Primary care
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Assessment and management of pain is crucial to the success of any program of care for dying patients and their families. With appropriate assessment and management, often using home health or hospice teams, pain can be controlled in more than 90% of patients. This article focuses on the symptomatic care of patients who are dying. The legal and regulatory issues that may inhibit delivery of adequate opioid therapy are also reviewed.
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Palliative care is about total patient care, management of disabling and debilitating symptoms, and the role of the primary care physician. As physicians, we must understand who, what, when, how, and where to institute, or refer patients for palliative care. Who? Any patient needing assistance with the control of physical and nonphysical symptoms can benefit from palliative care. ⋯ How? The primary care physician makes the initial referral to the palliative care physician or team. Where? All hospices should have a palliative care physician or consultant. This article provides a broad overview of palliative care management and incurable illnesses.
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This article addresses advance directives and methods to establish the goals of care for remaining life in the decisional and nondecisional patient. Without these discussions, patient autonomy is negated, and the opportunity to provide patient-centered care using shared decision making is lost.
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The end of life is a period of intensive care. It is imperative that physicians have training and skills in the care of dying patients. Understanding the process of dying and recognizing physical changes aids in prognostication. Skills in facilitating family coping, treating pain, respiratory distress and delirium are critical.
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Hospice and palliative care programs have grown rapidly in the United States over the last 25 years. Relief of suffering and maximization of quality of life including symptom control, psychosocial health, and spiritual care are the primary goals of hospice and palliative care. This article reviews the development, philosophy, and practice of hospice and palliative care, and describes barriers to and suggestions for integrating this approach into mainstream medicine.