Living as Fully and Comfortably as Possible At Every Stage of Serious Illness

WHAT IS PALLIATIVE MEDICINE?

Palliative medicine is specialized, patient- and family-centered care for people living with serious illness.

Its purpose is to prevent and relieve suffering, manage distressing symptoms, support informed decision-making, and help patients pursue the best quality of life reasonably possible.

Depending on the patient's needs and the services authorized under a particular program, palliative care may address:

• Pain
• Shortness of breath
• Fatigue and weakness
• Nausea and vomiting
• Loss of appetite
• Sleep disturbance
• Anxiety and depression
• Cognitive and emotional distress
• Reduced mobility and functional decline
• Medication burden
• Caregiver stress
• Social and practical challenges
• Spiritual or existential concerns
• Uncertainty about treatment choices
• Advance-care planning
• Coordination among multiple healthcare professionals

Palliative care can begin at any appropriate stage of a serious illness and may continue while the patient receives treatments intended to control, stabilize, or potentially cure the underlying condition.

Palliative care and hospice share a commitment to comfort, dignity, symptom relief, and support for patients and families. However, they are not interchangeable.

Palliative care:

• May be appropriate at different stages of serious illness
• May be provided alongside disease-directed or curative treatment
• Does not inherently require a six-month prognosis
• May be delivered in hospitals, clinics, facilities, homes, or virtual settings
• Is guided by the patient's needs, symptoms, goals, and clinical circumstances

Hospice care:

• Is intended for patients who meet applicable terminal-illness eligibility requirements
• Under the Medicare hospice benefit, generally requires physician certification that the patient's life expectancy is six months or less if the illness follows its normal course
• Requires the patient to elect hospice coverage for care related to the terminal illness
• Focuses on comfort rather than treatment intended to cure the terminal illness

When hospice becomes clinically appropriate, Hospitals Without Walls™ may help support an informed, respectful, and properly coordinated transition to a qualified hospice provider.

Palliative care does not require a patient to abandon hope. It helps define what the patient is hoping for and organizes care around informed and achievable goals.

WHO MAY BENEFIT?

Palliative care may be considered when serious illness causes symptoms, functional limitations, repeated healthcare utilization, difficult treatment decisions, caregiver burden, or substantial disruption to daily life.

Patients who may benefit include people living with:

• Cancer
• Heart failure or advanced cardiovascular disease
• Chronic obstructive pulmonary disease or other advanced lung disease
• Chronic kidney disease or renal failure
• Liver disease
• Dementia or other neurocognitive disorders
• Parkinson's disease
• Stroke related disability
• Amyotrophic lateral sclerosis
• Multiple sclerosis
• Serious neurologic or neuromuscular disease
• Complex diabetes with significant complications
• Frailty and progressive functional decline
• Multiple chronic conditions
• Recurrent infections or wounds
• Frequent hospitalizations or emergency department visits
• Significant pain or other persistent symptoms
• Serious illness accompanied by emotional, social, or spiritual distress

Eligibility and the appropriate level of service are determined individually, based on clinical need, professional assessment, applicable coverage requirements, available resources, and the terms of the patient's healthcare program or contract.

Hospitals Without Walls™ approaches serious illness through the principles of EntireoPathic Medicine™—considering the patient as a whole person rather than treating each diagnosis in isolation.

We seek to understand:

• What symptoms are interfering with the patient's life?
• What matters most to the patient?
• What outcomes does the patient consider meaningful?
• What treatments are currently being provided?
• What benefits and burdens may accompany those treatments?
• How is the illness affecting daily function and independence?
• What emotional, social, cultural, or spiritual concerns require attention?
• What support does the family or caregiver need?
• Who is responsible for each part of the care plan?
• How should changes in condition be communicated and addressed?
• Are the patient's goals understood across the care team?
• What should happen if the illness progresses or a crisis occurs?

These questions help create a coordinated plan that respects the patient's values, preferences, medical circumstances, and right to participate in decisions.

A palliative assessment may evaluate areas such as:

• Pain and symptom burden
• Disease progression and complications
• Medication effectiveness and adverse effects
• Nutrition and hydration concerns
• Sleep and energy
• Skin integrity and wounds
• Continence
• Respiratory symptoms
• Mobility and fall risk
• Functional ability
• Treatment burden

• Anxiety
• Depression
• Fear and uncertainty
• Emotional distress
• Coping capacity
• Cognitive changes
• Grief and anticipatory grief
• Behavioral symptoms

• Living situation
• Family and caregiver availability
• Transportation
• Financial or insurance barriers
• Access to medications and equipment
• Food and housing security
• Language and communication needs
• Cultural considerations
• Social isolation

• Sources of meaning, strength, and hope
• Religious or spiritual preferences
• Concerns about suffering, dignity, or mortality
• Unresolved relationships or personal priorities
• Desired spiritual or community support

• Caregiver capacity
• Physical and emotional strain
• Knowledge and training needs
• Safety concerns
• Respite needs
• Ability to carry out the care plan
• Need for additional community resources

Assessment findings are used to help determine priorities, coordinate appropriate services, and identify concerns that require referral or escalation.

