This course aims to ensure that nurses of all licensure levels understand the components and the delivery process of palliative care with specific strategies and interventions to utilize as a means to control distressing symptoms of serious illness, enhance comfort, and improve quality of life for the duration of the illness.
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Palliative Care
Disclosure Statement
This course aims to ensure that nurses of all licensure levels understand the components and the delivery process of palliative care with specific strategies and interventions to utilize as a means to control distressing symptoms of serious illness, enhance comfort, and improve quality of life for the duration of the illness.
Upon completion of this activity, learners should be able to:
- define the distinguishing features of palliative care, compare and contrast to hospice care and end-of-life care, and describe models of palliative care delivery
- discuss the eight domains of palliative care and the APRN or nurses's role in care delivery as aligned with clinical practice guidelines
- identify the role of advance care planning as a core component of palliative care and demonstrate an understanding of the essential documents and features comprising advance care planning
Definitions
The definition of palliative care (PC) has evolved over the last several decades. The World Health Organization (WHO; 2020) defines PC as
an approach that improves the quality of life of patients (adults and children) and their families facing problems associated with life-threatening illness. It prevents and relieves suffering through the early identification, correct assessment, and treatment of pain and other problems, whether physical, psychosocial, or spiritual (para. 1).
The National Coalition for Hospice and Palliative Care (NCHPC; 2018) defines PC as follows:
Beneficial at any stage of a serious illness, palliative care is an interdisciplinary care delivery system designed to anticipate, prevent, and manage physical, psychological, social, and spiritual suffering to optimize quality of life for patients, their families, and caregivers. Palliative care can be delivered in any care setting through the collaboration of many types of care providers. Through early integration into the care plan of seriously ill people, palliative care improves quality of life for both the patient and the family (p. ii).
Palliative Care
While the term PC is widely utilized throughout healthcare settings, it is often misunderstood. Many people confuse PC with end-of-life (EOL) or hospice care. The need for PC is heightened at the EOL due to increased symptom burden; however, it is appropriate at any point during a chronic illness. Unlike hospice care, PC can be provided simultaneously with curative treatment. It is based on the patient's need, not prognosis. The primary goal is to promote comfort. PC focuses on improving the quality of life and quality of care for patients with life-threatening or life-limiting illness and their families by reducing suffering, alleviating pain, and managing any other distressing symptoms such as depression, dyspnea, fatigue, nausea and vomiting, diarrhea or constipation, incontinence, inability to perform activities of daily living, insomnia, anxiety, restlessness, and loss of appetite. Pain management is a core PC component but also exists as a stand-alone medical subspecialty. Pain is subjective and is often complicated by the uniqueness of the experience to each individual. The etiology of pain is usually complex and multifaceted, thereby heightening the importance of proper clinical assessment, diagnosis, and identification of underlying and contributing conditions to reduce pain to an acceptable level. With the rise of the opioid epidemic that continues to plague the US, all healthcare providers (HCPs) must ascertain an accurate and comprehensive understanding regarding best practices for pain management to preserve the integrity of clinical practice, safeguard patient care, and reduce the risk for opioid use disorders (Center to Advance Palliative Care [CAPC], n.d.; Rabow et al., 2023).
PC aids in encouraging, promoting, and facilitating communication about goals of care and advance care planning (ACP). While PC is always a component of hospice care, it should not be reserved only for the EOL. PC is appropriate at any stage in a severe illness and ideally should be employed throughout the active treatment of the disease. It does not intend to hasten or postpone death but offers a support system to help patients live as actively and comfortably as possible. Hospice is within the continuum of PC (see Figure 1) and is the most intensive, refined form of PC. Hospice denotes that the disease is incurable, acknowledges that attempts to slow disease progression have failed, and accepts that time is limited. It is reserved for terminally ill patients with a life expectancy no greater than six months when the burden or risk of curative treatment outweighs the benefit or a lack of efficacy. Death is the expected outcome of hospice, and the preeminent goals focus on enhancing the quality of life, comfort, and alleviation of suffering for patients and their families. Research consistently demonstrates a pattern of late referral to hospice for eligible patients, which leads to decreased benefits for patients and caregivers at the EOL. The average time between hospice referral and death is only 90.2 days. However, when PC services are utilized, there is a notable improvement in the timely transition of patients into hospice care. In an attempt to resolve the long-standing confusion between PC and hospice care, the term non-hospice palliative care is emerging to more accurately reflect the broader scope that PC represents (Beasley et al., 2019; DeVita et al., 2023; National Hospice and Palliative Care Organization [NHPCO], 2019; WHO, 2020).
