual needs of the patient and family are also discussed. Palliative care presents unique challenges for some patient populations, most notably older patients, children/adolescents, and patients receiving critical care. An overview of the most important issues specific to these settings is provided.
INTRODUCTION The concept of palliative care has garnered much attention since the term was first used in the late 1960s to refer to a holistic approach to patient-centered care, with a focus on enhancing the quality of life for patients living with serious illness and their families. As currently practiced, palliative care is interdisciplinary team care designed to engage the expertise of providers from different clinical disciplines. The purpose of palliative care is to alleviate suffering and provide comfort; to this end, the primary goals are relief of pain and other distressing symptoms, effective communication with the patient and family in order to establish patient-centered goals of care, attentiveness to psychological and spiritual needs, and support for family members. With its roots in hospice care, the term “palliative care” has long been used interchangeably with “end-of-life care.” However, in contrast to hospice, the initiation of palliative care is not contingent upon the expecta- tion that the patient has less than six months to live or that disease-directed therapy has run its course. Across all special- ties, the emphasis now is on the integration of palliative care into the ongoing management strategy for any patient with a serious, life-threatening illness, regardless of age. Hospice care is palliative care provided in the last weeks and months of life, when disease-directed or curative treatment has been exhausted or deemed no longer to be of benefit [1]. Palliative care at the end of life is delivered most effectively through hospice. Palliative care/hospice was once primarily confined to the cancer setting because of the evident and often rapid health decline to death with this disease. Hospice extended to the acquired immunodeficiency syndrome (AIDS) setting for the same reason. Ongoing advances in medicine have changed these once-lethal diseases into chronic condi- tions, shifting the trajectory of illness and leaving a growing number of patients in need of palliative care for longer periods of time. Similarly, individuals with other life-limiting diseases, such as heart failure, chronic obstructive pulmonary disease (COPD), end-stage renal disease, and dementia, are in need of similar care. Thus, a growing number of individuals could benefit from palliative care. However, palliative/hospice care is underutilized in the United States for a variety of reasons, and many patients experience an unnecessary degree of physical and psychological suffering at the end of life [1; 2]. Both clinician- and patient-related factors contribute to the underuse of palliative/hospice care. In addition, evidence- based guidelines are lacking for end-of-life care for many noncancer life-threatening conditions. More research on the prevalence and severity of symptoms and functional status in patients with life-limiting diseases, as well as the efficacy of interventions is needed to generate these much-needed guidelines.
CONCEPT OF PALLIATIVE CARE
EVOLVING DEFINITION OF PALLIATIVE CARE The term “palliative care” was first used by Balfour Mount, a Canada-trained physician and visiting professor at St. Chris- topher’s Hospice, the first program of its kind. Dr. Mount subsequently established a palliative care program at Royal Victoria Hospital in Montreal, the first such program to be integrated in an academic teaching hospital [3]. Since that time, many attempts have been made to craft a definition of palliative care that represents its unique focus and goals. The challenge in defining palliative care has been encompassing all that such care refers to while specifying the timing of it ( Table 1 ) [4; 5; 6; 7; 8]. The timing of palliative care remains an important point of discussion. As a result of its roots in hospice care, the term “palliative care” has often been considered to be synonymous with “end-of-life care.” However, the current emphasis is to integrate palliative care earlier in the overall continuum of care ( Figure 1 ) [6; 9]. As the definition of palliative care has evolved, end-of-life care has become one aspect of palliative care. The time period assigned to “end of life” has not been defined, with the phrase being used to describe an individual’s last months, weeks, days, or hours [10; 11]. Designating a specific time period as the “end of life” is further challenged by disease trajectories that differ depending on the underlying life-limiting disease, a problem discussed in detail later in this course. EFFORTS TO ENHANCE PALLIATIVE CARE AT THE END OF LIFE Since the establishment of the first hospice in the United States in 1974, many initiatives have been undertaken to enhance the quality of care given at the end of life. The lack of progress in relieving end-of-life suffering was highlighted with the publica- tion of findings from the Study to Understand Prognoses and
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EVOLVING DEFINITION OF PALLIATIVE CARE
Year
Source and Definition
Comments
1990 World Health Organization (WHO): “…The active total care of patients whose disease is not responsive to curative treatment.”
Does not apply exclusively to palliative care
1993
The Oxford Textbook of Palliative Medicine : “The study and management of patients with active, progressive, far-advanced disease for whom the prognosis is limited and the focus of care is the quality of life.”
