Palliative Care Services | Early Stage | Middle Stage | Late Stage |
| Goals of Care | Discuss diagnosis, prognosis, likely course of the illness, and disease-modifying therapies; talk about patient-centered goals, hopes, and expectations for medical treatments. | Discuss diagnosis, prognosis, likely course of the illness, and disease-modifying therapies; talk about patient-centered goals, hopes, and expectations for medical treatments. Review patient’s understanding of prognosis; review efficacy and benefit-to-burden ratio for disease-modifying treatments; reassess goals of care and expectations; prepare patient and patient’s family for a shift in goals; encourage paying attention to important tasks, relationships, and financial affairs. | Assess patient’s understanding of diagnosis, disease course, and prognosis’ review appropriateness of disease-modifying treatments; review goals of care and recommend appropriate shifts; help patient explicitly plan for a peaceful death; encourage completion of important tasks and increased attention to relationships and financial affairs. |
| Programmatic Support | Advise patient to sign up for visiting nurse and in home services and case management services (if available). | Advise patient to sign up for visiting nurse and home services; consider palliative care program in hospital or at home, hospice, sub acute rehabilitation, case management services. | Advise patient to sign up for a palliative care program in hospital or at home, case-management services, hospice; consider nursing home placement with hospice or palliative care if patient’s home caregivers are overwhelmed. |
| Financial Planning | Advise patient to seek help in planning for financial, long-term , and insurance needs and to begin transfer of assets if patient is considering a future Medicaid application; refer patient to a lawyer who is experienced in health issues. | Advise patient to reassess adequacy of planning for financial, medical, home services, prescription, long-term care, and family-support needs; consider hospice referral and Medicaid eligibility. | Advise patient to review all financial resources and needs; inform patient and family about financial options for personal and long-term care (e/g/, hospice and Medicaid) if resources are inadequate to meet needs; explicitly recommend hospice and review its advantages; consider Medicaid eligibility. |
| Family Support | Inform patient and family about support groups; ask about practical support needs (e.g., transportation, prescription-drug coverage, respite care and personal care); listen to concerns. | Encourage support or counseling for family caregiver; ensure that caregivers have information about practical resources, stress, depression, and adequacy of medical care; identify respite and practical support resources; recommend help from family and friends; raise the possibility of hospice and discuss its benefits; listen to concerns | Encourage out-of-town family to visit; refer caregivers to disease-specific support groups or counseling; inquire routinely about health, well being, and practical needs of caregivers; offer resources for respite care; after death, send bereavement card and call after one or two weeks; screen for complicated bereavement; maintain occasional contact after patient’s death; listen to concerns |
The New England Journal of Medicine R. Sean Morrison, M.D. & Diane E. Meier, M.D. |