Full Answer Section

• Timing: Palliative care can be initiated at any point during the course of a serious illness, from the time of diagnosis onwards. It can be provided alongside curative treatments.
• Eligibility: Patients with any serious illness, such as cancer, heart failure, chronic obstructive pulmonary disease (COPD), kidney disease, dementia, or others, are eligible for palliative care. There is no requirement that the illness be terminal or that the patient has a limited life expectancy.
• Services: Palliative care is provided by a multidisciplinary team, which may include physicians, nurses, social workers, chaplains, and other specialists. Services offered include:
  • Pain and symptom management (e.g., nausea, fatigue, shortness of breath, anxiety, depression).
  • Emotional and spiritual support for the patient and family.
  • Help with decision-making and understanding treatment options.
  • Care coordination and communication among healthcare providers.
  • Practical support, such as connecting families with resources.
• Setting: Palliative care can be provided in various settings, including hospitals, clinics, nursing homes, and the patient’s home.

Hospice Care:

• Focus: Hospice care provides comprehensive comfort care for individuals who have a terminal illness with a prognosis of six months or less if the disease runs its natural course. The focus shifts from curative treatment to maximizing comfort and quality of life in the patient’s remaining time.
• Timing: Hospice care is initiated when curative treatments are no longer effective or desired, and the patient and physician agree that the focus should be on comfort and symptom management.
• Eligibility: Patients are eligible for hospice care when a physician certifies that they have a terminal illness with a life expectancy of six months or less. Patients typically forgo aggressive or curative treatments to focus on comfort.
• Services: Hospice care also involves a multidisciplinary team similar to palliative care, with a strong emphasis on:
  • Expert pain and symptom management tailored to the end-of-life phase.
  • Emotional, psychosocial, and spiritual support for the patient and family, including bereavement support after the patient’s death.
  • Medical equipment and supplies related to the terminal illness.
  • Medications for comfort and symptom control.
  • Respite care for caregivers.
  • Volunteer support.
• Setting: Hospice care is often provided in the patient’s home, but can also be offered in dedicated hospice facilities, hospitals, or nursing homes.

In essence, palliative care is broader and can be initiated earlier in the course of a serious illness, often alongside curative treatment, while hospice care is specifically for those with a terminal prognosis and focuses on comfort when curative options are no longer pursued.

Nursing Support in End-of-Life Care According to Patient Wishes:

As nurses, we are at the forefront of providing end-of-life care and have a profound opportunity to support patients in accordance with their wishes. This involves:

• Active Listening and Communication: The cornerstone of patient-centered care is active listening. We must create a safe and open environment where elderly patients feel comfortable expressing their fears, hopes, values, and preferences regarding their end-of-life care. Asking open-ended questions and truly hearing their responses is crucial.
• Assessing and Understanding Patient Values and Goals: We need to delve beyond medical directives and understand what truly matters to the patient. What brings them comfort? What are their priorities for their remaining time? What are their fears about death and dying? Understanding these values will guide our care.
• Facilitating Discussions about End-of-Life Preferences: Many elderly patients may be hesitant to discuss death and dying. Nurses can gently initiate these conversations, providing information about available options like palliative care, hospice, and advance directives in a sensitive and understandable manner.
• Collaborating with the Multidisciplinary Team: We act as a vital link between the patient, family, physicians, and other members of the care team. We must communicate the patient’s wishes and preferences effectively to ensure a coordinated and consistent approach to care.
• Providing Expert Symptom Management: Pain, nausea, shortness of breath, and anxiety are common distressing symptoms at the end of life. Nurses are skilled in assessing and managing these symptoms using pharmacological and non-pharmacological interventions, always prioritizing the patient’s comfort and quality of life.
• Offering Emotional and Spiritual Support: We provide a comforting presence and offer emotional support to both the patient and their family. We can also facilitate access to spiritual care providers, such as chaplains, if desired.
• Advocating for Patient Wishes: Our primary responsibility is to advocate for our patients. This means ensuring that their expressed wishes regarding treatment options, level of intervention, and place of death are respected and followed by the entire healthcare team.
• Educating Patients and Families: We provide clear and accurate information about the patient’s condition, prognosis, care options, and the implications of their choices. We empower them to make informed decisions about their care.
• Supporting Dignity and Respect: Even in the final moments of life, maintaining the patient’s dignity and treating them with utmost respect is paramount. This includes attending to their personal hygiene, providing privacy, and honoring their cultural and spiritual beliefs.
• Facilitating a Peaceful and Comfortable Death: When death is imminent, our role shifts to providing comfort, managing symptoms, and supporting the family through their grief. Creating a peaceful and dignified environment is a final act of care.

