The goal of this webinar was to educate healthcare professionals about the differences between palliative and curative care while exploring the history and philosophy of the hospice movement.

1. Palliative Care vs.
Curative Care

2. CE Provider
Information
VITAS Healthcare programs are provided CE credits for their Nurses/Social
Workers and Nursing Home Administrators through: VITAS Healthcare
Corporation of Florida, Inc./CE Broker Number: 50-2135. Approved
By: Florida Board of Nursing/Florida Board of Nursing Home
Administrators/Florida Board of Clinical Social Workers, Marriage and
Family Therapy & Mental Health Counseling.
VITAS Healthcare programs in Illinois are provided CE credit for their Nursing
Home Administrators and Respiratory Therapists through: VITAS Healthcare
Corporation of Illinois, Inc./8525 West 183 Street, Tinley Park, IL 60487/NHA
CE Provider Number: 139000207/RT CE Provider Number: 195000028/
Approved By the Illinois Division of Profession Regulation for: Licensed
Nursing Home Administrators and Illinois Respiratory Care Practitioner.
VITAS Healthcare, #1222, is approved to offer social work continuing education
by the Association of Social Work Boards (ASWB) Approved Continuing
Education (ACE) program. Organizations, not individual courses, are approved
as ACE providers. State and provincial regulatory boards have the final
authority to determine whether an individual course may be accepted for
continuing education credit. VITAS Healthcare maintains responsibility for
this course. ACE provider approval period: 06/06/2018 – 06/06/2021.
Social workers completing this course receive 1.0 ethics continuing e
ducation credits.
VITAS Healthcare Corporation of California, 310 Commerce, Suite 200, Irvine,
CA 92602. Provider approved by the California Board of Registered Nursing,
Provider Number 10517, expiring 01/31/2021.
Exceptions to the above are as follows: AL: No NHAs, DE: No NHAs, DC:
No NHAs, GA: No NHAs, KS: No NHAs, NJ: No NHAs, OH: No NHAs, PA:
No NHAs, TX: No NHAs, VA: No NHAs, WI: No NHAs and Nurses are not
required – RT only receive CE Credit in Illinois

3. Goal
• To appreciate the historical perspective
of curative and palliative care
• To comprehend the impact of palliative and
hospice care on patients and families,
the hospital, and the health system for
persons with advanced illness

4. Objectives
• Describe the history and
philosophy of the hospice and
palliative movement
• Identify the difference between
palliative and curative care
• List the benefits of palliative care
for patients with advanced illness
• Understand the benefits that
hospice and palliative care can
bring to hospital and health systems
• Understand hospice as a medical
specialty under the palliative
care umbrella

5. How People
Die
< 10% die suddenly of an unexpected
event, heart attack (MI), accident, etc.
> 90% die of a protracted,
life-threatening illness
• Predictable steady decline with
a relatively short “advanced”
phase (cancer)
• Slow decline punctuated by
periodic crises (advanced cardiac
disease, advanced lung disease,
Alzheimer’s/dementia)
Emanuel, et al. (2003). The Education in Palliative and End of Life Care Curriculum
(EPEC Project). Northwestern School University Feinberg School of Medicine.

6. 1
US Census Bureau (2011; US Census Briefs). The Older Population: 2010. Retrieved from https://www.census.gov/prod/cen2010/briefs/c2010br-09.pdf
2
US Centers for Disease Control. (2003). National Vital Statistics Reports, Volume 54/ Retrieved from https://www.cdc.gov/nchs/data/nvsr/nvsr54/nvsr54_14.pdf
3US Census Bureau. (2017, April). Facts for Features: Older Americans Month. Retrieved from: https://www.census.gov/newsroom/facts-for-features/2017/cb17-ff08.html
4US Centers for Disease Control (2017). Life Expectancy. Retrieved from https://www.cdc.gov/nchs/fastats/life-expectancy.htm
5US Centers for Disease Control, Morbidity and Morality Weekly Report. (2016, April). QuickStats: Percentage Distribution of Deaths, by Place of Death, United States, 2000-2014.
Retrieved from https://www.cdc.gov/mmwr/volumes/65/wr/mm6513a6.htm
Dying Then
and Now
19th Century:
• In 1900, 4% of
America’s population
was > 65 years of age1
• In 1900, life expectancy
was 49 years of age2
• Most people died
at home
Today:
• Nearly 15% of the
U.S. population is
> 65 years3
• 2017 life expectancy
in the U.S. was
78.6 years4
• Approximately 37%
of Americans die in
acute-care hospitals and
19% die in nursing homes5