Figure 1
The Continuum of Palliative, End-of-Life, and Hospice Care
- PC strives to fulfill the following objectives in patients with serious illnesses:
- to improve the patient's quality of life and positively influence the course of illness with an end goal of the patient living fully and at an acceptable comfort level throughout life
- to be utilized early in the patient's disease trajectory and offered in conjunction with therapies and medications that are intended to prolong life (i.e., chemotherapy, radiation, and clinical trial drugs)
- to provide relief from pain and other distressing symptoms
- to integrate the psychological and spiritual aspects of patient care
- to address goals of care and ensure all care provided is aligned with patient wishes, including ACP and decision-making in preparation for the EOL
- to enhance care coordination through a team approach to care and facilitate communication among the healthcare team, patient, and family/caregiver
- to offer a support system to help the patient and family cope during serious illness (CAPC, n.d.; WHO, 2020)
Models of Palliative Care
PC is provided by specially trained physicians, APRNs, registered nurses, and other clinical specialists who deliver additional patient support. Aside from the clinical team, PC can also be provided by an interprofessional team of support personnel, including social workers, physical therapists, massage therapists, occupational therapists, music and art therapists, touch/energy therapists, and chaplains. Some healthcare institutions employ fully staffed PC teams comprised of many of these multidisciplinary support services. In contrast, other institutions may have only one individual who is deemed responsible for delivering PC. PC is not setting-specific, as it can be provided through various channels (CAPC, n.d.; NCHPC, 2018). While hospital-based inpatient PC services are the most common car
...purchase below to continue the course
e delivery modality, PC can also be provided in outpatient settings such as:
- medical clinics or physician offices
- long-term care facilities, including long-term acute care facilities
- skilled nursing facilities
- assisted living facilities
- group homes
- the patient's home
- inpatient hospice facility through telemedicine services (NHPCO, 2019)
PC is covered under Medicare Part B and Medicaid and may have a required co-payment due at the time of service. Many private insurance providers also cover PC services. Despite what insurance provider the patient has, some treatments or medications may not be covered. Once the patient is eligible and elects hospice care, their care falls under the hospice benefit of Medicare Part A, Medicaid, or private insurance. Medicare and Medicaid cover all costs related to the terminal diagnosis, except that Medicare does not cover room and board if the patient lives in a facility. The services covered include clinical and support services, medications, medical equipment (e.g., hospital bed, oxygen, walker, wheelchair, bedside commode), and supplies (e.g., dressing, ostomy, and incontinence). Most private insurances also cover all care related to the terminal diagnosis when the patient is on hospice; however, for some private insurance companies, the patient must first meet their deductible or pay a co-payment (NHPCO, 2019).
The APRN and Nurse's Roles in Palliative Care
Data from the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) reports that six in ten adults in the US have a chronic disease, and four in ten adults have two or more chronic diseases. Heart disease, cancer, chronic lung disease, stroke, Alzheimer's disease, diabetes, and chronic kidney disease are among the leading causes of death and disability and annual health costs in the US. With the continued growth of the aging population, these numbers are expected to rise over the next decade, and PC's core principles and practices must be incorporated into routine clinical practice (NCCDPHP, 2022).
The NCHPC (2018) recommends that all clinicians and support staff working in patient care settings, especially primary care settings, acquire the core skills and knowledge regarding PC practice to reduce suffering. APRNs and nurses practice at the forefront of primary care across clinical settings and are, therefore, well-positioned to serve critical roles as members of the PC team. The NCHPC refers to these advanced practice providers as having the "ability to expand the capacity to deliver complex care and provide direct care" (NCHPC, 2018, p.1). HCPs must first develop and continuously evaluate the plan to monitor and address psychological responses, emotions, or changes in cognition as prognosis and goals of care evolve during the trajectory of the illness. All nurses should serve as advocates for their patient's sense of dignity and self-esteem by providing PC interventions to promote comfort and reduce suffering. The Hospice & Palliative Credentialing Center (HPCC) offers APRNs and nurses specializing in PC certification as an Advanced Certified Hospice and Palliative Nurse or Certified Hospice and Palliative Care nurse (ACHPN/CHPN; HPCC, n.d.). The role and specific interventions devised to meet the physical, spiritual, emotional, and psychosocial needs of the patient and family dealing with serious illness are summarized according to the NCHPC's (2018) eight domains below.
