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Foundation for Practice Excellence
As a person nears the end of life, the
quality of care provided by the interdisciplinary team
and other staff is critically important. The foundation
for practice excellence is based on general principles
of care as well as specific standards and competencies
for the various professional disciplines. Well-developed
training programs for non-professional members of the
team guide and direct their efforts in this rewarding
field of service.
The interdisciplinary healthcare team is
comprised of physicians, nurses, social workers,
counselors, home health aides, chaplains and spiritual
care providers, therapists, and trained volunteers.
Guided by principles, standards and competencies, each
member of the team plays an important role in delivering
care and creating a peace-filled, nurturing environment
during this time of transition. Together they provide
comprehensive palliative care aimed at relieving
symptoms and giving social, emotional, and spiritual
support
Content
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Principles for Care of
Patients at the End of Life
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Interdisciplinary Team:
Physicians, Nurses and Assistants, Social Workers, and
Chaplains/Spiritual Care Providers
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Additional team members
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Volunteers - Lay or professional people, adults
or teens, who have the tolerance, energy and
compassion to share and are specifically selected
and trained to augment hospice staff.
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Pharmacists – an integral part of all
interdisciplinary care teams.
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Residential staff: Bookkeepers,
receptionists, cooks, housekeepers, custodians,
maintenance personnel and others often contribute
significantly to the quality of life experienced by
people in residential hospice care.
If you know of additional principles,
standards and competencies for members of the
interdisciplinary end-of-life team or reference to the
contributions of residential hospice staff
available on the Internet, please forward the
information to
coordinator@abetterwaycoalition.org. Thank you.
Principles for Care of Patients at the
End of Life:
An Emerging Consensus among the
Specialties of Medicine
Milbank Memorial Fund
Clinical policy of care at the end of
life and the professional practice it guides should:
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Respect the dignity of both patient
and caregivers.
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Be sensitive to and respectful of the
patient's and family's wishes.
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Use the most appropriate measures
that are consistent with patient choices.
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Encompass alleviation of pain and
other physical symptoms.
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Assess and manage psychological,
social, and spiritual/religious problems.
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Offer continuity (the patient should
be able to continue to be cared for, if so desired,
by his/her primary care and specialist providers).
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Provide access to any therapy that
may realistically be expected to improve the
patient's quality of life, including alternative or
nontraditional treatments.
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Provide access to palliative care and
hospice care.
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Respect the right to refuse
treatment.
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Respect the physician's professional
responsibility to discontinue some treatments when
appropriate, with consideration for both patient and
family preferences.
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Promote clinical and evidence-based
research on providing care at the end of life.
Standards
Physicians
The
American Medical Association contends that since
people in the last phase of life seek peace and dignity,
they should be able to expect these eight elements of
care from physicians, health care
institutions, and the community:
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The opportunity to discuss and plan
for end-of-life care.
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Trustworthy assurance that physical
and mental suffering will be carefully attended to
and comfort measures intently secured.
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Trustworthy assurance that
preferences for withholding or withdrawing
life-sustaining intervention will be honored.
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Trustworthy assurance that there will
be no abandonment by physicians.
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Trustworthy assurance that dignity
will be a priority.
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Trustworthy assurance that burden to
family and others will be minimized.
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Attention to the personal goals of
the dying person.
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Trustworthy assurance that care
providers will assist the bereaved through early
stages of mourning and adjustment.
Nurses
Hospice Palliative Care Nursing Standards of Practice
Valuing - The hospice
palliative care nurse believes in the intrinsic
worth of others, the value of life and that death is
a natural process
Connecting - The hospice
palliative care nurse establishes a therapeutic
connection (relationship) with the person and their
family through making, sustaining and closing the
relationship.
Empowering - The hospice
palliative care nurse provides care in a manner that
is empowering for the person and family.
Doing for - The hospice
palliative care nurse provides care based on best
practices or evidence-based practice in the
following areas: pain and symptom management,
coordination of care and advocacy.
Finding Meaning - The
hospice palliative care nurse assists the person and
family to find meaning in their life and their
experience of illness.
Social Workers
Standards for Social Work Practice in Palliative and
End of Life Care
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Ethics and Values - The values,
ethics, and standards of both the profession and
contemporary bioethics shall guide social workers
practicing in palliative and end-of-life care. The NASW
Code of Ethics (NASW, 2000) is one of several essential
guides to ethical decision-making and practice.
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Knowledge - Social workers in
palliative and end-of-life care shall demonstrate a
working knowledge of the theoretical and biopsychosocial
factors essential to effectively practice with clients
and professionals.
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Assessment - Social workers
shall assess clients and include comprehensive
information to develop interventions and treatment
planning.
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Intervention/Treatment Planning
- Social workers shall incorporate assessments in
developing and implementing intervention plans that
enhance the clients' abilities and decisions in
palliative and end-of-life care.