7. Death and
Dying in the
Future
• By 2060, an estimated 48 million people (47% of all
deaths globally) will die with serious health-related
suffering, which represents an 87% increase from
26 million people in 2016. 83% of these deaths will
occur in low-income and middle-income countries.
• Serious health-related suffering will increase in all
regions, with the largest proportional rise in low-income
countries (155% increase between 2016 and 2060).
Globally, serious health-related suffering will increase
most rapidly among people aged 70 years or older
(183% increase between 2016 and 2060).
• In absolute terms, increases will be driven by rises
in cancer deaths (16 million people, 109% increase
between 2016 and 2060).
• The condition with the highest proportional increase
in serious health-related suffering will be dementia
(6 million people, 264% increase between
2016 and 2060).
Sleeman, et al. (2019). The escalating burden of serious related suffering: projections to
2060 by world regions, age groups, and health conditions. The Lancet, 7(7);882-892.

8. Hospice
History
• Linguistic root words:
– Hospital
– Hospitality
– Shelter
– Respite
– Caring
• A place of refuge and solace

9. Hospice
History (cont.)
• 1967 – Dame Cicely Saunders opened
St. Christopher’s in London
• 1969 – Publication of “On Death and
Dying” by Elisabeth Kubler-Ross brought
death and dying into the mainstream
• 1974 – New Haven Hospice of
Connecticut established
• 1978 – VITAS founded
• 1978 – National Hospice
Organization formed
– National Hospice & Palliative Care
Organization (NHPCO)
– Mission: “To lead and mobilize
social change for improved care
at the end of life”

10. What Is Palliative Care?
The study and management of patients
with active, progressive, far-advanced
disease for whom the prognosis is limited
and the focus of care is quality of life.
—Oxford’s Textbook of Palliative Medicine

11. Palliative Care: Definition
National Hospice and Palliative Care Organization. (2020). Explanation of Palliative Care.
Retrieved from https://www.nhpco.org/palliative-care-overview/explanation-of-palliative-care/
Palliative care is patient- and family-centered care that
optimizes quality of life by anticipating, preventing, and
treating suffering. Palliative care throughout the continuum
of illness involves addressing physical, intellectual, emotional,
social, and spiritual needs, and facilitating patient autonomy,
access to information, and choice.
—National Consensus Project for Quality Palliative Care

12. Explanation
of Palliative
Care
National Coalition for Hospice and Palliative Care. (2018). Clinical Practice Guidelines for Quality Palliative Care, 4th Edition.
Retrieved from https://www.nationalcoalitionhpc.org/wp-content/uploads/2018/10/NCHPC-NCPGuidelines_4thED_web_FINAL.pdf
• Palliative care is:
– Appropriate at any stage
in a serious illness
– Beneficial when provided
along with curative treatments
– Provided over time to patients
based on their needs
– Offered in all care settings
– Focused on what is most
important to the patient,
family, and caregiver(s)
– Interdisciplinary to attend to
the patient's holistic care needs

13. Palliative
Care
• Manages pain and symptoms
• Regards dying as a normal process
• Neither hastens nor postpones death
• Integrates psychological and
spiritual care
• Supports patient and family
• Incorporates a team approach
• Enhances quality of life
• Is applicable early in the course
of illness

14. Palliative
Care: Clinical
Expertise
• Symptom management in
advanced illness:
– Pain
– Dyspnea
– Nausea and vomiting
– Fatigue
– Anxiety and depression
• Care transitions and coordination
of care
• Goals-of-care/end-of-life discussions
– Timely hospice referral and admission

15. How Does
Hospice
Differ From
Palliative
Care?
Palliative Care
Hospice

16. Traditional
Model
Continuum of Care - Traditional
Presentation/
Diagnosis
Acute
Illness
Chronic
Death
Life-
Threatening

17. Hospice/
Palliative
Care
Interface
Robinson, et al. (2004). Assessment of the education for physicians on end-of-life care
(EPEC™) project. Journal of Palliative Medicine, 7(5), 637-645.
Hospice
Curative/disease
modifying therapy
Time course
of illness
Last months
of life
Palliative care
Family
bereavement
care

