The shift to palliative care.

New model can improve quality of life in long term care

AS RESEARCHERS AND REGULATORS FINE-TUNE THEIR FOCUS ON improving the quality of life in long term care, the need for programs that address those needs is becoming increasingly apparent. Palliative care is Lone such program.

By its very definition--the study and management of patients with active, progressive, or far-advanced disease for whom the prognosis for recovery is limited and the focus of care is quality of life--palliative care stands out as a logical choice for long term care. The discipline recognizes the multifaceted nature of suffering and quality of life and responds with care that addresses those many dimensions.

In a recent study in the Journal of the American Medical Association, Peter Singer, MD, identified the elements of quality of life that are most important to people as they approach their last years: receiving adequate pain and symptom management; avoiding inappropriate prolongation of dying; achieving a sense of control; easing one's burden; and strengthening relationships with loved ones.

Like traditional hospice programs, the model of palliative care that can be incorporated into long term care looks beyond a disease focus, placing the patients and their families in a holistic circle of care. Patients' needs are addressed by an interdisciplinary team consisting of the facility's medical director, director of nursing (or representative), director of social services (or representative), and various supportive care services such as rehab, chaplaincy, pharmacy, and frontline caregivers.

As suggested by Singer, the team must strive to control pain and symptoms, strengthen relationships, relieve burden, and avoid unnecessary intervention just to prolong life, unless that is what the patient desires.

In many ways, a palliative care program in long term care is a paradigm shift; rather than making autonomous decisions "in the best interest" of the patient, the health care professional must place the satisfaction and needs of the patient and family first. Success is based on the team's ability to meet the needs and expectations of the patient and family--outcomes that should be measured.

Staff training can come from many sources, including a medical director if he is certified in palliative medicine, gerontology, or another specialty that addresses the needs of the frail and elderly. Local hospice programs may also be willing to provide in-service programs, particularly if they see the nursing home as a source for subsequent referrals.

Before implementing a palliative care program, be sure to establish some flexible guidelines for participation. Any member of your staff may identify the person in need. Once a referral is made, send both the patient and her attending physician a consent form allowing the team to interview and examine the patient.

Each member of the team should assess the patient using standard tools. The social worker, for example, can use the McMaster Quality of Life scale in conducting psychosocial and baseline quality-of-life assessments. A nurse could apply the Karnofsky or Palliative Performance Scale when evaluating functional status. Similarly, the medical director might choose to use a symptom assessment scale such as the Memorial Symptom Assessment Scale.

After the various assessments are complete, the team should hold an interdisciplinary group meeting to develop a palliative plan of care. Following the meeting, the medical director can dictate a comprehensive summary of the team's findings and send the report with appropriate recommendations to the attending physician. Each member of the team should visit the patient one to two times a week, generating ongoing progress reports for review by the group.

A recent report in The Gerontologist notes that nursing homes are increasingly providing hospice services to their residents, a trend that's expected to continue. Still, only 1.3 percent of nursing facilities have specialized hospice units. As aging baby boomers become more of a force in shaping long term care, formal palliative care programs are likely to expand, benefiting both patients and providers. The patients receive a higher quality of care. As for the facility, palliative care is marketable to outside physicians, hospitals, and the general public. Bringing true palliative care to long term care also begins a crucial process--the integration of comprehensive palliative care into all parts of the health care delivery system.

Kenneth M. Levine, DO, is medical director of palliative care services at Las Flores Nursing Center in Mesa, Arizona.