Health Care Guideline: Palliative Care For Adults
Health Care Guideline:Palliative Care for AdultsText in blue in thisalgorithm indicates alinked correspondingannotation.Patient presents with new orestablished diagnosis of a seriousillnessSixth EditionJanuary 20201Initiate palliative care discussion2Assess patient’s palliative careneeds based on the specifieddomains of palliative care3Begin advance care planningprocess645Physical aspectsof careCultural aspectsof carePsychological andpsychiatricaspects of care789Social aspects ofcareSpiritual aspectsof careEthical and legalaspects of care10Develop or revisepalliative care plan and establish goalsof care through the process of shareddecision-makingSerious Illness: Terminal illness Chronic, progressive andprobably life-shorteningillness11 Life-threatening illnesswith a chance of fullrecoverynoDoes patient meethospice criteria? Severe neurodegenerativediseasesyesHospice care teamcoordinates palliative careplan with primary clinicianDoes patientchoose hospice, and ishospice available?yesno12Care for the dyingpatientImplement palliative care plan13Through periodicreassessment, is the careplan meeting the patient’sneeds?Grief and bereavementnoyesContinue withcurrent care plannoyesReturn to Table of ContentsPatient conditionis worsening?noRemission orresolution ofdisease?Copyright 2020 by Institute for Clinical Systems ImprovementyesOut of guidelinewww.icsi.org1
Palliative Care for AdultsSixth Edition /January 2020Table of ContentsWork Group LeaderMartha McCusker, MD, FACPInternal Medicine/Geriatrics,Hennepin HealthcareWork Group MembersCentraCare HealthMerryn Jolkvosky, MD, CHCQMPalliative CareHealthPartners MedicalGroup and ClinicsRob Ruff, BCCChaplaincy ServicesLakewood Health SystemJulie Benson, MDFamily Medicine, Hospice andPalliative CareM HealthDrew A. Rosielle, MD, FAAHPMPalliative CareNorth Memorial HealthMelissa Schmidt, MSW, LICSWPalliative Care BereavementICSIAudrey Hansen, MA, BSN,PHN, PMPTeam DirectorJodie Dvorkin, MD, MPHAssociate Medical DirectorSenka Hadzic, MPHClinical Systems ImprovementFacilitatorAlgorithms and Annotations.1–45Algorithm.1Evidence Grading.3Recommendations Table.4–6Foreward.7Introduction.7–9Scope and Target Population.9Aims.10Clinical Highlights.10Implementation Recommendation Highlights.10–11Related ICSI Scientific ty Improvement Support.46–56Aims and Measures.47–48Implementation Recommendations.49Implementation Tools and Resources.50Implementation Tools and Resources Tables.51–56Assessment Tools.51Physician Education Resources (Fast Facts).51–52General Tools and Resources.52–56Supporting 76Appendix A: Literature Search Terms.64–65Appendix B: How to Discuss Serious Illness.66–68Appendix C: Signs and Symptoms That Indicate Death.69Appendix D: Choosing Wisely RecommendationsRegarding Palliative Care.70–76Disclosure of Potential Conflicts of Interest.77–78Acknowledgements.79Document History and Development.80–82Document History.81ICSI Document Development and Revision Process.82www.icsi.orgInstitute for Clinical Systems Improvement2
Palliative Care for AdultsSixth Edition /January 2020Evidence GradingLiterature SearchA consistent and defined literature search process is used in the development and revision of ICSI guidelines.Literature searches for this guideline were done under the following parameters: Time frame: Jan. 1, 2013, through Dec. 1, 2018. Types of studies searched for: systematic reviews and meta-analysis, randomized controlled trials,implementation studies and observational studies (case-control, cohort and cross-sectional studies). Population: adults. All studies were published in English and included humans.For a detailed list of literature search terms, see Appendix A.In addition to the literature searches, articles were obtained by work group members and ICSI staff. Thosevetted by the work group were included in the guideline when appropriate.MethodologyICSI utilizes the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology system. GRADE involves systematically evaluating the quality of evidence (high, moderate, low,very low) and developing a strength of recommendation (strong, weak). For more detailed information onGRADE, please visit http://www.gradeworkinggroup.org/. In addition, when GRADE methodology couldnot be applied, the work group developed consensus recommendations.Return to Table of Contentswww.icsi.orgInstitute for Clinical Systems Improvement3