Lacks essential aspects, such as support provided to families, as well as specificity about timing First definition to reflect integration of palliative care earlier into the disease continuum
2004 National Consensus Project: “The goal of palliative care is to prevent and relieve suffering and to support the best possible quality of life for patients and their families, regardless of the stage of the disease or the need for other therapies…” Palliative care expands traditional disease-model medical treatments to include the goals of enhancing quality of life for patient and family, optimizing function, helping with decision making, and providing
opportunities for personal growth. As such, it can be delivered concurrently with life-prolonging care or as the main focus of care.
2007 WHO (revision): “An approach that improves the quality of life of patients and their families facing the problem associated with life- threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual.” 2009 American Society of Clinical Oncology: “Palliative cancer care is the integration into cancer care of therapies to address the multiple issues that cause suffering for patients and their families and have an impact on the quality of their lives. Palliative cancer care aims to give patients and their families the capacity to realize their full potential, when their cancer is curable as well as when the end of life is near.” 2013 National Consensus Project: “Palliative care means patient and family- centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information, and choice.”
Improvement over original WHO definition, but expansion of palliative care throughout the continuum of care not explicit Defines palliative care for patients with cancer, but definition can be applied to palliative care in all settings
Characterization of palliative care in the United States, as defined by the U.S. Department of Health and Human Services and the National Quality Forum
Source: [4; 5; 6; 7; 8]
Table 1
Preferences for Outcomes and Risks of Treatment (SUPPORT) [12; 13]. The results of this landmark study indicated that in-hospital deaths were characterized by prolonged suffering, uncontrolled pain, and caregiver hardship. In response, the Institute of Medicine (IOM) commissioned a report on the quality of care at the end of life, and the authors of this report, Approaching Death: Improving Care at the End of Life , noted that too many patients “suffer needlessly” at the end of life and emphasized the need for better training of healthcare profes- sionals and reform of outdated laws that inhibited the use of pain-relieving drugs [2]. A subsequent IOM report pointed out the need for enhanced pediatric palliative care [14]. Several initiatives have been developed to address the deficiencies in the quality of palliative care; to optimize the use of hospice; to help the lay public better understand the meaning of palliative care and hospice and their benefits; and to enhance the knowl- edge, skills, and attitudes of healthcare professionals. Five orga- nizations—the American Academy of Hospice and Palliative Medicine (AAHPM), the Center to Advance Palliative Care
(CAPC), the Hospice and Palliative Nurses Association, the Last Acts Partnership, and the National Hospice and Palliative Care Organization (NHPCO)—joined forces in the National Consensus Project for Quality Palliative Care Consortium and published clinical practice guidelines to help reduce the variation in palliative care programs and enhance continuity of care across healthcare settings [6]. The National Quality Forum (NQF) built on these guidelines when it proposed a national framework for palliative and hospice care [15]. Other efforts included the first core curriculum in hospice and palliative care, created by the AAHPM; the development of the Education in Palliative and End-of-Life Care (EPEC) Project (https://www.bioethics.northwestern.edu/programs/ epec); and the subsequent development of the EPEC-Oncology (EPEC-O) curriculum and the End-of-Life Nursing Education Consortium Project (https://www.aacnnursing.org/ELNEC).
