Palliative Care vs. Hospice Care For the CV Patient
This article was authored by Caroline Lloyd Doherty, AGACNP-BC, AACC.
It wasn't too long ago that I equated consulting the palliative care team with consulting the hospice team. When a patient was not a candidate for a procedure, someone should have a 'goals of care' discussion including the possibility of hospice. Now, having done a post-masters in palliative care, I understand that palliative care and hospice are very different. It's no wonder that patients and families are unclear about the differences, when many clinicians are uncertain as well.
The World Health Organization definition of palliative care is "an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual."
One difference between palliative care and hospice is that there are strict Medicare criteria that a patient must meet in order to qualify for hospice. These include that the patient must be terminally ill [PDF] with a life expectancy of less than six months. Clinicians who manage patients with cardiovascular illness struggle with the decision to refer patients to hospice because the disease trajectory is not often predictable. The good news is that the palliative care team can be consulted at any time to help manage the patient's physical symptoms as well as psychosocial and spiritual needs. The team is multidisciplinary and includes the expertise of nurse practitioners, physician assistants, nurses, chaplains, pharmacists, social workers, music and art therapists, and physicians. Most importantly, patients can simultaneously undergo curative treatments while receiving palliative care. This is not the case with hospice.
We have all had those cases where the focus on comfort and end of life discussions have been addressed too late to benefit the patient as they spend their last days in the intensive care unit having never had a conversation about their goals and wishes. Why is this the case? Many clinicians worry that they will take away hope. They also may hesitate because of time constraints or because they do not feel confident about their ability to do it well. Studies have actually shown that conversations do not take away hope. Additionally, patients and families report a sense of choice and control when armed with information about their disease and about options for symptom relief. Death is inevitable, but often what patients fear most is the thought of suffering in intractable pain or feeling so short of breath that they feel like they are drowning.
Arguably the clinician most suited for goals of care discussions is the one who comes to know the patient well over time and who the patient trusts. There is a great shortage of palliative care trained providers, so it is necessary for all of us to step up and have goals of care discussions with our patients and to educate them about the differences between palliative care and hospice options. All team members have a responsibility to contribute toward the goal of improving communication to improve patient-centered care.
Learn more about palliative care with two on-demand webinars from the ACC: "Palliative Care Symptom Management for the Cardiovascular Clinician" and "Clinical Pharmacists Contributions to Cardiovascular Care in Older Adults".