Palliative Care for AdultsSixth Edition /January 2020Evidence GradingRecommendations TableThe following table is a list of evidence-based recommendations for palliative care.Note: Other recommendation language may appear throughout the document as a result of work groupconsensus but not included in this evidence-based recommendations table.TopicEarlyInterventionQuality of Recommendation(s)EvidenceLowPalliative care can begin atthe time of diagnosis of aserious illness regardless oftreatment plan and continuethroughout the course of apatient’s illness.EarlyInterventionLowPalliative care discussion orreferral should be consideredwhenever a patient developsor presents with a serious orlife-threatening illness, in allcare settings.Assess Domainsof PalliativeCareInformedConsentStrength ofAnnotationRecommendation NumberRelevant ResourcesStrong1Temel, 2010 (RandomizedControl Trial); KassBartelmes, 2004 (Summary);Morrison, 2004 (CaseReport) Steinhauser, 2000(Observational Study)Strong1Kavalieratos, 2016(Systematic Review/MetaAnalysis); Khandelwal, 2015(Systematic Review); Lamba,2014 (Report); Smith, 2014(Review); Strand, 2013(Summary); Weissman, 2011(Consensus Report)LowStrongClinicians should usevalidated assessment tools,where available, to assesspalliative care needs for eachof these domains: physical,cultural, psychological,social, spiritual and ethical/legal.2Aslakson, 2017 (TechnicalBrief); Bakitas, 2009(Randomized Control Trial);Pulchaski, 2009 (Report);Smith, 2009 (Case Report);Gries, 2008 (Case Report);Chochinov, 2006 (Summary);Moro, 2006 (ObservationalStudy); Kemp, 2005(Summary); Searight, 2005(Summary); Morrison, 2004(Case Report); Curtis, 2002(Case Report); Werth, 2002(Summary); Kagawa-Singer,2001 (Case Report); Block,2000 (Case Report); Chang,2000 (Observational Study);Post, 2000 (Summary);Phillip, 1998 (ObservationalStudy); Reed, 1987(Observational Study)LowInformed consent should beStrongobtained for any treatmentor plan of care from either apatient with decision-makingcapacity or an appropriatesurrogate decision-maker.2Silveira, 2010(Observational Study);Arnold, 2006 (Summary)Return to Table of Contentswww.icsi.orgInstitute for Clinical Systems Improvement4
Palliative Care for AdultsSixth Edition /January 2020Evidence GradingTopicQuality of Recommendation(s)EvidenceStrength ofAnnotationRecommendation NumberRelevant ResourcesLowStrongThe interdisciplinary careteam (IDT) of health careproviders should ideallyinclude at a minimumphysicians, advance practiceproviders, nurses, socialworkers, spiritual counselors,and bereavement staff.Other clinicians may alsoparticipate on the IDT.2Bakitas, 2009 (RandomizedControl Trial); Pulchaski,2009 (Report); Smith, 2009(Case Report); Gries, 2008(Case Report); Chochinov,2006 (Summary); Kemp,2005 (Summary); Searight,2005 (Summary); Morrison,2004 (Case Report); Curtis,2002 (Case Report); Werth,2002 (Summary); KagawaSinger, 2001 (Case Report);Block, 2000 (Case Report);Post, 2000 (Summary); Reed,1987 (Observational Study)CareConferencesLowStrongCare conferences with thepatient, family and membersof the interdisciplinaryteam are recommended onan ongoing basis to discusspatient’s condition, courseof illness, treatment options,possibility of progression todeath, goals and plan of care.2Agar, 2017 (RandomizedControl Trial), Gries,2008 (Case Report);Moneymaker, 2005(Pamphlet); McDonagh,2004 (Observational Study);Curtis, 2001(ObservationalStudy)Advance CarePlanningLowFacilitation of advance careplanning conversationsis appropriate for alladult patients. Regularreview of goals andwishes should occur as thepatient’s condition or lifecircumstances change.Strong3Weissman, 2011 (Report);Gries, 2008 (Case Report);Block, 2006 (Case Study);Sinclair, 2006 (Summary);Lee, 2002 (Summary);Vandekieft, 2001(Summary);Balaban, 2000 (Summary)Provider’sOrder forLife-SustainingTreatmentLowAdopt the Provider’sStrongOrder for Life-SustainingTreatment (POLST) as acommunity standard todocument and communicatethe preferences of individualpatients with a serious illnessas an official medical orderwritten by a provider.3Wang, 2017 (SystematicReview); Jennings, 2016(Observational Study);Hickman, 2015 (SystematicReview); Bamba, 2012(Summary)InterdisciplinaryCare TeamReturn to Table of Contentswww.icsi.orgInstitute for Clinical Systems Improvement5
Palliative Care for AdultsSixth Edition /January 2020Evidence GradingTopicEthical Aspectsof CareQuality of Recommendation(s)EvidenceAs the disease progresses,clinicians should recognizethose patients who arereceiving nonbeneficial,low-yield therapy andreassess the treatment planwith the patient and family.LowStrongRelevant Resources9Snyder Sulmasy, 2019(Manual); Schneiderman,2003 (Randomized ControlTrial)Clinicians should engage inStrongshared decision-making withthe patient and/or familywhen establishing or revisinggoals of care.10Shay, 2015 (SystematicReview); Stiggelbout, 2015(Summary); Belanger,2011 (Systematic Review);Makoul, 2006 (Review)Assess forLowHospice ReferralIn a patient with seriousillness, clinicians shouldrecognize the prognosis ofless than 6 months, and if inline with the patient goals ofcare, refer to hospice.Strong11Joseph, 2016 (SystematicReview); BrinkmanStoppelenburg, 2014(Systematic Review);Lamont, 2001 (ObservationalStudy); Brody, 1997(Summary); SUPPORT, 1995(Control Trial)Care forDying PatientLowClinicians should identifywhen a patient is activelydying and communicate thatto the patient and family.Strong12Taylor, 2017 (ObservationalStudy); Kennedy, 2014(Review); Solloway, 2005(Observational Study);Ellershaw, 2003 (Report)Grief andBereavementLowClinicians should engage inongoing assessment of griefand bereavement throughoutthe illness trajectory andintervene or refer forongoing bereavementservices when warranted.Strong13Griffin, 2007 (Guideline);Strobe, 2006 (Report);Hollenbeck, 2005(Guideline); Ellifrit, 2003(Observational Study);Chochinov, 1989 (Review);Sheldon, 1998 (ClinicalReview)Shared DecisionMakingLowStrength ofAnnotationRecommendation NumberReturn to Table of Contentswww.icsi.orgInstitute for Clinical Systems Improvement6
