___________________________________________ Palliative Care and Pain Management at the End of Life
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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MDCA1525
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