GENERAL PRINCIPLES OF GERIATRIC PALLIATIVE CARE
Most serious illness occurs in adults aged 65 years and older. These illnesses are often characterized by their chronic nature, high prevalence of untreated symptoms, progressive physical and functional decline, and extensive family caregiver needs. Geriatric palliative care integrates the core competencies of these specialized fields of medicine with a goal of improving the care and enhancing the quality of life of these older adults living with serious illness. These competencies include high-quality symptom management, coordination of care, clear communication about medical conditions, matching a patient’s goals of care with the appropriate treatments, and family and caregiver support.
Specialty palliative care is provided by an interdisciplinary team including physicians, nurses, social workers, chaplains, and other individuals with expertise in palliative medicine. This model of care is patient and family centered, honoring patient and family values and preferences through a process of shared decision making. It also recognizes and attempts to address the complex multidimensional needs of patients and their families, including social, psychological/emotional, spiritual, and medical aspects (Figure 22–1).
The interdisciplinary model of care. This figure illustrates how core members of the palliative care team work together to meet the needs of the patient and family.
Palliative care can be provided for any serious illness, at any stage, concurrently with life-prolonging treatments and is not prognosis dependent. Studies consistently demonstrate that palliative care can improve outcomes across diverse health care settings, including better pain management, reduced hospital utilization, and greater family satisfaction.
Hospice care is a form of palliative care for patients with limited life expectancy who meet certain conditions formalized under the Hospice Medicare Benefit. Hospice care provides medical, psychological, and spiritual support to the patient and family at the end of life. Under the Medicare Hospice Benefit, a patient is eligible for hospice care when a patient has an estimated prognosis of 6 months or less if the illness progresses as expected. When enrolling in hospice, the patient’s treatment priorities should focus on alleviating symptoms and prioritizing comfort. Older adults with multiple chronic conditions are often not offered hospice even though it might be beneficial, because prognostication is more difficult in this population (see Chapter 4, “Goals of Care & Consideration of Prognosis”). When admitted to hospice, the hospice agency is required to provide services that are reasonable and necessary for management of terminal illness and related conditions, including physician and nursing visits, medications, medical equipment and supplies, and counseling. Hospice care is usually delivered in the patient’s home or current place of residence, such as a nursing home or assisted-living community.
CHALLENGES TO PROVIDING PALLIATIVE CARE IN LONG-TERM CARE SETTINGS
Nearly 25% of deaths in the United States occur ...