 | Tom Welk
DMin is Director of Pastoral Care & Professional Education at Harry Hynes Memorial Hospice. He also teaches at the University of Kansas School of Medicine-Wichita. He has certification with the American Association of Pastoral Counselors in Clinical Pastoral Education. His memberships include Park Ridge Center for Study of Health, Faith, and Ethics, and St. Louis University Center for Health Care Ethics, Charter Board Member Kansas Health Ethics, Inc., and Ethics Committee Member for National Hospice Organization. He has received the President's Award of Excellence for Public and Community Awareness, for the "Dying Well" project from The National Hospice Organization. Tom's group presentations include: Association of Kansas Hospices, Midwest Congress on Aging, and Kansas Health Ethics Conference. Tom Welk can be contacted by fax at (316) 265-6066, by e-mail at: twelk@hynesmemorial.org, or at his office at (316)219-1791. |
Hospice
2003-12-01 10:58:00
Palliative vs. hospice care
: What is the difference between palliative care and hospice care?
ANSWER: When modern programs to care for the dying were organized in the late 60s (St. Christopher's in London being the most notable) and early 70s, the word "hospice" was used for these programs. Dame Cicely Saunders, the foundress of St. Christopher's, borrowed this term from the Middle Ages, when it was used to designate way-stations for pilgrims on their way to the Holy Land. She viewed life as a journey, and just as pilgrims needed a place of support to be able to finish an arduous journey, so those near the end of life's journey need support in order to complete the journey well. Because hospice took care of terminally ill people (prognosis of six months or less), it quickly became associated with death. The culture we live in does not deal well with death. Coming under the care of a hospice program was seen as tantamount to a death sentence, leading many patients/families to resist admission to a hospice program. For this reason some of those involved in end of life care began advocating for the use of another concept: palliative care. This word comes from the Latin pallium, cloak. Medically, it is identified with efforts to control ("cloak/cover") pain and manage troublesome symptoms. Like hospice, it also is equated with "comfort" care, in contrast to curative care, which is associated with interventions directed toward "fixing." Curative interventions do not have comfort as their initial goal. In curative efforts pain and discomfort are seen as a price to pay so that in the long run there will be better physical functioning. "No pain no gain," sums up this approach. Since both hospice and palliative care are seen as providing comfort, what is the difference? Why not use them interchangeably? Obviously, some do. The following observations may help to point out some distinctions:1) Hospitals (whose primary focus is on cure) have become increasingly aware of the need to manage pain. Many have instituted pain assessment as the fifth vital sign. These efforts are described as "palliative" care. Individuals do not necessarily have to be in the dying role to receive this care. Hence, when used in the hospital setting, palliative care is primarily directed toward keeping the patient physically comfortable (pain free). Obviously, this is a positive goal. But it is important to make a distinction between suffering and pain. Pain relates to the physical dimension of human functioning. It is only one ingredient in the more encompassing concept of suffering. When things are not right in the psychosocial/spiritual dimension of human functioning the result can be great suffering. The psychosocial and spiritual challenges (e.g., fear, alienation, despair) of human functioning must also be addressed to maximize patient comfort. These challenges may be especially acute during the time of a terminal illness when dying may occur within six months or less. Hospice programs which stay true to their mission of providing comprehensive support clearly and skillfully address all the different aspects of suffering: pain control and symptom management; emotional/psychological support; social/family issues; and spiritual counseling. No one area is seen as being more or less important than the others. This support is provided by an interdisciplinary team of physicians, nurses, health care aides, social workers, chaplains and volunteers. To sum up, the term "palliative care" is most frequently applied to the hospital setting and given to those who are in the sick role and seen as realistically benefiting from aggressive curative interventions. The primary focus of palliative care is pain control and symptom management in order to maximize physical comfort. Hospice care is universally associated with taking care of those considered in the dying role. It cares for individuals who have exhausted curative interventions. Further pursuit of these interventions would be futile. Hospice also deals with pain control and symptom management to ensure physical comfort; but this is seen as only the starting point. Other challenges that can be even greater sources of suffering must also be addressed, i.e., psychosocial/spiritual needs.