Palliative Care for AdultsSixth Edition /January 2020ForewordIntroductionPalliative care is medical care that focuses on relief of the symptoms and stress of a serious illness for peopleand their families living with a life-threatening condition. The World Health Organization (2018) definespalliative care as “an approach that improves the quality of life for patients and their families facing theproblems associated with life-threatening illness, through the prevention and relief of suffering by meansof early identification and impeccable assessment and treatment of pain and other problems, physical,psychosocial and spiritual.” Derived from the Latin word palliatus, meaning to “cloak or cover,” the nameis meant to convey care that wraps the patient with another layer of comfort and support. The WHO goeson to elaborate that palliative care: provides relief from pain and other distressing symptoms; affirms life and regards dying as a normal process; intends neither to hasten or 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; offers a support system to help the family cope during the patient’s illness and in their own bereavement; uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated; enhances quality of life and may also positively influence the course of illness; is applicable early in the course of illness, in conjunction with other therapies that are intended toprolong life, such as chemotherapy or radiation therapy, and includes those investigations needed tobetter understand and manage distressing clinical complications.Implicit in this definition is the assertion that palliative care may be provided as the primary focus of treatment, or concurrently with other medical interventions at any stage of a serious illness. By intervening atthe onset of a serious illness, health care professionals can assure that appropriate interventions are offeredto meet the goal of reducing the burden of disease and maximizing the quality of life.Working in partnership with the primary physician, the palliative care team provides the following: Time to devote to intensive family meetings and patient/family counseling Skilled communication about what to expect in the future in order to ensure that care is matched tothe goals and priorities of the patient and the family Expert management of complex physical and emotional symptoms, including complex pain, depression, anxiety, fatigue, shortness of breath, constipation, nausea, loss of appetite and difficulty sleeping(Center to Advance Palliative Care [CAPC]) Attention to psychosocial and spiritual care needsThe National Consensus Project (2018), National Quality Forum (2012) and The Joint Commission (2012)have outlined systematic components of palliative care services to support these outcomes. In addition, theCenter to Advance Palliative Care (CAPC) provides a wealth of resources to assist in the development ofquality palliative services. This guideline aims to help clinicians understand the philosophy and structureof palliative care, as well as provide aims and measures to operationalize palliative care services.Return to Table of ContentsInstitute for Clinical Systems Improvementwww.icsi.org7
Palliative Care for AdultsSixth Edition /January 2020ForewardThe Evidence for Palliative Care ProgramsTechnological advances in medical care have allowed individuals to live longer, but often at the expense ofincreased symptom burden and quality of life. The need for palliative services is driven by patients’ desirefor relief of suffering, whether caused by the underlying illness or its treatment. The landmark SUPPORTstudy (1995) documented the scope and nature of challenges associated with seeking to provide effective,comprehensive care for individuals facing serious illness. A series of reports from the Institute of Medicine(1998, 2002, 2003) provided further documentation of how the burdens of disease and treatment were notbeing adequately addressed.Early hospital-based palliative care programs emerged in hospitals like the Cleveland Clinic and MedicalCollege of Wisconsin, and evidence began to accumulate demonstrating it is possible to concurrentlyprovide disease-directed therapies and palliative