18. Support for
Palliative
Care
95% of respondents agree that it is important
that patients with serious illness and their
families be educated about palliative care.
92% of respondents say they would be likely
to consider palliative care for a loved one if
they had an advanced illness.
92% of respondents say it is important that
palliative care services be made available at
all hospitals for patients with serious illness
and their families.
Center to Advance Palliative Care. (2011). Public Opinion Research on Palliative Care. Retrieved from
https://media.capc.org/filer_public/18/ab/18ab708c-f835-4380-921d-fbf729702e36/2011-public-opinion-research-on-palliative-care.pdf

19. 14% 3%
5%
8%
70%
How knowledgeable, if at all, are you
about palliative care?
Somewhat knowledgeable
Knowledgeable
Very knowledgeable
Don't know
Not at all knowledgeable
Consumer
Awareness
About
Palliative
Care
Center to Advance Palliative Care (2011). 2011 Public Opinion Research on Palliative Care. Data from a Public Opinion Strategies national
survey of 800 adults age 18+ conducted June 5-8, 2011. Retrieved from: https://media.capc.org/filer_public/18/ab/18ab708c-f835-4380-921d-
fbf729702e36/2011-public-opinion-research-on-palliative-care.pdf

20. Palliative
Care and
Hospice
Care

21. Eligibility
Palliative Care
• No prognosis requirements
Hospice
• 6 months or less on average,
should the advanced illness run
its normal and expected course
• Physician estimate
• Clinical determination

22. Reimbursement
Mechanism
Hospice
• Medicare Part A
• Medicaid
• Private insurance
• Charity care
Palliative Care
• Fee-for-service
• Grants
• Member-based per
month (health plan
contracted)

23. 85%
7%
5%
1%
1%
1%
Medicare Hospice Benefit
Private Insurance/Managed Care
Medicaid Hospice Benefit
Other Payment Source
Self-Pay
Charity or Uncompensated Care
Who Pays
for Hospice?
National Hospice and Palliative Care Organization. (2014). 2014 NHPCO Facts and Figures. NHPCO.org

24. Location
of Care
Hospice
• Patient home:
– Community
– Assisted living
– Long-term care
• Level of care:
– Routine home care
– Continuous care
– Inpatient care
– Respite care
Palliative Care
• Fee-for-service:
– Hospital
– Outpatient
– Skilled facilities
– Long-term care
• Member per month:
– Community-dwelling

25. Professional
Services
Palliative Care
• Depends upon the goals and
resources of the program
• No regulatory requirements
Hospice
• Interdisciplinary team mandated:
– Physician
– Nurse
– Social worker
• Optional support:
– OT/PT/Speech
– Respiratory therapy
– Music, massage,
pet, etc.
– Pastoral counselor
– CNA/aide
– Volunteer

26. Other
Support
Palliative Care
• No required services
Hospice
• Medications
• Equipment
• Bereavement care
• 24-hour availability
• Supplies:
– Incontinence products
– Nutritional support
– Wound care products

27. The
Symptom
Burden of
Serious
Illness
Other
Cancer Illnesses
Pain 84% 67%
Trouble breathing 47% 49%
Nausea and vomiting 51% 27%
Sleeplessness 51% 36%
Confusion 33% 38%
Depression 38% 36%
Loss of appetite 71% 38%
Constipation 47% 32%
Bedsores 28% 14%
Incontinence 37% 33%
Seale, C., Cartwright, A. (1994). The Year Before Death. Beatty.

28. Early
Palliative
Care in Lung
Cancer
Temel. et al. (2010). Early palliative care for patients with metastatic non-small-cell lung cancer.
New England Journal of Medicine, Aug 19;363(8):733-42.
0
10
20
30
40
50
HADS-D HADS-A PHQ-9
Standard Care Early Palliative Care

29. Severity of Symptoms in Hospitalized Elders
Pantilat, et al. (2012). Longitudinal assessment of symptom severity among hospitalized elders diagnosed with cancer,
heart failure, and chronic obstructive pulmonary disease. Journal of Hospital Medicine, September, 7(7)567-572.
Percent of moderate/severe symptoms in the past 24 hours at baseline, 24 hours later, and post discharge follow-up for cancer, heart failure (HF), and
chronic obstructive pulmonary disease (COPD).
53
39
22
47
42
25
71
34
54
0
20
40
60
80
100
Baseline 24-Hrs Follow-up
Pain
Cancer HF Follow-up
38 42
16
59
45
24
60
36
45
0
20
40
60
80
100
Baseline 24-Hrs Follow-up
Dyspnea
Cancer HF COPD
67
44
13
57
68
26
80
47
38
0
20
40
60
80
100
Baseline 24-Hrs Follow-up
Anxiety
Cancer HF COPD
64
53
16
63 65
28
77
46
55
0
20
40
60
80
100
Baseline 24-Hrs Follow-up
Symptom Burden
Cancer HF COPD

30. Concurrent
Palliative
Care in
Metastatic
Lung Caner
Temel, et al. (2010). Early palliative care for patients with metastatic non-small-cell lung cancer.
New England Journal of Medicine, Aug 19;363(8):733-42.