Clinical Practice Guidelines for Quality Palliative Care
The NCHPC released the fourth edition of the Clinical Practice Guidelines for Quality Palliative Care in 2018. The guidelines are organized into eight domains and offer tools and resources to help clinicians provide optimal relief from symptoms and stressors associated with severe illness. These are generally applicable to both advance practice and licensed nurses, indicated below with the umbrella term HCP (NCHPC, 2018). The eight domains are described in Table 1.
Table 1
The Eight Domains of Palliative Care
Domain 1: Structure and Processes of Care | - The HCP serves as a member of the interdisciplinary PC team, obtaining the professional qualifications, education, and necessary training to acquire the core skillset.
- The HCP performs a comprehensive assessment and develops the PC plan aligned with the patient's wishes.
- The HCP facilitates early referrals to PC and coordination of care, recognizing that communicating and collaborating with professional colleagues dramatically improves the experience and outcome for patients and families.
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Domain 2: Physical Aspects of Care | - The HCP focuses on the screening, assessment, and treatment of symptoms, offering interventions to relieve distressing physical manifestations of the illness (such as pain, nausea, constipation, fatigue, and dyspnea), as well as anticipating and preventing the symptoms associated with serious illness and its treatment.
- The HCP performs a comprehensive pain assessment and provides pain control that meets a level acceptable to the patient or the healthcare surrogate if the patient cannot report distress.
- The HCP performs ongoing assessments to determine the effectiveness of treatment and the need for modifications of the treatment plan, such as lower or higher doses of medications, which serves as a means to effectively manage the symptoms associated with serious illness and treatments to improve well-being, functionality, and quality of life to a level acceptable to the patient or healthcare surrogate.
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Domain 3: Psychological and Psychiatric Aspects of Care | - The HCP uses therapeutic communication to develop, maintain, and facilitate communication between the patient, family, and healthcare team to support the comprehension of information regarding disease progression and treatment choices.
- The HCP assesses the psychological and psychiatric aspects of care in the context of serious illness, including mental health assessment, suicidal ideation, preexisting psychiatric diagnoses, psychiatric diagnoses stemming from serious illness, or side effects of medications.
- The HCP uses clinical judgment and assessments to determine if referrals to mental health professionals, psychologists, or psychiatrists may be indicated; the APRN places referrals to mental health professionals, psychologists, and/or psychiatrists if indicated.
- The HCP advocates for patients when treating psychological issues such as anxiety, depression, hopelessness, post-traumatic stress disorder, substance use disorder, and withdrawal symptoms.
- The HCP performs ongoing monitoring and assessment of long-term and evolving psychological and psychiatric responses and mental health issues throughout the trajectory of illness and through the EOL.
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Domain 4: Social Aspects of Care | - The HCP integrates social assessments into the care plan to identify the social and practice needs of the patient and family, such as patient strengths; availability of caregiving and social support; access to reliable food, housing, and transportation; need for adaptive equipment; and other social or environmental issues.
- The HCP assesses and addresses patient and family social support needs, including family structure and function, roles, responsibilities, quality of relationships, communication, decision-making preferences, practical resources, and safety.
- The HCP assesses patient and family coping strategies and develops a care plan for social services and support congruent with the patient's condition, goals, social environment, culture, and setting to maximize patient and family coping and quality of life.
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Domain 5: Spiritual, Religious, and Existential Aspects of Care | - The HCP recognizes that spirituality is a core component of PC, through which patients and families may seek meaning, purpose, and transcendence while enduring serious illness and contemplating death.
- The HCP performs a spiritual assessment, ensuring that spiritual, religious, and existential aspects of care are addressed, including screening for unmet needs and referring to chaplains or other spiritual leaders as indicated.
- The HCP acknowledges that spirituality can be expressed through values, beliefs, traditions, rituals, or practices.
- The HCP understands that the patient may have beliefs that contrast with those of close family members; fosters the patient and family wishes regarding cultural rituals, customs, or practices; and avoids imposing individual beliefs on others.
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Domain 6: Cultural Aspects of Care | - The HCP assesses and respects the patient and family values, beliefs, and traditions related to health and illness and acknowledges the impact of cultural influences on the PC delivery process.
- The HCP delivers culturally-sensitive care and avoids imposing personal biases or beliefs on patients and their families.
