End-of-life care encompasses a wide range of needs in the last few years of a patient’s life including serious illness care, palliative care, and hospice. In end-of-life care programs, patients receive specialized medical treatment and social supports for conditions such as cancer, Alzheimer’s, end-stage renal disease, congestive heart failure, or many other advanced, life-threatening conditions. This type of care is focused on providing relief from the symptoms and stress of a serious illness and improving quality of life for both the patient and their family during this difficult journey.
No one person administers this type of care. The patient is supported by the entire care team—specialists, primary care providers, nurses, and/or social workers. End-of-life care is appropriate at any age and can be provided along with curative treatment at all stages of a serious illness. This means addressing it in the months and even years prior to a patient’s end-of-life, rather than limiting it to the weeks and days leading up to their passing.
At hospitals and clinics across the Partners system, clinicians are piloting new ways of supporting patients through end-of-life transitions, whether it’s developing new ways of care delivery, being better prepared to identify patients that have reached this stage in their life, or knowing how to have the most productive conversation about preparing and planning for the end-of-life.
Less than one third of patients with advancing serious illness (such as cancer, COPD, or dementia) discuss their values, goals and wishes with their clinicians. If conversations do occur, they tend to focus on medical procedures and treatments rather than a patient’s values and priorities. Individuals who have conversations with their clinicians about their goals and wishes are more likely to receive the care they want, have fewer non-beneficial medical treatments, and report better quality of life. Population Health has been working to educate clinicians on how to have the most productive conversation about patients’ preferences and making this information easily accessible to clinicians across the system.
- Shift the culture around serious illness so that both clinicians and patients are comfortable talking about these topics
- Educate clinical staff (doctors, social workers, or a nurse care managers) on best practices with interactive training sessions featuring clinical role-playing
- Making the Serious Illness Conversation Guide (developed by Ariadne Labs in collaboration with Brigham and Women’s and Dana-Farber clinicians) an easily accessible resource
- Integrating a Serious Illness module into patients’ electronic health records so notes about a patient’s goals and wishes are evident in their digital record and easily accessible across the Partners system
The Home-Based Palliative Care (HBPC) team helps support seriously ill patients who may not be appropriate or eligible for a designated hospice facility. The team consists of physicians, Nurse Practitioners, and Social Workers, who all make home visits in the greater Boston area. This team provides pain and symptom management in the patient’s home and also develops complex home care plans in collaboration with patients’ primary care physicians and specialists. When hospice becomes the best care plan for the patient, HBPC clinicians support patients and their families through the transition.
The Home-Based Palliative Care team supports seriously ill patients for one to two years before they transition to hospice, though sometimes patients are referred to the team when they are much closer to end-of-life. In these instances, the team helps patients transition to traditional hospice care.
The Home-Based Palliative Care program was launched Massachusetts General Hospital in 2014. In the years since, it has also been adopted by Brigham and Women’s Hospital. The goal is to scale this program across the Partners system.
Hospice is an intervention that patients and their families can elect when a patient has a terminal illness, a life expectancy of six months or less, and has decided to forego any further curative treatment for their illness. The care focuses on managing the physical, spiritual and emotional needs of the patient and their loved ones at the end-of-life. Hospice care can occur in one’s home or in hospice services in nursing facilities, assisted living facilities, hospice homes, or hospitals.
The Partners Hospice Collaborative Network is a group of Massachusetts licensed hospices*. The collaborative is committed to working in partnership with Partners on continuously improving the quality, outcomes, and efficiency of hospice care to best serve our patients and their families. The collaborative allows hospices across the state to share lessons learned and develop more standardized best-practices. The goal is to better connect our physicians and patients with high quality hospice providers and continue to integrate patient care across the continuum and improve end-of-life care.
This group of hospices is identified by Partners as meeting specific standards of quality in organizational structure and stability, clinical capabilities, geographic service area, clinical quality indicators, care at the time of death, bereavement care, and provider and family satisfaction.
*The Partners Hospice Collaborative Network includes the Cooley Dickinson VNA & Hospice, an affiliate of Partners Healthcare.
Partners Population Health offers Serious Illness Care Management programs for specific conditions:
To learn more about our End Stage Renal Disease Care Management Program, visit our High Risk Care Management page.
To learn about our Congestive Heart Failure Telemonitoring Program, visit our Assistive Technology page.