Persistent symptoms can limit function, disturb sleep, increase emotional distress, burden caregivers, and contribute to avoidable crises.

Our coordinated approach may support the evaluation and management of:

• Pain
• Breathlessness
• Fatigue
• Weakness
• Nausea
• Vomiting
• Constipation
• Diarrhea
• Loss of appetite
• Difficulty swallowing
• Insomnia
• Anxiety
• Depression
• Delirium
• Agitation
• Excessive secretions
• Itching
• Swelling
• Reduced mobility
• Other distressing symptoms associated with serious illness or treatment

Symptom management may involve medication review, nonpharmacologic strategies, functional support, patient and caregiver education, monitoring, specialist consultation, or changes to the care plan.

All treatment decisions must be made by appropriately qualified and authorized healthcare professionals within their lawful scope of practice.

Clear Conversations. Informed Choices. Respectful Care.

Patients and families may face complex decisions involving tests, procedures, hospitalizations, medications, rehabilitation, artificial nutrition, life-sustaining treatment, or transitions in the focus of care.

Hospitals Without Walls™ supports structured communication intended to help patients and their authorized representatives understand:

• The patient's medical condition
• Available treatment options
• Reasonably expected benefits and burdens
• Areas of uncertainty
• Potential changes in function or quality of life
• The patient's stated goals and priorities
• Which decisions may need to be made
• Who should participate in those decisions
• What support is available

Our role is not to impose a predetermined choice. Our role is to support informed, voluntary, patient-centered decision-making in coordination with the patient's treating professionals.

Goals of care planning helps connect medical treatment with what the patient values most.

A patient's priorities may include:

• Relief from pain or breathlessness
• Remaining at home when safely possible
• Preserving independence
• Maintaining alertness and communication
• Continuing disease-directed treatment
• Avoiding burdensome interventions
• Attending an important family event
• Supporting cultural or religious practices
• Reducing caregiver strain
• Preparing for possible disease progression
• Spending meaningful time with loved ones

Goals may change as the illness, treatment options, function, or personal circumstances change. For that reason, goals of care planning should be revisited at clinically appropriate intervals and after important changes in condition.

Advance-care planning gives patients an opportunity to communicate their values, preferences, and decision-making instructions before an emergency makes communication difficult or impossible.

When appropriate, the care process may include discussion of:

• The patient's understanding of the illness
• Values and acceptable quality-of-life considerations
• Selection of an authorized healthcare decision-maker
• Advance directives
• Preferences concerning life-sustaining treatments
• Physician or medical orders for life-sustaining treatment, where applicable
• Preferred place of care
• Emergency plans
• Circumstances that should prompt hospitalization
• Preferences for future care if the condition worsens

Advance care planning documents do not replace ongoing clinical judgment, informed consent, or communication with the patient. They help inform care when they are valid, available, applicable, and consistent with governing law.

Serious illness affects the entire family and care network.

Family caregivers may be responsible for medication administration, mobility assistance, personal care, symptom observation, transportation, appointments, communication with clinicians, and emergency decisions—often without sufficient training or support.

Depending on program design and available resources, caregiver support may include:

• Education about the patient's condition
• Guidance on warning signs and escalation procedures
• Medication and symptom-management education
• Safe mobility and transfer instruction
• Care plan clarification
• Emotional support
• Assessment of caregiver strain
• Connection to community resources
• Social work services
• Spiritual care resources
• Respite care referrals
• Support during transitions in care
• Bereavement resource referrals when appropriate

Supporting caregivers can strengthen the care plan and help identify problems before they become crises.

Depending on the applicable contract, clinical need, geographic availability, professional licensure, and payer authorization, palliative services may be coordinated through:

• Patient homes
• Hospitals
• Medical practices
• Skilled nursing facilities
• Assisted living communities
• Post acute settings
• Community based organizations
• Telehealth and virtual care
• Mobile healthcare services
• Remote patient monitoring
• Partner healthcare organizations

The objective is not to replace necessary hospital or specialty care. It is to strengthen continuity across settings and reduce the risk that the patient becomes lost between different professionals, organizations, and episodes of care.

One Patient. One Coordinated Plan.

Serious illness frequently requires the involvement of multiple professionals and organizations.

Based on patient needs and program structure, coordinated palliative care may involve:

• Primary care physicians
• Palliative medicine physicians
• Medical specialists
• Nurse practitioners
• Physician assistants
• Registered nurses
• Pharmacists
• Social workers
• Behavioral health professionals
• Chaplains or spiritual-care professionals
• Rehabilitation professionals
• Dietitians
• Home health professionals
• Hospice professionals
• Community health workers
• Care coordinators
• Facility personnel
• Family and authorized caregivers

Each participating professional remains responsible for services provided within that professional's role, licensure, credentials, and scope of practice.

Hospitals Without Walls™ seeks to improve communication, clarify responsibilities, identify gaps, and organize the care continuum around the patient.