- The HCP practices cultural humility ("a process of openness, self-awareness, being egoless, and incorporating self-reflection and critique after willingly interacting with diverse individuals and embracing diversity" (NCHPC, 2018, p. 61).
- The HCP participates in ongoing continuing education through cultural sensitivity training to acquire the skills to recognize how culture influences patient and family decision-making; their approach to illness; pain, psychological, social, and spiritual factors; and grief, death, and bereavement.
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Domain 7: Care of the Patient Nearing the End of Life | - The HCP facilitates timely referrals to hospice in response to patients' changing needs and ongoing adjustments to the care plan to meet all of the patient's needs when nearing death.
- The HCP offers counseling and education to patients and families about approaching death and the dying process and ensures adequate bereavement and grief support services are available to the family and care team.
- The HCP plays a vital role in caring for patients and families as death approaches and must be skilled in recognizing the signs and symptoms at EOL, including in the final days and weeks of life. HCPs should be aware of these changes:
- decreased level of consciousness
- muscle relaxation of the face
- labored breathing (dyspnea, apnea, Cheyne stokes respirations)
- hearing is not diminished
- touch is diminished, but the patient can feel the pressure of touch
- mucus collecting in large airways (i.e., terminal secretions, death rattle)
- incontinence of bowel or bladder
- mottling (cyanosis) occurring with poor circulation
- pupils no longer reactive to light
- bradycardia, weak pulse, and/or hypotension
- cool extremities
- perspiration
- decreased urine output
- inability to swallow
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Domain 8: Ethical and Legal Aspects of Care | - The HCP applies the core ethical principles of PC to patients with serious illness, which include autonomy, substituted judgment (ethical duty of guardians and surrogate decision makers), beneficence, justice, and nonmaleficence, striving to prevent, identify, and resolve ethical dilemmas common to PC, such as:
- forgoing or discontinuing treatments
- establishing do not resuscitate (DNR) orders
- instituting state-specific portable medical orders, such as provider orders for life-sustaining treatment (POLST) and medical orders for life-sustaining treatment (MOLST)
- the application of sedation or pain control in the imminently dying patient
- The HCP facilitates appropriate referrals to ethics consultants or committees for decision-making and conflict-resolution assistance.
- The HCP honors patient autonomy by supporting patient preferences and decisions made by legal proxies or healthcare surrogates and is well-versed in the local and state laws related to ACP and decisions regarding life-sustaining treatments.
- The HCP facilitates goals of care discussions and ACP, including discussing the importance of completing advanced directives.
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(NCHPC, 2018)
Benefits of Palliative Care
Despite strong evidence that patients benefit from early integration of PC services and EOL discussions incorporating ACP, these concepts are still not routinely addressed in clinical practice. Prognosis affects patients' choices about cardiopulmonary resuscitation (CPR) and additional life-sustaining measures at the EOL when adequately informed about their diagnosis. Unfortunately, many HCPs do not discuss goals of care due to a lack of time, discomfort, experience discussing difficult topics such as death and dying, and fear of negatively affecting the patient's and family's hopes and coping with their diagnosis. However, EOL discussions do not cause emotional harm to patients and their families. When open communication regarding prognosis, treatment options, and goals of care occurs, there is an increase in patient satisfaction, decreased patient anxiety, improved outcomes and quality of life, and an increased likelihood that the patient will ultimately die in their preferred location. Bereaved families also reported higher satisfaction and increased comfort of their loved ones when EOL and options for future care were discussed openly and honestly with the care team. They also report a better understanding of what to expect as their family member declines and ultimately dies due to disease progression. Thorough and open ACP also increases patient autonomy and reduces hospitalizations and the use of unwanted or unnecessary treatments leading to decreased healthcare costs. ACP discussions have also led to decreased rates of ventilator use, resuscitation efforts, and intensive care unit admissions. These discussions can also lead to an appropriate change in code status and early referral to hospice. APRNs or nurses are often well-positioned to facilitate these open, honest conversations with patients and families to ensure a timely referral to hospice services. There is evidence that ACP discussions led by APRNs lead to an increase in the completion of advance directives, including code status (Goswami, 2021; Hughes et al., 2019; Luta et al., 2021).
Choosing hospice is consistently linked to improved quality of life, enhanced symptom control, increased psychosocial and spiritual support, and more comfort through the dying process. Hospice often incorporates bereavement services for caregivers/family and is associated with decreased major depression in bereaved caregivers. Caregivers of patients who received aggressive care in the last weeks of life are more likely to develop a major depressive disorder, experience regret, feel unprepared for the patient's death, and report poorer quality of life (Bhatnagar & Lagnese, 2023; Wajid et al., 2021).
