Hospice and Palliative Care: Goals, Pain, and End-of-Life Practice
Core concepts
Palliative care is comfort-focused care for serious illness at any stage, delivered alongside curative treatment; hospice is a specific Medicare benefit for terminal illness with a prognosis of six months or less if the disease runs its usual course, and it forgoes curative intent for the terminal diagnosis. Know the interdisciplinary team (physician, nurse, social worker, chaplain, aide, volunteers), the family as unit of care, and bereavement support for survivors.
Master the pain and symptom lexicon: total pain (physical, emotional, social, spiritual), the WHO analgesic ladder concept, opioid myths and fears, and the difference between addiction, physical dependence, and tolerance. Understand advance care planning documents - living will, durable power of attorney for health care, POLST/MOLST - and that a POLST is for seriously ill patients and travels across settings, while an advance directive names a surrogate and states preferences.
Traps in questions
- Equating palliative care with giving up; it is appropriate at diagnosis.
- Confusing hospice eligibility (prognosis) with a do-not-resuscitate order - they are separate.
- Choosing to "increase pain medication only when the patient requests" when the standard is scheduled, proactive dosing with rescue doses.
- Missing the social worker's role: psychosocial/spiritual assessment, family meetings, goals-of-care facilitation, grief support, resource linkage.
Rule of thumb
When a patient's stated goal and the family's wishes conflict and the patient has capacity, the patient's expressed wishes govern; the social worker facilitates a family meeting to align understanding, not to override the patient.
Worked example: A dying patient's adult son demands "everything be done" while the patient said she wants comfort only. Best action: confirm and document the patient's wishes, convene the team and family to explain hospice and comfort care, and support the son's grief.