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EVOLUTION OF THE PALLIATIVE CARE MODEL
Medicare Hospice Benefit
Diagnosis of Life-limiting Disease Diagnosis of Life-Limiting Disease
Life-prolonging (curative) Treatment Life-prolonging (curative) treatment
Death
Hospice care
Time
Medicare Hospice Benefit
Life-prolonging (curative) treatment Life-prolonging (curative) treatment
Treatment Diagnosis of Life-Limiting Disease
Death
Symptom management (palliative care)
Time
Family Bereavement
Source: [9]
Figure 1
COMPONENTS OF HIGH-QUALITY PALLIATIVE CARE Because palliative care focuses on the physical and psychoso- cial needs of the patient and his or her family, the patient’s and family’s perspectives are vital considerations in develop- ing high-quality palliative care programs. An early survey of patients with life-limiting diseases identified five priorities for palliative care: receiving adequate treatment for pain and other symptoms, avoiding inappropriate prolongation of life, obtaining a sense of control, relieving burden, and strength- ening relationships with loved ones [16]. In another study, a spectrum of individuals involved with end-of-life care (physi- cians, nurses, social workers, chaplains, hospice volunteers, patients, and recently bereaved family members) echoed these findings, with the following factors being noted as integral to a “good death:” pain and symptom management, clear decision making, preparation for death, completion, contributing to others, and affirmation of the whole person [17]. The priorities set by patients and healthcare professionals were considered carefully in the structuring of clinical practice guidelines for high-quality palliative care developed by the National Consensus Project (NCP) for Quality Palliative Care. These guidelines are organized according to eight domains [6]:
• Structure and processes of care • Physical aspects • Psychological and psychiatric aspects • Social aspects • Spiritual, religious, and existential aspects • Cultural aspects • Care of the patient nearing the end of life • Ethical and legal aspects In its publication, the NQF sets forth 39 guidelines based on these eight domains ( Table 2 ) [6]. Models of Care Palliative care service is rendered through several different mod- els, including hospital-based inpatient programs, outpatient clinics (based in hospitals or private practices), and combined consultation services and inpatient programs. Hospice pro- grams may provide a consultative service but generally assume direct responsibility for end-of-life palliative care rendered at home, hospital, or other hospice resident facility [15]. The Joint Commission began offering an advanced certification program for palliative care in September 2011 [18]. In an effort to enhance access to end-of-life care, models of care are being adapted for a variety of specific settings, such as rural communi- ties, correctional facilities, long-term care facilities, children’s hospitals, and intensive care units [19; 20; 21; 22; 23; 24].
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GUIDELINES FOR PALLIATIVE AND HOSPICE CARE 1. Since palliative care is holistic in nature, it is provided by a team of physicians, advanced practice registered nurses, physician assistants, nurses, social workers, chaplains, and others based on need. 2. An interdisciplinary comprehensive assessment of the patient and family forms the basis for the development of an individualized patient and family palliative care plan. 3. In collaboration with the patient and family, the interdisciplinary team (IDT) develops, implements, and updates the care plan to anticipate, prevent, and treat physical, psychological, social, and spiritual needs. 4. The IDT has defined processes to ensure access, quality, and continuity of care, especially during transitions of care. 5. Palliative care is provided in any care setting, including private residences, assisted living facilities, rehabilitation, skilled and intermediate care facilities, acute and long-term care
hospitals, clinics, hospice residences, correctional facilities, and homeless shelters. 6. Education, training, and professional development are available to the IDT.
7. Care is coordinated and characterized as the right care at the right time throughout the course of an individual’s disease(s) or condition. The IDT recognizes that transitions of care occur within care settings, between care settings, and between care providers. Care transitions are anticipated, planned, and coordinated to ensure patient goals are achieved. 8. Providing palliative care to patients with a serious illness and their families has an emotional impact, therefore the IDT creates an environment of resilience, self-care, and mutual support. 9. In its commitment to continuous quality improvement (CQI), the IDT develops, implements, and maintains a data-driven process focused on patient- and family-centered outcomes using established quality improvement methodologies. 10. Recognizing limitations in reimbursement for interdisciplinary palliative care, the IDT endeavors to secure funding for long-term sustainability and growth. 11. The palliative care IDT endeavors to relieve suffering and improve quality of life, as defined by the patient and family, through the safe and timely reduction of the physical symptoms and functional impairment associated with serious illness. 12. The IDT assesses physical symptoms and their impact on well-being, quality of life, and functional status. 13. Interdisciplinary care plans to address physical symptoms, maximize functional status, and enhance quality of life are developed in the context of the patient’s goals of care, disease, prognosis, functional limitations, culture, and care setting. An essential component of palliative care is ongoing management of physical symptoms, anticipating changes
in health status, and monitoring of potential risk factors associated with the disease and side effects due to treatment regimens. 14. The palliative care team provides written and verbal recommendations for monitoring and managing physical symptoms.
