special subjects
The Dying Patient
Palliative Care and Hospice
Palliative care aims to improve quality of life by helping relieve bothersome physical symptoms and psychosocial and spiritual distress. Palliative care is compatible with many curative treatments and can be provided at the same time. For example, the palliative aspect of care emphasizes treatment of pain or delirium for a patient with liver failure who may be on a liver transplant list. However, to say that a patient's care has changed from curative to supportive or from treatment to palliation is an oversimplification of a complex decision process. Most seriously ill patients need a customized mix of treatment to correct, prevent, and mitigate the effects of various illnesses and disabilities. Clinicians should initiate palliative care as soon as patients are identified as seriously ill and especially when they are sick enough to die. Palliative care can be provided by individual practitioners, interdisciplinary teams, and hospice programs. Individual palliative care specialists focus on the recognition and treatment of pain and other bothersome symptoms. Interdisciplinary palliative care teams are made up of various professionals (eg, physicians, nurses, social workers, chaplains) who work together with patients' primary and specialty clinicians to relieve physical, psychosocial, and spiritual stress. Consider palliative care for all potentially dying patients, even those pursuing aggressive or curative therapies. Hospice is a program of care and support for people who are very likely to die within a few months. Hospice care focuses on comfort and meaningfulness, not on cure. Services may include providing physical care, counseling, drugs, durable medical equipment, and supplies. In some countries, such as the US, hospice mostly provides services in the home; in others, such as England, hospice services are mainly in inpatient facilities. In typical hospice care, family members serve as the primary caregivers, often with additional help from home health aides and volunteers. The hospice staff is available 24 hours a day every day. Hospice personnel are specially trained. The hospice team usually consists of the patient's personal physician, hospice physician, or medical director; nurses; home health aides; social workers; chaplains or other counselors; trained volunteers; and speech, physical, and occupational therapists as needed. Physicians may be reluctant to use hospice because a treatable condition could develop. However, this reluctance is not justified because many treatable conditions are within the scope of hospice care. In the US, Medicare covers all medical care related to the hospice diagnosis, and patients are still eligible for medical coverage unrelated to the hospice diagnosis. Also, patients can leave hospice at any time and re-enroll later. 