For additional information regarding this topic and care at the EOL, please refer to the NursingCE.com courses, Ethical Issues at the End-of-Life and Coping with Patient Death.
Advance Care Planning
ACP is a process that involves making decisions and having conversations about the types of healthcare treatment a person would want when they cannot make those decisions for themself. ACP can be completed at any age. Various factors, such as a mild chronic medical condition or a terminal illness with a limited life expectancy, can influence the timing of completion. ACP should be proactive, as its purpose is to ensure that individuals receive medical care that aligns with their values and goals. Regardless of the patient's clinical picture, ACP should be incorporated into the care plan. As the patient's clinical picture changes, ACP documents should be addressed and adjusted to meet the current needs and goals of the patient (Silveira, 2022).
ACP is a core aspect of PC, allowing patients to articulate and document their goals, values, and preferences. It supports shared decision-making and helps clinicians formulate a treatment plan and provide care that aligns with the patient's preferences through the EOL. Goals of care discussions and ACP are essential components of PC at all stages of illness but become increasingly dire as the patient's health status declines. Ideally, primary care providers should encourage patients to identify a surrogate healthcare decision-maker (healthcare proxy) before the onset of illness or the loss of decision-making capabilities (Goswami, 2021; & Silveira, 2022).
According to a report from the California State University (CSU) Palliative Care Institute, at minimum, it is appropriate to ask patients at any stage of health if they have thoughts about their healthcare preferences in the event of a crisis. However, "an illness with a terminal trajectory is one that unequivocally should be accompanied by ACP and PC, ideally starting at diagnosis" (Ballentine, 2018, p. 4). As with all aspects of care, there are legal and ethical dimensions surrounding ACP for the EOL. These are critical discussions that encompass serious decision-making during highly stressful times. Fundamental concepts of ACP include assessing the readiness of the patient and family to have these discussions, identifying a surrogate decision-maker(s), gauging patient and family understanding of the diagnosis and disease trajectory, discussing goals of care and treatment options, documenting the patient's preferences in the electronic medical record, and readdressing as the disease progresses or treatment options change (Goswami, 2021). Some of the fundamental components of ACP planning include the following:
Advance Directives
Advance directives are legally valid documents that address the specific treatments or medical care the patient wants and does not want if/when they cannot make decisions. These documents may also name secondary decision-makers authorized to speak for the patient if they are unable. The most common advance directives include a living will and durable power of attorney (DPOA). These documents do not go into effect until the patient loses the capacity to make their own decisions and can be changed at any point by the patient, either orally or in writing, as long as they have the cognitive function to do so.
- These must be completed while the patient maintains the mental capacity to make decisions.
- Advance directives may be subject to state regulations. For instance, one state's advanced directive may not work in another state. Therefore, HCPs should counsel patients on the legal implications of traveling and the role of advanced directives per their state's guidelines.
- CaringInfo, a program of the NHPCO, offers free resources to help patients and clinicians make decisions about EOL care. CaringInfo also provides a website allowing patients and clinicians to download their state's advance directive forms (CaringInfo, n.d.; Silveira, 2022).
Living Will
A living will outlines the patient's wishes regarding future medical treatment, including life-sustaining measures and procedures. It enables the patient to outline legal instructions regarding preferences for specific medical care when they cannot make decisions for themselves. For example, a living will may address CPR, mechanical ventilation, and enteral nutrition and hydration. The document is known as a living will since it goes into effect while the patient is still living. For a living will to be valid, it must adhere to state guidelines. These guidelines differ from one state to another; some states require a living will to be standardized following a set outline, while others are more flexible and allow the individual more freedom in the language used as long as the document is signed and witnessed. Some states have specific guidelines regarding who can witness the signing of a living will. HCPs involved in an individual's treatment are often not permitted to act as witnesses. Once the individual cannot make their own healthcare decisions, their living will go into effect. Many states have specific guidelines that dictate criteria to deem a patient unable to make medical decisions (Sabatino, 2022; Silveira, 2022).