Advance Directives vs. Physician Order for Life Sustaining Treatment (POLST) and Their Legal Implications:

Advance directives and POLST forms are legal documents that help ensure an elderly patient’s wishes regarding end-of-life care are honored, even if they become unable to communicate their decisions. However, they serve different purposes and have distinct legal implications:

Advance Directives:

• Definition: Advance directives are legal documents that allow a competent adult to express their wishes regarding future medical care in the event they lose the capacity to make decisions for themselves. The two main types are:
  • Living Will: A written document that outlines specific medical treatments the individual would or would not want to receive in certain end-of-life scenarios (e.g., mechanical ventilation, artificial nutrition and hydration).
  • Medical Power of Attorney (Durable Power of Attorney for Healthcare): A document that designates a specific person (the healthcare agent or proxy) to make medical decisions on the individual’s behalf if they become incapacitated.
• Legal Implications:
  • Advance directives are legally binding documents, recognized by state laws.
  • Healthcare providers are legally obligated to follow the instructions outlined in a valid advance directive to the extent permitted by law.
  • The designated healthcare agent has the legal authority to make medical decisions consistent with the patient’s known wishes or, if those are unclear, in the patient’s best interest.
  • Advance directives provide legal protection for healthcare providers who follow the patient’s expressed wishes or the decisions of their designated agent.
  • It is crucial that advance directives are executed properly according to state-specific requirements (e.g., witnessed and notarized).
  • Advance directives can be revoked by the patient at any time as long as they have the capacity to do so.

Physician Order for Life Sustaining Treatment (POLST) (Also known as MOLST, POST, etc., depending on the state):

• Definition: A POLST form is a medical order, signed by a physician (or other authorized healthcare practitioner), that specifies a patient’s wishes regarding life-sustaining treatments. It is intended for patients with serious illnesses or frailty who are nearing the end of life or who have specific preferences about the medical interventions they want or do not want.
• Scope: POLST forms translate a patient’s wishes into actionable medical orders regarding treatments such as:
  • Cardiopulmonary Resuscitation (CPR): Whether or not to attempt CPR.
  • Medical Interventions: The level of medical treatment desired (e.g., full treatment, limited interventions, comfort-focused care).
  • Artificial Nutrition and Hydration: Whether or not to provide artificial feeding and fluids.
  • Other specific treatments as indicated.
• Legal Implications:
  • POLST forms are legally binding medical orders that must be followed by all healthcare professionals across different care settings (e.g., hospital, nursing home, home).
  • They are designed to ensure that the patient’s wishes are honored consistently and avoid unwanted or medically inappropriate interventions.
  • POLST forms take precedence over previously executed advance directives if there is a conflict. This is because they represent the patient’s most recent and specific medical orders.
  • POLST programs are typically state-specific, with standardized forms and legal frameworks in place.
  • To be valid, the POLST form must be completed voluntarily by a competent adult (or their legally authorized surrogate) in consultation with a healthcare provider, signed by the patient (or surrogate) and the physician (or authorized practitioner).
  • POLST forms can be reviewed and revised by the patient at any time if their wishes change.

Key Differences and When to Use:

• Advance directives are broader documents outlining general preferences for future medical care and often designate a healthcare agent. They are useful for all adults to plan for potential future incapacity.
• POLST forms are specific medical orders for life-sustaining treatments, intended for individuals with serious illnesses or frailty. They translate the patient’s current wishes into actionable orders that must be followed by healthcare professionals.

In providing care for elderly patients, it is essential to:

• Inquire about the existence of advance directives and POLST forms.
• Ensure these documents are readily accessible in the patient’s medical record.
• Understand the specific wishes outlined in these documents.
• Advocate for the patient’s wishes to be followed by the healthcare team.
• If no advance directives or POLST forms exist, initiate sensitive discussions with the patient (if competent) and their family about their preferences and the option of completing these documents.
• Document all discussions and the presence or absence of advance directives and POLST forms clearly in the patient’s chart.

By understanding the differences and legal implications of palliative care, hospice, advance directives, and POLST, nurses can effectively support elderly patients in their end-of-life journey, ensuring their wishes are respected and their final days are as comfortable and dignified as possible.