care. Palliative care teams are shown to facilitate effectivecommunication, identify patient-centered goals, align these with appropriate treatments, improve quality oflife for the patient and family, decrease symptom burden and reduce costs. (Morrison, 2008) These resultssupported the ongoing growth of hospital-based palliative care programs, which CAPC reports that as of2016 can be found in more than 75% of all U.S. hospitals with more than 50 beds.Outpatient palliative care services evolved to address palliative needs earlier in the disease process. Earlypalliative care, including outpatient services, can improve quality of life, reduce symptoms, support patientcentered goals and promote increased survival. (Temel, 2010)In addition to the benefits patients derive from palliative services, palliative care programs can support healthsystem efforts to work toward the “Triple Aim” of improved patient experience, improved population healthand reduced per capita costs of health care. (Berwick, 2008) The comprehensive, systematic approach toserious illness aligns palliative care with efforts to reduce avoidable rehospitalization, facilitate transitionsbetween settings of care, and identify patient- and goal-directed services within the purview of collaborating,accountable care organizations. As this guideline shows, the strengths and benefits of palliative care servicesapply in various settings and specialties.Primary and specialty palliative careNearly all health care professionals offer palliative care to their patients in some manner. Indeed, there isa presumption that providers will all be able to provide a level of primary palliative care for symptomscommonly encountered in their respective practices. There is, however, growing recognition that primarycare providers may need more education and training to recognize and evaluate other forms of distress andsuffering in patients with serious illness. (Quill, 2013) Educational programs have been developed in recentyears to assist clinicians in developing the skills needed to address serious illness conversations with theirpatients. More challenging cases of distressing symptoms or complicated communication systems wouldbe appropriate for referral to specialty p
Palliative care is medical care that focuses on relief of the symptoms and stress of a serious illness for people and their families living with a life-threatening condition. The World Health Organization (2018) defines palliative ca
DEPARTMENT DIVISION NAME Family Medicine Palliative Medicine Algu,Kavita Palliative Medicine Arvanitis,Jennifer Palliative Medicine Berman,Hershl (Hal) Palliative Medicine Buchman,Stephen (Sandy) Palliative Medicine Cellarius,Victor Palliative Medicine Goldman,Russell Palliative Medicine Hashemi,Narges Palliative Medicine Howe,Marnie
palliative care plan 2012-2016 Inpatient palliative care There are 300 specialist palliative care beds located in NSW public hospitals, affiliated hospitals and other facilities in the NSW health system. Care is also routinely provided in non-designated palliative care beds. In 2008-09, there were 19,800 palliative care
polices, pain policies, integrated palliative care services or hospices. Palliative care, public health and human rights . Three disciplines (palliative care, public health, and human rights) are now interacting with a growing resonance. The maturing of palliative care as a clinical specialty a
1 Palliative Care Quality End of Life Care Resource Book Palliative Care Needs Round Checklist (Based on the ACU and Calvary Palliative Care Needs Rounds Checklist) Palliative Care Needs Round Checklist Triggers to discuss resident at needs rounds One or more of: 1. You would not be surprised if the resident died in the next six months 2.
L N E C Pediatric Palliative Care Issues of Justice in Palliative Care Provision of quality palliative care Inequity in care delivery 56% of child deaths in hospital (US) Obstacles to access Lack of knowledge regarding pediatric palliative care Responsibility to provid
Mar 11, 2015 · FOR QUALITY PALLIATIVE CARE To build a national consensus around the definition, philosophy and principles of palliative care To promote consistent and high quality care Clinical practice guidelines for quality palliative care released 2004, revised 2009 Established the eight domains of palliative care
Palliative Care Services Operational Policy 15 NATIONAL ADVISOR FOR PALLIATIVE MEDICINE SERVICES It is a great honour and delight to produce this operational policy for palliative care services in the Ministry of Health. Over the past 10 years, the understanding of palliative
Palliative Care Service Penetration Palliative care service penetration is the percentage of annual hospital admissions seen by the palliative care team. Penetration is used to determine how well palliative care programs are reaching patients in need. 100 initial consults / 3,50
