2009-07-31 / Columnists

PHC Health Talk

Hospice And Palliative Care
Commentary by Martin A. Grossman MD. Director, Department of Medicine Medical Director, Inpatient Hospice Unit

Martin Grossman MD. Martin Grossman MD. Good medical care involves proper diagnosis, treatment and management of symptoms within the context of the whole patient. Unfortunately, the complexities of modern medicine often lead to a focus on medical tests and various treatments while the patient's symptoms remain undertreated. Palliative care involves a focus on alleviating a patients' suffering using various methods and medications aimed at combating the discomforts caused by the disease process. Palliative care is available to any patient regardless of their life expectancy.

Allowing a person to express how they are feeling about their illness often opens the door to understanding. It is widely recognized that a good doctor patient relationship and good 'bedside manners' on the part of the physician can significantly improve the way the patient 'feels' about their illness and treatment. In fact, most hospitals today have palliative care teams that can bring special expertise to the patient's bedside, aiding in the management of pain and suffering.

Sometimes however, despite the significant advances in modern medicine, a cure for the patient's illness is not possible.

Often, because of advanced age and its associated multiple severe disease states, or during the advanced stages of the disease process, the goals of care can shift from diagnosis and curative treatment to alleviation of pain and suffering. At this level, palliative care becomes even more crucial.

For patient's that are at the end stages of illness, hospice care will sometimes be discussed. Hospice care utilizes a multidisciplinary team whose focus is on making the patient feel better through aggressive management of symptoms, which may include pain, nausea, constipation, and shortness of breath.

With hospice care, treatment of the illness is no longer pursued. Instead, energies are channeled to alleviate suffering and to ensure the patient lives as comfortably as possible. This allows the last days, weeks or months of a patient's life to be spent with family and friends and confronting the challenges of the dying process together.

Physicians, nurses, social workers and clergy are all a part of the hospice care team so that the patient is treated as a whole individual and all aspects of comfort - medical, social and spiritual - can be professionally addressed. To qualify for a hospice program, a doctor must determine that the patient has a life expectancy of less than six months.

The patient must also agree not to pursue curative therapy while enrolled in hospice.

While cancer is a common diagnosis that can invoke hospice care, there are many other conditions that also qualify: congestive heart failure, emphysema, stroke, dementia, kidney failure and liver failure just to name a few.

Studies have shown that most patients with a terminal illness wish to die at home surrounded by their loved ones, rather than in a hospital or nursing home. Hospice helps guide the patient and the family through this difficult process. For instance, a hospital bed, oxygen, and various palliative medications will be arranged for home use. The hospice team will also regularly visit the patient and their family.

Unfortunately, there are times when symptoms are so intense that they cannot be managed at home. Under this circumstance, the patient may then be transported to a hospital-based hospice unit. Despite its presence in the hospital, the unit maintains focus on comfort care and the patient and family experience is often quite different from a typical hospital stay. The goal of the hospital hospice unit is to aggressively stabilize the symptoms so the patient can return home in a more comfortable state.

When inpatient hospice care is needed the patient is transported directly to the hospice floor at any hour of the day or night, bypassing the often hectic and impersonal emergency room. The patient can also be treated by their regular physician as well as physicians with expertise in hospice and palliative care. All rooms at the hospice unit are single bed, so the only roommates the patient has are family and friends.

The nursing staff also receives special training in end-of-life care so that they too are attuned to the focus of relieving pain and suffering.

Visiting hours on the hospice unit are 24 hours a day, 7 days a week so that the maximum amount of final time can be spent together with family and friends.

Family members are encouraged to stay and spend the night in the patient's room so that the feeling of being 'at home' can be maintained, and the hospice unit provides meals and cots to visiting family members so that they can spend time without worrying about food and travel. In fact, there are even allowances for pet visitation.

The advances of medical care over the past 50 years have been staggering. Despite this, all of us will sooner or later have to confront that fact that we are all temporary visitors to this world. Modern medicine has also provided the tools to ensure that when that time is near, pain and suffering can be kept to a minimum.

It is interesting to note that patients in a hospice program will often live longer than their counterparts not involved in hospice. Perhaps, when the symptoms of the dying process are alleviated, the patient wants to live longer. That desire to live in a pain free and caring atmosphere can sometimes grant more time to the dying patient to be with the people who matter most to them.

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