15. The IDT includes a social worker with the knowledge and skills to assess and support mental health issues, provide emotional support, and address emotional distress and quality of life for patients and families experiencing the expected responses to serious illness. The IDT has the training to assess and support those with mental health disorders, either directly, in consultation, or through referral to specialist level psychological and/or psychiatric care. 16. The IDT screens for, assesses, and documents psychological and psychiatric aspects of care based upon the best available evidence to maximize patient and family coping and quality of life. 17. The IDT manages and/or supports psychological and psychiatric aspects of patient and family care including emotional, psychosocial, or existential distress related to the experience of serious illness, as well as identified mental health disorders. Psychological and psychiatric services are provided either directly, in consultation, or through referral to other providers. 18. The IDT provides recommendations for monitoring and managing long-term and emerging psychological and psychiatric responses and mental health concerns. 19. The palliative care IDT has the skills and resources to identify and address, either directly or in collaboration with other service providers, the social factors that affect patient and family quality of life and well-being. 20. The IDT screens for and assesses patient and family social supports, social relationships, resources, and care environment based on the best available evidence to maximize coping and quality of life. 21. In partnership with the patient, family, and other providers, the IDT develops a care plan for social services and supports in alignment with the patient’s condition, goals, social environment, culture, and setting to maximize patient and family coping and quality of life across all care settings. 22. A palliative care plan addresses the ongoing social aspects of patient and family care, in alignment with their goals, and provides recommendations to all clinicians involved in ongoing care. 23. Patient and family spiritual beliefs and practices are assessed and respected. Palliative care professionals acknowledge their own spirituality as part of their professional role and are provided with education and support to address each patient’s and family’s spirituality. 24. The spiritual assessment process has three distinct components—spiritual screening, spiritual history, and a full spiritual assessment. The spiritual screening is conducted with every patient and family to identify spiritual needs and/or distress. The history and assessment identify the spiritual background, preferences, and related beliefs, values, rituals, and practices of the patient and family. Symptoms, such as spiritual distress and spiritual strengths and resources, are identified and documented. 25. The IDT addresses the spiritual needs of the patient and family. 26. Patient and family spiritual care needs can change as the goals of care change or patients move across settings of care. 27. The IDT delivers care that respects patient and family cultural beliefs, values, traditional practices, language, and communication preferences and builds upon the unique strengths of the patient and family. Members of the IDT work to increase awareness of their own biases and seek opportunities to learn about the provision of culturally sensitive care. The care team ensures that its environment, policies, procedures, and practices are culturally respectful. 28. The IDT ensures that patient and family preferred language and style of communication are supported and facilitated in all interactions. 29. The IDT uses evidence-based practices when screening and assessing patient and family cultural preferences regarding health care practices, customs, beliefs and values, level of health literacy, and preferred language. 30. A culturally sensitive plan of care is developed and discussed with the patient and/or family. This plan reflects the degree to which patients and families wish to be included as partners in decision-making regarding their care. When hosting meetings to discuss and develop the plan, the IDT ensures that patient and family linguistic needs are met. 31. The IDT includes professionals with training in end-of-life care, including assessment and management of symptoms, communicating with patients and families about signs and symptoms of approaching death, transitions of care, and grief and bereavement. The IDT has established structures and processes to ensure appropriate care for patients and families when the end of life is imminent. 32. The IDT assesses physical, psychological, social, and spiritual needs, as well as patient and family preferences for setting of care, treatment decisions, and wishes during and immediately following death. Discussions with the family focus on honoring patient wishes and attending to family fears and concerns about the end of life. The IDT prepares and supports family caregivers throughout the dying process, taking into account the spiritual and cultural background and preferences of the patient and family. 33. In collaboration with the patient and family and other clinicians, the IDT develops, implements, and updates (as needed) a care plan to anticipate, prevent, and treat physical, psychological, social, and spiritual symptoms. The care plan addresses the focus on end-of-life care and treatments to meet the physical, emotional, social, and spiritual needs of patients and families. All treatment is provided in a culturally and developmentally appropriate manner. 34. During the dying process, patient and family needs are respected and supported. Post-death care is delivered in a manner that honors patient and family cultural and spiritual beliefs, values, and practices. 35. Bereavement support is available to the family and care team, either directly or through referral. The IDT identifies or provides resources, including grief counseling, spiritual support, or peer support, specific to the assessed needs. Prepared in advance of the patient’s death, the bereavement care plan is activated after the death of the patient and addresses immediate and longer-term needs. 36. The core ethical principles of autonomy, substituted judgment, beneficence, justice, and nonmaleficence underpin the provision of palliative care. 37. The provision of palliative care occurs in accordance with federal, state, and local regulations and laws, as well as current accepted standards of care and professional practice. 38. The patient’s preferences and goals for medical care are elicited using core ethical principles and documented. 39. Within the limits of applicable state and federal laws, current accepted standards of medical care, and professional standards of practice, person-centered goals form the basis for the plan of care and decisions related to providing, forgoing, and discontinuing treatments.
