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