Patients with serious illness may experience sudden or progressive changes in symptoms, cognition, mobility, nutrition, or function.

A coordinated palliative plan may identify:

• Symptoms requiring routine follow-up
• Changes requiring same day clinical contact
• Warning signs requiring urgent evaluation
• Circumstances requiring emergency services
• Which professional or organization should be contacted
• How after hours concerns should be handled
• Medication and treatment instructions
• Patient and family preferences
• Required communication among participating providers

Palliative care does not eliminate all hospitalizations or emergencies. Its purpose is to improve preparation, recognition, communication, and clinical response while ensuring that necessary emergency care is not delayed.

Emergency Notice: Hospitals Without Walls™ website services are not a substitute for emergency care. Anyone experiencing a medical emergency should call 911 or the appropriate local emergency number immediately.

Palliative needs may evolve over time.

A patient may move among:

• Hospital care
• Outpatient care
• Home based services
• Home health
• Rehabilitation
• Skilled nursing care
• Assisted living
• Long-term care
• Specialty palliative care
• Hospice care

Hospitals Without Walls™ may help support communication and continuity during these transitions so that critical information, treatment preferences, medication plans, and follow-up responsibilities are not unnecessarily fragmented.

When hospice evaluation becomes appropriate, the patient and family should receive clear information about available options without pressure, abandonment, or automatic discontinuation of support.

Palliative-care quality cannot be measured through utilization or cost alone.

Depending on the contract and available data, measures may include:

• Change in pain and symptom burden
• Patient reported quality of life
• Goal concordant care
• Patient and family experience
• Timeliness of palliative assessment
• Completion of medication review
• Documentation of goals-of-care discussions
• Advance care planning documentation
• Caregiver needs and burden
• Functional status
• Care plan completion and follow up
• Emergency department utilization
• Hospital admissions and readmissions
• Transitions between care settings
• Hospice referral and timing, when clinically appropriate
• Place of care and place of death, when voluntarily expressed and lawfully measured
• Communication among participating providers
• Total cost of care, when contractually authorized and methodologically appropriate

Outcomes must be interpreted carefully because patients receiving palliative care often have advanced illness, substantial symptom burden, and complex social or functional needs.

Hospitals Without Walls™ does not promise that every hospitalization, emergency visit, complication, or cost can be prevented.

Hospitals Without Walls™ seeks partnerships with:

• Hospitals and health systems
• Health plans and insurance companies
• Physician groups
• Accountable care organizations
• Government agencies
• Military and veterans healthcare programs
• Skilled nursing and post-acute facilities
• Assisted living and senior communities
• Home health organizations
• Community healthcare organizations
• Employers and commercial organizations

Programs may be designed around defined populations, clinical needs, service areas, quality priorities, and contractual objectives.

Potential program components may include:

• Serious-illness population identification
• Comprehensive palliative assessment
• Symptom-management coordination
• Goals of care support
• Advance care planning
• Caregiver support
• Transitional care
• Mobile and home based services
• Telehealth
• Remote monitoring
• Medication review
• Behavioral and PsychoSpiritual support
• Interdisciplinary case conferences
• Referral coordination
• Quality and utilization reporting

Final program design depends on the contracting organization's objectives, patient population, applicable law, payer requirements, professional resources, data availability, and mutually approved scope of services.

Hospitals Without Walls™ believes that people living with serious illness deserve:

• Relief from avoidable suffering
• Honest and understandable communication
• Respect for personal values and choices
• Participation in decisions
• Coordinated care across settings
• Support for family and caregivers
• Attention to physical, emotional, social, and spiritual needs
• Protection from discrimination, coercion, and abandonment
• Access to appropriate treatment and emergency care
• Dignity throughout the course of illness

Palliative medicine is not about giving up.

It is about helping people live as fully, comfortably, meaningfully, and safely as possible while navigating serious illness.

Hospitals Without Walls™ works with healthcare organizations seeking to improve palliative support, coordination, patient experience, caregiver support, and continuity across the care continuum.

Hospitals Without Walls™ is a healthcare coordination and partnership model. Specific clinical services vary according to the participating organization, location, professional licensure, credentialing, contractual scope, payer authorization, and applicable law.

Information on this website is educational and does not constitute individualized medical advice, diagnosis, treatment, insurance coverage confirmation, or a guarantee of clinical or financial outcomes.

Patients should consult their qualified treating healthcare professionals regarding individual medical needs and treatment decisions.

The clinical principles presented on this page are consistent with authoritative guidance describing palliative care as an approach that relieves suffering and addresses physical, psychosocial, and spiritual needs while supporting patients and families.

• World Health Organization — Palliative Care
• National Institute on Aging — What Are Palliative Care and Hospice Care?
• Centers for Medicare & Medicaid Services — Hospice and Palliative Care
• CMS — Medicare Hospice Coverage
• CMS Innovation Center — Palliative Care Projects: Synthesis of Evaluation Results
• National Academies — Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life