Source: [6] Reprinted with permission from National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality Palliative Care. 4th ed. Richmond, VA: National; 2018. Table 2
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Healthcare Team The delivery of comprehensive palliative care relies on a team of skilled providers with experience and training in the principles of palliative care ( Figure 2 ). The team may be organized around a primary care clinician or a palliative care specialist who functions as consultant or principal provider [15; 25; 26; 27]. Palliative care interventions have been shown to significantly improve patient outcomes, although the data are stronger for patients with cancer than for life-limiting diseases overall [28; 29]. This is illustrated by results of a randomized controlled trial of early palliative care provided as an adjunct to standard oncologic care for patients with metastatic non-small cell lung cancer. In this study, involving 151 subjects enrolled from a single academic practice, patients in the intervention group were seen by a palliative care clinician regularly (once or more per month) for 12 weeks; in comparison to the group receiving only standard care, the intervention (palliative care) group had a measurably better quality of life, lower rate of depression, and improved survival by 2.7 months [30]. The composition of a hospice care team is essentially the same as for a standard palliative care team. The primary service provided during hospice care is skilled nursing care and man- agement of distressing symptoms, followed by bereavement services and medical social services ( Figure 3 ) [31]. Clinical specialists (e.g., oncologists, cardiologists, pulmonologists) also become members of a palliative care team when they are involved with the care of their patients during the end of life. Family physicians and general internists typically provide primary palliative care; this level of care requires skill in core palliative care competencies (such as basic symptom assess- ment and management and knowledge of psychosocial and community services) [6; 8]. The composition of the healthcare team and the roles of its members may differ across palliative care settings, and roles and responsibilities should be clear and well documented to help members work effectively as a team. Team members’ roles should also be communicated to the patient and the family. The primary care physician is usually responsible for refer- ral to palliative care through hospice when the patient has a non-cancer diagnosis. In general, the primary care physician becomes the attending physician, assuming primary respon- sibility for the patient [32; 33]. The primary care physician should be prepared to relinquish some autonomy in order to work effectively with the interdisciplinary team [32]. Home- based hospice care is organized around a team that includes the attending physician, registered nurse, social worker, and counselor. These team members are necessary for Medicare reimbursement [34]. The attending physician collaborates with other members of the hospice team to manage symptoms and fulfills other basic obligations, such as admission orders, medication prescriptions and refills, certification of hospice eligibility, and signing of the death certificate [33].
High-quality palliative care also requires special expertise in honest, compassionate communication. In addition to enhanc- ing the patient’s and family’s experience, these skills help to establish trust and overcome barriers to adequate care and relief of symptoms. Several communication tasks are especially important: conveying accurate prognostic information while maintaining hope, eliciting information about symptoms, decision making about curative and palliative treatments, han- dling emotions, and dealing with requests from patients and families who have unrealistic goals [35; 36; 37]. The challenges of communicating effectively are discussed later in this course.
USE OF PALLIATIVE CARE AND HOSPICE SERVICES
Despite the increasing use of hospice, palliative care and hospice are underutilized services. The NHPCO statistics show the share of Medicare decedents who used hospice increased from 44.0% in 2010 to 51.6% in 2018; decreased to 47.3% in 2021, because of the COVID-19 pandemic; then increased to 49.1% in 2022 [1]. Hospice use varies according to several demographic factors. Patients treated in hospice are primarily women, although the gap has been closing, with 54.3% of the hospice population being female [1]. Studies show that White individuals are more likely to use hospice than are individuals in minority populations [38; 39; 40; 41]. However, from 2018 to 2022, NHPCO data show that hospice utilization by Medicare decedents increased among all race/ ethnicity groups surveyed. In 2022, 51.6% of White, 38.3% of Hispanic, 38.1% of Asian American, 37.4% of Black, and 37.1% of North American Native Medicare decedents were enrolled in hospice [1]. The lower rates of hospice use in minority populations have been attributed to many factors, including beliefs about health care, death, and end-of-life care; lack of awareness of hospice services; mistrust of the healthcare system; cultural differences in healthcare decision making and in disclosure of illness to the patient; lack of insurance; lack of healthcare professionals’ cultural competency; lower referral rates by health care profes- sionals; and the hospice caregiver requirement [40; 42; 43; 44]. Most Common Diagnoses Cancer and human immunodeficiency virus (HIV)/AIDS were once the predominant diseases in hospice and palliative care programs, but as treatments for these diseases have improved, the number of individuals with the diseases in hospice pro- grams has decreased while the number of individuals with chronic, progressive diseases has increased. In 2021, Alzheimer dementia/nervous system disorders/organic psychosis (25%), cancer (23%), and cardiac/circulatory system diseases (22%) were the three most common diagnoses (by ICD-10 code) in the hospice population, accounting for nearly three-quarters of all hospice beneficiary diagnoses ( Figure 4 ) [1].
