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p. 82

End-of-life care consists of palliative and hospice care. It is ideally

introduced early in the disease progression to provide support to patients

of all ages with a serious chronic or life-threatening illness. Medicare

patients who enter a hospice program agree to relinquish their regular

Medicare benefits as they relate to the terminal illness and accept the

palliative rather than curative approach that will be provided by hospice.

The hospice provides all care related to the hospice diagnosis under a

managed-care model at a fixed reimbursement.

Case 6-1 (Question 1)

In 2008, the Hospice Conditions of Participation were updated to include

a review of the medication profile as part of the initial assessment of

new patients. The medication regimens of hospice patients should be

continually reviewed and updated, with unnecessary, ineffective, or

duplicative medications discontinued.

Case 6-1 (Question 2)

Patients near end of life can experience a number of distressing

symptoms. These should be anticipated and treated in a timely manner

that is acceptable to the patients and their families.

Case 6-1 (Question 3), Table

6-3

Well-trained pharmacists can improve medication management for

hospice patients, while helping the hospice manage their drug costs.

Case 6-1 (Question 2)

Many barriers exist regarding pain management and the use of opioids. Case 6-1 (Question 4)

Effective pain management uses a variety of approaches. Case 6-2 (Question 1)

Pain and symptom management may at times require an aggressive

approach.

Case 6-3 (Questions 1–3)

HOSPICE AND PALLIATIVE CARE

Terminology

Hospice care and palliative care are similar, but distinct, terms sharing the common

belief that the relief of suffering is a long-standing, central, and fully legitimate aim

of medicine. End-of-life care refers to both hospice care and palliative care. The

basic principle of end-of-life care is to optimize the quality of life for the patient and

family in the last weeks and months of life, as well as to provide support for the

family beyond the end of life into bereavement.

Palliative care, which includes hospice care, is ideally introduced early in the

disease progression to provide support to patients of all ages with a serious chronic

or life-threatening illness. It can be provided concurrently with other treatments to

cure or reduce disease or it can be provided independently. The word palliation,

derived from the Latin word pallium (a cloak), has been defined as “treatment to

reduce the violence of a disease.” The World Health Organization and the National

Consensus Project define palliative care as an approach that improves the quality of

life of patients and their families who are facing a life-threatening illness, by

preventing and relieving suffering through early identification and impeccable

assessment and treatment of pain and other physical, psychosocial, and spiritual

problems.

1–4 Palliative care

Affirms life and regards dying as a normal process;

Provides relief from pain and other distressing symptoms;

Intends neither to hasten nor postpone death;

Integrates the psychological and spiritual aspects of patient care;

Offers a support system to help patients live as actively as possible until death;

Uses a multidisciplinary team approach to address the needs of the patient and his

or her family during the patient’s illness; and

Provides bereavement counseling when indicated.

3

Hospice and palliative medicine became a recognized subspecialty of internal

medicine in 2006, awarded by the American Board of Medical Specialties.

5 The

Joint Commission offers an Advanced Certification Program for Palliative Care to

recognize hospitals that provide high-quality palliative care services.

6

p. 83

p. 84

Hospice, originally a place or way station for people making a pilgrimage, is

considered both a philosophy of care and a place to deliver care. Hospice care

focuses on the palliation of pain and other symptoms when active treatment to cure a

terminal illness ends. Hospice care can be delivered in a building designated as a

hospice, in the patient’s home, or in a facility where the patient resides. As a

programmatic model for delivering palliative care, hospice care provides an

interdisciplinary team approach to the individualized symptom management (e.g.,

pain), as well as psychosocial, emotional, spiritual, and bereavement support for the

patient and his or her family and caregivers during the last months of life.