Palliative Care and Pain Management at the End of Life ___________________________________________
CRITERIA FOR PALLIATIVE CARE ASSESSMENT AT THE TIME OF HOSPITAL ADMISSION AND DURING HOSPITAL STAY At Time of Hospital Admission Primary criteria a A potentially life-limiting or life-threatening condition AND Not surprised if the patient were to die within 12 months More than one admission for same condition within several months Admission for difficult physical or psychologic symptoms Complex care requirements (e.g., functional dependency, complex home support for ventilator/ antibiotics/feedings) Decline in function, feeding intolerance, or unintended decline in weight (e.g., failure to thrive)
Secondary criteria b
A potentially life-limiting or life-threatening condition AND Admission from long-term care facility Older age, with cognitive impairment and acute hip fracture Metastatic or locally advanced incurable cancer Chronic use of home oxygen Out-of-hospital cardiac arrest Current or past use of hospice program Limited social support No history of advance care planning discussion/document A potentially life-limiting or life-threatening condition AND Not surprised if the patient were to die within 12 months More than one admission for same condition within several months Stay in intensive care unit of seven days or more Lack of documentation of goals of care
During Hospital Stay Primary criteria a
Disagreements or uncertainty among the patient, staff, and/or family about major medical treatment decisions, resuscitation preferences, or use of nonoral feeding or hydration
Secondary criteria b
A potentially life-limiting or life-threatening condition AND Awaiting, or deemed ineligible for, solid-organ transplantation Patient/family/surrogate emotional, spiritual, or relational distress Patient/family/surrogate request for palliative care/hospice services
Patient is a potential candidate for feeding tube placement, tracheostomy, initiation of renal replacement therapy, placement of left ventricular assist device or automated implantable cardioverter-defibrillator, bone marrow transplantation (high-risk patients)
a Primary criteria are the minimum indicators for screening patients at risk for unmet palliative care needs. b Secondary criteria are more specific indicators of a high likelihood of unmet palliative care needs. Source: [118] Reprinted, with permission, from Weissman DE, Meier DE. Identifying patients in need of a palliative care assessment in the hospital setting: a consensus report from the Center to Advance Palliative Care. J Palliat Med. 2011;14(1):17-23. Table 6
Clinicians also need to evaluate their own attitudes about the use of curative therapies and hospice. Their interpretation of quality of life, a focus on longer survival rather than better quality of life, a fear of failure, and religious and cultural beliefs may influence their decision making about treatment options for patients near the end of life [131]. COMMUNICATION ISSUES Communicating effectively about palliative care and hospice requires basic patient-physician communication skills as well as skills specific to the end-of-life setting. The importance of effective patient-clinician communication across all healthcare settings has received heightened attention over the past several years, as studies have shown a direct relationship between
enhanced communication and better patient decision making, patient satisfaction, adherence to treatment, health-related quality of life, and survival [35; 67]. Basic Patient-Clinician Communication Among the most important factors for effective communication across all healthcare settings are knowledge of the language pref- erence of the patient and family; an awareness of the patient’s and family’s health literacy levels; and an understanding of and respect for the patient’s and family’s cultural values, beliefs, and practices (referred to as cultural competency) [132; 133; 134]. These issues are significant, given the growing percent- ages of racial/ethnic populations. According to U.S. Census Bureau data from 2019, more than 67.8 million Americans
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MDCA1525
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