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MEMBERS OF THE PALLIATIVE CARE TEAM
Primary care physician Physician specialists Pain management experts
Nurses Respiratory therapists Pharmacists Physical therapists Occupational therapists Nutritionists Social workers
Psychiatrists Psychologists Bereavement counselors Spiritual counselors
Patient (and family)
Home health aides Trained volunteers Neighbors and friends Family
Source: [15; 25; 26; 27]
Figure 2
SERVICES PROVIDED DURING HOSPICE CARE
97.8
100
Noncore services
Core services
83.6 82.1
79.9
79.5
80
60
53.5
40
31.3
21.5
17.7
20
9.8
9.3
4.2
0
Skilled nursing
Bereave- Medical Pastoral Physician Dietary Volunteer
Personal
Home- maker
Contin-
Respite
Thera- peutic
ment
social
or
care
uous home care
spiritual
Source: [31] Reprinted from Caffrey C, Sengupta M, Moss A, Harris-Kojetin L, Valverde R. Home health care and discharged hospice care patients: United States, 2000 and 2007. Natl Health Stat Report. 2011;(38):1-27. Figure 3
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DISTRIBUTION OF DIAGNOSES IN HOSPICE CARE, 2021
Cancer (29.6%) Circulatory/heart disease (17.4%) Dementia (15.6%) Respiratory disease (11.0%) Other (14.7%)
Source: [1]
Figure 4
BENEFITS OF PALLIATIVE CARE AT THE END OF LIFE Most of the studies designed to determine the benefits of pal- liative care/hospice at the end of life have centered on patients with cancer. However, an increasing number of researchers are focusing on palliative care interventions for patients with other life-limiting diseases. The field of palliative care/hospice research has grown considerably in the past decade, but reli- able meta-analyses of palliative care studies have been limited because of variations in methodology and in the focus and extent of services [45]. Increasingly, studies are confirming the benefits of palliative care/hospice in terms of quality of life, satisfaction with care, and end-of-life outcomes, as well as cost-effectiveness. A systematic review indicated weak evidence of benefit for pal- liative care/hospice. The results did demonstrate significant benefit of specialized palliative care interventions in four of 13 studies in which quality of life was assessed and in one of 14 studies in which symptom management was assessed [29]. However, the authors of the review noted that most of the stud- ies lacked the statistical power to provide conclusive results, and the quality-of-life measures evaluated were not specific for patients at the end of life [29]. Other research has shown that palliative care intervention was associated with significantly better quality of life and greater patient and/or family caregiver satisfaction [45; 46; 47]. Data to support benefit in reducing patients’ physical and psychological symptoms have been lack- ing [45]. Such symptoms were significantly improved when patients received care delivered by palliative care specialists [28].
Surveys of patients’ family members also demonstrate the value of palliative care. The Family Assessment of Treatment at the End of Life (FATE) survey was developed to evaluate family members’ perceptions of their loved one’s end-of-life care in the Veterans Administration (VA) healthcare system. FATE consists of nine domains: well-being and dignity, information and communication, respect for treatment preferences, emo- tional and spiritual support, management of symptoms, choice of inpatient facility, care around the time of death, access to VA services, and access to VA benefits after the patient’s death. Using the assessment tool, researchers found that palliative care and hospice services were associated with significantly higher overall scores compared with usual care [48]. In addition to the benefits realized by patients, palliative care is beneficial for patients’ family members as well. According to a survey of bereaved family members, a significantly higher proportion of respondents had their emotional or spiritual needs met when the patient received palliative care (compared with “usual care”) [49]. Palliative care was also seen to improve family member coping skills and the ability to manage the inevitable tasks associated with terminal illness; that is, more family members knew what to expect when the patient was dying, felt competent to participate in the care of the dying person, and felt confident in knowing what to do when the patient died [49]. Other studies have shown benefit for care- givers through positive effects on caregiver burden, anxiety, satisfaction, and the ability to “move on” more easily after the patient’s death [46; 50].
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