Advance planning helps physicians provide care that patients want Most people will eventually die from chronic conditions. These patients require the same kind of advance care planning as those suffering from predictably terminal conditions such as cancer. Understanding preferences for medical treatment in patients suffering from chronic illness requires that physicians and other health care providers consider patients’ concerns about the severity of prospective health states, length and invasiveness of treatments, and prognosis. While predicting what Table 2. Components of individualized EOL care 2 Component Rationale
patients might want is difficult, research offers some insights into treatment patterns and preferences under hypothetical situations that can give providers more insight into their patients’ desires under similar circumstances. By discussing advance care planning during routine outpatient visits, during hospitalization for exacerbation of illness, or when the patient or physician believes death is near, physicians can improve patient satisfaction with care and provide care at the end of life that is in accordance with the patient’s wishes. Suggested components of an individualized approach to EOL care are summarized in Table 2.
Frequent assessment of the patient’s physical, emotional, social, and spiritual well- being Management of emotional distress Offer referral to expert-level palliative care Offer referral to hospice if the patient has a prognosis < 6 months. Management of care and direct contact with patient and family for complex situations by a specialist level palliative care physician Round-the-clock access to coordinated care and services
Interventions and care should be based on accurately identified needs.
All clinicians should be able to identify distress and direct its initial and basic management. This is part of the definition of palliative care, a basic component of hospice, and clearly of fundamental importance. People with palliative needs beyond those that can be provided by non- specialist-level clinicians deserve access to appropriate expert-level care. People who meet the hospice eligibility criteria deserve access to services designed to meet their end-of-life needs.
Care of people with serious illness may require specialist-level palliative care physician management, and effective physician management requires direct examination, contact, and communication.
Patients in advanced stages of serious illness often require assistance, such as with activities of daily living, medication management, wound care, physical comfort, and psychosocial needs. Round-the-clock access to a consistent point of contact that can coordinate care obviates the need to dial 911 and engage emergency medical services. All clinicians should be able to identify and direct the initial and basic management of pain and other symptoms. This is part of the definition of palliative care, a basic component of hospice, and clearly of fundamental importance. Even patients who are not emotionally distressed face problems in such areas as loss of functioning, prognosis, coping with diverse symptoms, finances, and family dynamics, and family members experience these problems as well, both directly and indirectly. A focus on the family is part of the definition of palliative care; family members and caregivers both participate in the patient’s care and require assistance themselves. Person-centered care requires awareness of patients’ perspectives on their social environment and of their needs for social support, including at the time of death. Companionship at the bedside at time of death may be an important part of the psychological, social, and spiritual aspects of end-of-life care for some individuals.
Management of pain and other symptoms
Counseling of patient and family
Family caregiver support
Attention to the patient’s social context and social needs
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Book Code: CA23CME
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