31. Patients who die on hospice live on
average 30 days longer than those
who die without it.
Lung Cancer
CHF Colon Cancer
Connor, et al. (2007). Comparing hospice and non-hospice patient survival among patients who die
within a three-year window. Journal of Pain Symptom Management, 33(3):238-46.

32. Inpatient
Palliative Care
Programs:
Center to
Advance
Palliative Care
(CAPC)
• Palliative care teams working in hospitals:
– Improve patient and family satisfaction with care
– Reduce 30-day readmission rates
– Reduce ICU utilization
– Can save 9-25% of costs for each inpatient stay
through a mixture of shorter length of stay and
reduced cost per day
• Palliative care teams working in home-based programs:
– Have been shown to save ACOs, health
plans, and health systems as much as $12,000
per person enrolled
– Reduce emergency department visits, hospital
admissions, hospital readmissions, and hospital
length of stay
• Health plans that train case managers in skills specific
to this patient population and who provide expanded
access to specialty palliative care have seen similar
savings while maintaining high rates of satisfaction
Center to Advance Palliative Care. (2020). The Case for Palliative Care. Retrieved from https://www.capc.org/the-case-for-palliative-care/

33. CAPC
Cost Impact
Analysis
Center to Advance Palliative Care. (2020). The Case for Palliative Care. Retrieved from https://www.capc.org/the-case-for-palliative-care/
Palliative Care Reduces Avoidable
Spending and Utilization in All Settings
48%
Readmissions
28%
Cost day
50%
Admissions
35%
ED visits
43%
Hospital
ED Transfers
36%
Total Costs
INPATIENT OUTPATIENT SKILLED NURSING HOME-BASED

34. 0
200
400
600
800
1000
1200
DirectCostperDay,$
0
200
400
600
800
1000
1200
1400
1600
1800
2000
-6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6
DirectCostperDay,$
Days Before and After Palliative Care Consultation
Cost Savings Associated With US Hospital
Palliative Care Consultation Programs
Morrison, et al. (2008). Cost savings associated with US hospital palliative care consultation programs.
Archives of Internal Medicine, 168(16):1783-1790. Retrieved from doi:10.1001/archinte.168.16.1783
Mean direct costs per day for palliative care patients who were discharged alive (A) or died (B) before and after palliative care consultation.
The solid line represents the regression curve of actual costs before palliative care consultation (day 0) and estimated costs (days 1-6) assuming
that palliative care consultation had not occurred. The dashed line represents direct costs per day for usual care patients for the 6 days before and
after hospital day 6 (patients with lengths of stay of ≤ 10 days), hospital day 10 (for patients with lengths of stay of 11-20 days), or hospital day
18 (for patients with lengths of stay of > 20 days).
Before palliative care consultation
After palliative care consultation
Day of palliative care consultation
A B

35. Cost Savings
Associated
With US
Hospital
Palliative Care
Consultation
Programs
(cont.)
Morrison, et al. (2008). Cost savings associated with US hospital palliative care consultation programs.
Archives of Internal Medicine, 168(16):1783-1790. Retrieved from doi:10.1001/archinte.168.16.1783
Mean direct costs per day for patients who died and who received
palliative care consultation on hospital days 7, 10, and 15 compared
with mean direct costs for usual care patients matched by propensity
score. Hospital day 1 is the first full day after the day of admission.
250
500
750
1000
1250
1500
1750
2000
1 3 5 7 9 11 13 15 17 19 21 23 25
DirectCostperDay,$
Usual Care Palliative care consultation day 10
Palliative care consultation day 7 Palliative care consultation day 15

36. Routine Care
vs. Inpatient
Palliative
Care
Gade, et al. (2008). Impact of an inpatient palliative care team: A randomized control trial.
Journal of Palliative Medicine, 11(2), 180-90. doi: 10.1089/jpm.2007.0055
Outcome
Inpatient
Palliative Care
Routine Care
Care experience 6.9 6.6
Doctor/nurses
communication
8.3 7.5
ICU admissions on
readmission
12 21
MSPB 6-months –4,855/patient –
Median hospice stay 24 days 12 days