Durable Power of Attorney for Healthcare (DPOAHC)
A DPOAHC identifies an individual the patient has elected to make healthcare decisions on their behalf. The terminology used to describe this individual varies from state to state, but examples include the healthcare proxy, healthcare agent, healthcare representative, or surrogate decision maker. This individual is only given the authorization to make healthcare decisions. In some states, the decision-making authority of the DPOAHC goes into effect once the patient becomes incapable of making their own decisions. Other states recognize an immediately effective DPOAHC. This gives the DPOAHC the authority to make decisions on the patient's behalf immediately; however, if the patient maintains decision-making capacity, they can override any decisions made by the DPOAHC (Sabatino, 2022).
For additional information regarding this topic, please refer to the NursingCE.com course titled Advance Care Planning.
References
Ballentine, J. M. (2018). The five trajectories: Supporting patients during serious illness. CSU Institute for Palliative Care, 1-14. https://csupalliativecare.org/wp-content/uploads/Five-Trajectories-eBook-02.21.2018.pdf
Beasley, A., Bakitas, M. A., Edwards, R., & Kavalieratos, D. (2019). Models of non-hospice palliative care. Annals of Palliative Medicine, 8(Suppl 1), S15-S21. http://apm.amegroups.com/article/view/19229/22761
Bhatnagar, M., & Lagnese, K. R. (2023). Hospice care. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK537296
CaringInfo. (n.d.). Advance directives. National Hospice and Palliative Care Organization. Retrieved May 22, 2023, from https://www.caringinfo.org/planning/advance-directives/by-state
Center to Advance Palliative Care. (n.d.). What is palliative care? Retrieved May 22, 2023, from https://getpalliativecare.org/whatis
DeVita, V. T., Jr., Lawrence, T. S., & Rosenberg, S. A. (2023). DeVita, Hellman, and Rosenberg’s cancer principles & practice of oncology (12th ed.). Wolters Kluwer.
Goswami, P. (2021). Advance care planning and end-of-life communications: Practical tips for oncology advanced practitioners. Journal of the Advanced Practitioner in Oncology, 12(1), 89-95. https://doi.org/10.6004/jadpro.2021.12.1.7
Hospice & Palliative Credentialing Center. (n.d.). Certification. Retrieved May 23, 2023, from https://www.advancingexpertcare.org/hpcc
Hughes, N. M., Noyes, J., Eckley, L., & Pritchard, T. (2019). What do patients and family/caregivers value from hospice care? A systematic mixed studies review. BMC Palliative Care, 18(18), 1-13. https://doi.org/10.1186/s12904-019-0401-1
Luta, Z., Ottino, B., Hall, P., Bowden, J., Wee, B., Droney, J., Riley, J., & Marti, J. (2021). Evidence on the economic value of end-of-life and palliative care interventions: A narrative review of reviews. BMC Palliative Care, 20(89). https://doi.org/10.1186/s12904-021-00782-7
National Center for Chronic Disease Prevention and Health Promotion. (2022). Chronic diseases in America. Centers for Disease Control and Prevention. https://www.cdc.gov/chronicdisease/resources/infographic/chronic-diseases.htm
National Coalition for Hospice and Palliative Care. (2018). Clinical practice guidelines for quality palliative care (4th ed.). https://www.nationalcoalitionhpc.org/wp-content/uploads/2018/10/NCHPC-NCPGuidelines_4thED_web_FINAL.pdf
National Hospice and Palliative Care Organization. (2019). Palliative care or hospice? The right service at the right time for seriously ill individuals. https://www.nhpco.org/wp-content/uploads/2019/04/PalliativeCare_VS_Hospice.pdf
Rabow, M. W., Pantilat, S. Z., Shah, A. C., Poree, L., & Mitra, R. (2023). Palliative care & pain management. In: M. A. Papadakis, S. J. McPhee, & M. W. Rabow (Eds.). 2023 Current medical diagnosis & treatment (62nd ed.). McGraw-Hill.
Sabatino, C. (2022). Advance directives. Merck Manual Professional Version. https://www.merckmanuals.com/professional/special-subjects/medicolegal-issues/advance-directives
Silveira, M. J. (2022). Advance care planning and advance directives. UpToDate. Retrieved May 22, 2023, from https://www.uptodate.com/contents/advance-care-planning-and-advance-directives
Wajid, M., Rajkumar, E., Romate, J., George, A. J., Lakshmi, R., & Simha, S. (2021). Why is hospice care important? An exploration of its benefits for patients with terminal cancer. BMC Palliative Care, 20(70). https://doi.org/10.1186/s12904-021-00757-8
World Health Organization. (2020). WHO definition of palliative care. https://www.who.int/news-room/fact-sheets/detail/palliative-care