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Attitude/Self-Awareness -
Social workers in palliative and end-of-life care shall
demonstrate an attitude of compassion and sensitivity to
clients, respecting clients' rights to
self-determination and dignity. Social workers shall be
aware of their own beliefs, values, and feelings, and how
their personal self may influence their practice.
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Empowerment and Advocacy - The
social worker shall advocate for the needs, decisions,
and rights of clients in palliative and end-of-life
care. The social worker shall engage in social and
political action that seeks to ensure that people have
equal access to resources to meet their biopsychosocial
needs in palliative and end-of-life care.
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Documentation - Social
workers shall document all practice with clients in
either the client record or in the medical chart. These
may be written or electronic records.
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Interdisciplinary Teamwork -
Social workers should be part of an interdisciplinary
effort for the comprehensive delivery of palliative and
end-of-life services. Social workers shall strive to
collaborate with team members and advocate for clients'
needs with objectivity and respect to reinforce
relationships with providers who have cared for the
patient along the continuum of illness.
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Cultural Competence - Social
workers shall have, and shall continue to develop,
specialized knowledge and understanding about history,
traditions, values, and family systems as they relate to
palliative and end-of-life care within different groups.
Social workers shall be knowledgeable about, and act in
accordance with, the NASW Standards for Cultural
Competence in Social Work Practice (NASW, 2001).
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Continuing Education - Social
workers shall assume personal responsibility for their
continued professional development in accordance with
the NASW Standards for Continuing Professional Education
(NASW, 2002) and State requirements.
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Supervision, Leadership, and
Training - Social workers with expertise in
palliative and end-of-life care should lead educational,
supervisory, administrative, and research efforts with
individuals, groups, and organizations.
Chaplains/Spiritual Care Providers
Spiritual Care Standards of Practice:
Screening, Assessment, Problem Identification, Plan of
Care Developed, Plan Implementation and Monitoring,
Evaluation and Outcome Measurement.
Standards for end-of-life spiritual care have
not been located on the Internet.
Competencies
Center to Advance Palliative Care CAPC Manual:
How To Establish A Palliative Care Program
The following competencies can be used in
any setting where professionals are involved in
end-of-life care.
Physicians
Physicians on the interdisciplinary
palliative care team have a number of core competencies:
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Expertise in human health and disease
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Expertise in effective communication
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Skilled in helping to clarify the
goals of care
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Skilled in facilitating
decision-making
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Expertise in symptom control
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Leadership in treatment planning.
Nurses and Assistants - Team Nursing Care
is provided by a team composed of
registered nurses, licensed practical/vocational nurses
and certified nursing assistants (sometimes called a
home health aide.)
Nurses
Nurses on the interdisciplinary
palliative care team have a number of core competencies:
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Make assessments
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Communicate patient needs and status
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Have most frequent and continuous
contact with patients
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Advocate for patient and family
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Provide care
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Enable patient and family
participation in decision-making
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Explain and educate
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Organize patient's environment to
minimize loss of control
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Provide psychological assessment and
support.
Certified Nursing Assistants
Major aspects of practice for certified
nursing assistants:
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Hospice and palliative nursing
assistant practice
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Management of pain and other
end-of-life symptoms
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Ethical issues
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Communication concerns
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Cultural issues
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Loss and bereavement
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Spiritual care
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Care of the patient and family when
death is nearing
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Personal and professional
development.
Social Workers
A social worker with expertise in
palliative care is a central member of the palliative
care team. The discipline of social work is often poorly
understood. Social workers are extensively trained in
psychology and family systems. Consideration of the
patient, the family, and social circumstances are
necessary to provide complete palliative care. The core
tasks of the palliative care social worker include
assessment and intervention.
Social workers on the interdisciplinary
palliative care team have a number of core competencies,
which include the ability to assess and intervene.
The Social Worker Assesses:
The Social Worker Intervenes to:
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Provide needed information
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Aid in effective communication within
the patient/family unit
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Promote confidence to influence
events and make decisions
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Provide needed resources
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Promote adjustment to personal and
social consequences of illness, disability and death
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Provide insight into family's
adjustment, strengths and needs
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Assist in practical planning and
linkages with social services
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Help with finances and insurance
benefits
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Provide supportive psychotherapy and
counseling for emotional support
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Provide bereavement services after
the patient's death.
Chaplains/Spiritual Care Providers
Severe life-threatening illness
challenges the spiritual dimension of every patient and
family, and the chaplain is the team member with
training and expertise in meeting spiritual needs. The
response to the challenge can either lead to intense
distress or growth. A trained chaplain should not be
confused with spiritual leaders of various
denominations. Although the latter may play an important
role, it should not be assumed that they have any more
training or expertise in palliative care than anyone
else. Chaplains on the interdisciplinary palliative care
team have a number of core competencies and will be able
to:
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Assess spiritual distress
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Provide support and counseling to
patient/family
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Lead or promote supporting rituals,
as appropriate
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Promote linkages to the community.
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