37. 50
25
25
Without Hospice
Hospital
Home
Nursing Facility
Where Do
Patients
Spend Their
Last Days?
7
48
32
11
2
With Hospice
Hospital
Home
Nursing Facility
Hospice Unit
Residential Care Facility
National Hospice and Palliative Care Organization. (2018). 2018 NHPCO Facts and Figures. NHPCO.org

38. 27.9%
12.5%
13.4%
12.4%
7.7%
12.1%
14.1%
1-7
8-14
15-30
31-60
61-90
91-180
> 180
DayStratifications
Hospice
Length of
Service
National Hospice and Palliative Care Organization. (2020). NHPCO Facts and Figures: 2019 Edition
% of Patients by Days of Care for 2018*
*These values are computed using only days of care that occurred in 2018.
Days of care occurring in other years are not included. Days of care have
been combined for patients who had multiple episodes of care in 2018.

39. 0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.4
0.45
0.5
In-hospital deaths ICU admissions 30-day hospital
readmissions
Incrementalreductioninvarious
outcomes(proportional)
53-105 days 15-30 days 8-14 days 1-7 days
Hospice
Impact
Kelley, et al. (2013). Hospice enrollment saves money for Medicare and improves care quality
across a number of different lengths-of-stay. Health Affairs, 32(3):552–561.

40. Reasons for
Readmission
• Failure in discharge planning
• Insufficient outpatient and
community care
• Advanced, progressive illness

41. Care
Transitions

42. Medicare
Hospice
Benefit
Interdisciplinary
Team of Hospice
Professionals
Home Medical
Equipment
Medication Bereavement
Support
Continuous
Care
Respite CareInpatient CareRoutine
Home Care
These Services Are Mandated
by the Medicare Hospice Benefit

43. Four Levels
of Hospice
Care
National Hospice and Palliative Care Organization. (2020). NHPCO Facts and Figures: 2019 Edition.
1. Routine Home Care: 98.2%
– Available wherever
the patient calls home
– “Basic” and most
frequently delivered level
2. Intensive Comfort Care®
(continuous care): 0.2%
– Shifts of acute symptom
management in the home
for up to 24 hours/day per
Medicare guidelines.
3. Inpatient Care: 1.2%
– For symptoms that
cannot be managed
in the home
4. Respite: 0.3%
– Provides a break
for primary caregiver
– Inpatient setting
– Limited to five
consecutive days

44. Interdisciplinary
Hospice Team Patient and
Family
Volunteers
Physicians
Spiritual
Counselors
Social
Workers
Bereavement
Counselors
Hospice
Aides
Therapists
Nurses

45. Services Hospice Home Health
Nurse 24 hours/day Yes Variable
Nurse frequency of visits Unlimited Diagnosis-driven
Physician support Yes No
Medications included Yes No
Equipment included Yes No
Levels of care
Home, inpatient,
respite, continuous
home
Home
Bereavement support Yes No
Funding Medicare A Medicare B
Location of service Anywhere Home
Respiratory therapist Yes Variable
Service
Differentiators

46. Bereavement
• Hospice provides bereavement
services and offers grief and loss
support for the family after
patient dies
• For up to 13 months following
a death, hospice provides:
– Grief education resources,
letters, cards
– Phone support and/or visits,
if needed or requested by family
– Bereavement support groups
– Annual memorial activities
– Memory Bears

47. Hospice
Impact:
Satisfaction
• Hospice care is associated with better
symptom relief, patient goal attainment,
and quality of EOL care.
• Families of patients enrolled in hospice
more often reported that patients received
“just the right amount” of pain medicine and
help with dyspnea.
• Families of patients enrolled in hospice
also more often reported that patients’
EOL wishes were followed and EOL care
was “excellent.”
• Families of patients who received > 30 days
of hospice care reported the highest quality
EOL outcomes.
Kelley, et al. (2013). Hospice enrollment saves money for Medicare and improves care quality
across a number of different lengths of stay. Health Affairs, 32(3):552–561.

