PRINCIPLES OF PALLIATIVE

AND HOSPICE CARE

STEPHEN JANSSEN L. ROSETE MAN MSN RN USRN

It is reported that:
Nearly 50% of all patients going
through the dying process spend most
of their time in moderate to severe
pain.
Most Americans would prefer to die in
their own home, yet most die in
institutions.
Nearly 50% of dying patients in the
United States experience multiple
physical and emotional symptoms that
go untreated or are under-treated.
These patients also experience
decreased quality of life, often due to
symptoms such as pain, dyspnea,
depression, anxiety, delirium,
fatigue/weakness,
restlessness/agitation, and

Ethics & End of Life

Care

JCAHO & End of Life Care

JCAHO Standards
Standard PC.8.70 Comfort and dignity are optimized
during end of life care. EP 1 To the extent possible, as
appropriate to the patients and family needs and the
hospitals services, interventions address patient and
family comfort, dignity, and psychosocial, emotional, and
spiritual needs, as appropriate, about death and grief.
PATIENT AND FAMILY RIGHTS (PFR)

PFR.2.2 The organization informs patients and families about their

rights and responsibilities related to refusing or discontinuing
treatment.
PFR.2.3 The organization respects patient wishes and preferences to
withhold resuscitative services and forgo or withdraw life-sustaining
treatments.
Joint Commission International Accreditation Standards for Hospitals
3rd Edition Standards Only 2007 Joint Commission International
PFR.2.4 The organization supports the patients right to appropriate
assessment and management of pain.
PFR.2.5 The organization supports the patients right to respectful
and compassionate care at the end of life.
CARE OF PATIENTS (COP)

COP.6 Patients are supported in managing pain effectively.

COP.7 The organization addresses end-of-life care.
COP.7.1 As appropriate to the care and services provided,
assessments and reassessments of the dying patient and their family
are designed to meet individualized needs.
COP.7.2 Care of the dying patient optimizes his or her comfort and
dignity.

Barriers to Quality End Of Life

Care

Lack of knowledge of health care professionals can

significantly impact
how well patients & their families will have their physical,
psychological,
social & spiritual needs managed through the dying
process.
Aging population refers to the approximately 70 million
individuals
reaching age of 65 by the year 2030 (Administration on
Aging 2000).
Increased life expectancy means increase in number of
elderly having to
cope with concurrent chronic illness and their associated
physical, social
and spiritual difficulties.
Delayed access refers to the need for more timely referrals
by healthcare
professionals to hospice & palliative care in order for
patients and their

Palliative Care &

Hospice
during End of Life
An overview of the philosophy of hospice and
palliative care is that dying is a unique experience
and part of the normal life cycle. Support and care
is provided using an interdisciplinary team approach
with the focus on enhancing the quality of life for
persons facing a life-threatening illness across
settings.
Palliative care can and should co-exist with curative
care. Introduction of palliative care earlier in the
course of an illness makes it possible to recognize
when subtle shifts occur and allows patients,
families and professionals to adapt goals
accordingly.
Goals of care change often throughout the course
of illness by integrating physical, psychological,
social and spiritual aspects of care. Frequent
reassessment and clarification of goals, is needed
by the interdisciplinary team, the patient and family.
In many healthcare settings, during clinical
rotations, students have opportunities to work with
patients and families experiencing the dying
process.
8

Palliative Care
Definition of Palliative Care:
an approach that improves the quality of life of
patients and their families, facing the problems
associated with life-threatening illness, through them
prevention and relief from suffering, by means of early
identification, impeccable assessment, treatment of pain
and other problems - physical, psychosocial, and
spiritual (World Health Organization, 2002; Sepulveda
et al., 2002).

Eligibility for initiation of Palliative Care:

Palliative care is appropriate and can be implemented at
any time during the illness experience.

Principles of Palliative
Care

Hospice
Definition:
Hospice care is the support and care for persons in the final phases
of an incurable disease so that they may live as fully and
comfortably as possible (NHPCO, 2000). Hospice also supports the
surviving family through the dying and bereavement process (Egan
& Labyak, 2001). Hospice provides comprehensive palliative,
medical and supportive services across a variety of settings and is
based on the understanding that dying is a part of the normal life
cycle. Care can be provided in the home, in residential facilities,
long-term care facilities and other settings (i.e. prisons).

Eligibility for Hospice:

Enrollment is limited to those expected to die within six months.
The Medicare Hospice benefit has currently expanded its hospice
service options so that patients/families can receive end of life care
long before the last six months of life to better meet the needs of
patients dying from chronic illnesses.
An additional option that has been made available to patients (and
their families) who are actively in the dying process or have been
determined as terminal is that they can be designated as an inpatient
hospice.

Principles of Hospice
Care

Advance Directive
(also called a Living Will)
An Advance Directive is a document that lets patients state their
wishes about medical care in the event that they develop a terminal or
irreversible conditions and can no longer make their own medical
decisions (TxPEC, 2009).
An Advance Directive (Living Will) becomes effective when
1. the patients physician certifies in writing that the patient
has a terminal or irreversible condition, and
2. after the patients physician writes a do not resuscitate
(DNR) order specifying the patients wishes to withhold
medical care.
3. The patient may revoke the Directive at any time.
Hospitals are required by Medicare Conditions of Participation and
JCAHO to inquire about Advanced Directive status upon the patients
admission and to instruct the patient about his/her option of having an
Advance Directive if so desired. If the patient has a Directive, the
hospital is required to make it part of the patients medical record.
However, hospitals are not required to make the patient create an
Advance Directive or Power of Attorney for medical care.

Other Laws and

Directives
related
to End Act
ofis a law
Federal
Patient Self Determination
that allows for patients to make choices about what
is done to their bodies
while they are receiving
Life:
medical care through the development of the
Advanced Directive (Living Will).

Texas Natural Death Act (1991) is a state law

that allows the withdrawal or withholding of medical
care to be requested by a competent adult who is
terminally ill.
Texas Medical Power of Attorney Lets the
patient name someone to make decisions about his/her
medical care-including decisions about life support-if
he/she can no longer speak for him/herself.
The patients attending physician must certify in writing
that the patient is unable to make health care decisions,
and file the certification in the patients medical record.
This person does not necessarily have to be a
family member.
This person may be a Court Appointed Guardian
to make
decisions for an individual who is deemed
incapable of making

Nursing &
Advance Directives
Nurses have a unique opportunity to enact the federal
Patient Self-Determination Act through communication
with patients and by assisting them explore their values
and beliefs regarding the end of life. The nurse can
promote patient comfort with decisions concerning
advance directives. They can also be sure that the
entire healthcare teams is aware of the patients wishes
(Nevidjon & Sowers, 2000).
Note: Any problems/questions associated with Advance
Directives or Durable Power of Attorney should be
referred to the nurse in charge. Each organization has
its own policies about who can/cant witness a
signature.