48. Hospice
Impact:
Satisfaction
• Hospice care is associated with better
symptom relief, patient goal attainment,
and quality of EOL care.
• Families of patients enrolled in hospice
more often reported that patients received
“just the right amount” of pain medicine and
help with dyspnea.
• Families of patients enrolled in hospice
also more often reported that patients’
EOL wishes were followed and EOL care
was “excellent.”
• Families of patients who received > 30 days
of hospice care reported the highest quality
EOL outcomes.
Kelley, et al. (2013). Hospice enrollment saves money for Medicare and improves care quality
across a number of different lengths of stay. Health Affairs, 32(3):552–561.

49. Hospice
Impact:
Satisfaction
• Hospice care is associated with better
symptom relief, patient goal attainment,
and quality of EOL care.
• Families of patients enrolled in hospice
more often reported that patients received
“just the right amount” of pain medicine and
help with dyspnea.
• Families of patients enrolled in hospice
also more often reported that patients’
EOL wishes were followed and EOL care
was “excellent.”
• Families of patients who received > 30 days
of hospice care reported the highest quality
EOL outcomes.
Kelley, et al. (2013). Hospice enrollment saves money for Medicare and improves care quality
across a number of different lengths of stay. Health Affairs, 32(3):552–561.

50. Hospice: In
Conclusion
• Hospice is:
– A service, not a place
– Provided in the patient’s preferred
setting, whether a private residence,
nursing home, assisted living facility,
or inpatient hospice setting
– Care that comforts and supports
when an advanced illness no longer
responds to curative treatments
– Making the most of the time
that remains
– Covered by the Medicare
Hospice Benefit

51. Summary
• Palliative care supports persons with
advanced illness and facilitates more
timely hospice referral
• Hospice and palliative care supports:
– Patients and families
– Clinicians
– Hospitals and health systems
• All successful palliative care programs
partner with a hospice

52. Partner With Hospice
“You matter because you are you.
You matter to the last moment of life, and we
will do all we can, not only to help you die
peacefully, but also to live until you die.”
—Dame Cicely Saunders
St. Christopher’s Hospice London, England

53. Questions?

54. Ballentine, J. (2020). Palliative care and COVID-19. Shelley Institute
for Palliative Care. Retrieved from https://csupalliativecare.org/
palliative-care-and-covid-19/
Center to Advance Palliative Care. (2011). 2011 Public Opinion Research
on Palliative Care. Retrieved from https://media.capc.org/filer_public/18/ab/
18ab708c-f835-4380-921d-fbf729702e36/2011-public-opinion-research-on-
palliative-care.pdf
Emanuel, et al. (2003). The Education in Palliative and End of Life Care
Curriculum (EPEC Project). Northwestern School University Feinberg
School of Medicine.
Gade, et al. (2008). Impact of an inpatient palliative care team: a
randomized control trial. Journal of Palliative Medicine, 11(2), 180-90.
doi: 10.1089/jpm.2007.0055
Hamel, et al. (April 2017). Views and experiences with end-of-life
medical care in the U.S. Kaiser Family Foundation. Retrieved from
https://www.kff.org/other/report/views-and-experiences-with-end-of-
life-medical-care-in-the-u-s/
Kelley, et al. (2013). Hospice enrollment saves money for Medicare
and improves care quality across a number of different lengths-of-stay.
Health Affairs, 32(3), 552–561.
Morrison, et al. (2008). Cost savings associated with US hospital palliative
care consultation programs. Archives of Internal Medicine, 168(16),
1783-90. https://doi.org/10.1001/archinte.168.16.1783
References

55. National Coalition for Hospice and Palliative Care. (2018).
Clinical Practice Guidelines for Quality Palliative Care, 4th Edition.
Retrieved from https://www.nationalcoalitionhpc.org/wp-content/uploads/
2018/10/NCHPC-NCPGuidelines_4thED_web_FINAL.pdf
National Hospice and Palliative Care Organization. (2020).
Explanation of Palliative Care. Retrieved from https://www.nhpco.org/
palliative-care-overview/explanation-of-palliative-care
National Hospice and Palliative Care Organization. (2020).
NHPCO Facts and Figures: 2019 Edition.
Pantilat et al. (2012). Longitudinal assessment of symptom severity
among hospitalized elders diagnosed with cancer, heart failure, and
chronic obstructive pulmonary disease. Journal of Hospital Medicine,
September, 7(7)567-572.
Robinson, et al. (2004). Assessment of the education for physicians
on end-of-life care (EPEC™) project. Journal of Palliative Medicine,
7(5), 637-645. https://doi.org/10.1089/jpm.2004.7.637
Seale, C., Cartwright, A. (1994). The Year Before Death. Beatty.
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