60 Rehabilitation Nursing • Vol. 35, No. 2 • March/April 2010
Palliative or Hospice Care?
Understanding the Similarities
Nancy Henne Batchelor, MSN RN CNS
With advances in health care and medical technology, the focus of medical care has been on curing. As people live longer,
the possibility of experiencing chronic and life-limiting disease not only increases but also spurs the ethical question “Is
length of life or quality of life most important?” Palliative care may be confused with hospice care, as both focus on symp-
tom management and improved quality of life for those with chronic life-limiting disease. A better understanding of each
healthcare option is needed for appropriate and timely patient referral. The purpose of this article is to identify the similarities
and differences between these two options, clarify when referral is appropriate for hospice or palliative care services, and
discuss the nurse’s role in caring for patients with chronic disease.
The projected life expectancy in 2050 for men and
women, respectively, is 81 and 87 years, according to
the 2000 census (He, Sengupta, Velkoff, & DeBarros,
2005). Statistics of significant health characteristics
reveal that 80% of those 65 years of age and older
have at least one chronic condition and 50% have at
least two chronic conditions (He et al.). As the num-
ber of people with life-limiting disease continues
to rise, there is a need to identify the trajectories of
illness and healthcare alternatives that can provide
viable choices when health status declines.
Nurses care for patients with multiple comor-
bidities who are being referred more frequently for
rehabilitation. Not only is rehabilitation ordered af-
ter surgery; it also is offered after acute illness or as a
general strengthening measure to prevent increasing
frailty secondary to chronic disease. When caring for
patients in a rehabilitation setting, nurses may face
questions regarding patient outcomes and the pos-
sibility of ceasing aggressive treatment. With knowl-
edge of end-of-life issues and palliative and hospice
care, nurses working in rehabilitation and any other
healthcare settings can help patients and families un-
derstand the basic principles of these modalities and
make informed decisions regarding their care.
Trajectories of Decline and End-of-
Three trajectories of decline have been identified for
people experiencing chronic illness: 20% experience
long-term maintenance of good function despite a
known fatal illness, with a few weeks or months of
rapid decline as the illness progresses and leads to
death (Trajectory 1); 25% experience slow decline
in physical capacities and periods of exacerbations
ending in a rather sudden death (Trajectory 2); and
40% experience long-term dwindling of function,
requiring years of personal care (Trajectory 3; Lynn,
2005). The remaining 15% of the population dies of
sudden illness or accidents.
Chronic conditions limit activity for more than 40
million people (Lorenz et al., 2004). Consequently, it
is safe to assume the majority of people with serious
chronic illness will live a long time with that illness,
and they will require supportive medical and nursing
care along the spectrum. The goal of healthcare pro-
viders and, in particular, the rehabilitation team is to
maximize and extend stable periods while adapting
to and managing chronic illness. Consider a patient
with progressive heart disease, for example. Manage-
ment requires an interdisciplinary approach using
multimodal strategies. During an acute event, a pa-
tient may experience a change in functional ability and
physical symptoms, as well as depression, anxiety, or
fear related to the diagnosis. Pharmacological manage-
ment may be necessary, as well as nonpharmacological
modalities to reduce risk factors and compensate for
damage that already has occurred. In addition, cardiac
rehabilitation may help to promote maximum function
through strategies to increase endurance and quality
of life. The Institute of Medicine’s 1997 report “Ap-
proaching Death: Improving Care at the End of Life”
identified care issues prevalent at the end of life includ-
ing failure to provide palliative and other types of care
known to be effective; provision of care that is known
to be ineffective or harmful; legal, organizational, and
economic obstacles detrimental to optimal care at the
end of life; failure to provide training that reflects at-
titudes, knowledge, and skills regarding good care for
dying patients; and the inability to discuss end-of-life
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Rehabilitation Nursing • Vol. 35, No. 2 • March/April 2010 61
issues realistically and comfortably (Institute of Medi-
More than 1 in 10 hospice families believe their
family member was referred “too late” to hospice; in
fact, one-third of hospice patients received care for less
than 1 week (National Hospice and Palliative Care Or-
ganization [NHPCO], 2008b; Teno et al., 2007). Almost
70% of those who die each year could benefit from
palliative or hospice care (NHPCO, 2008d). NHPCO
research consistently shows that most people prefer to
die at home, yet most die in hospitals (National Hos-
pice Foundation, 2007).
When cure is not possible, it is difficult to deter-
mine the right time to discuss palliative and end-of-
life care. When the subject is broached, the automatic
interpretation is death, the end, and one size fits all.
Healthcare professionals, patients, and families may
equate palliative care with hospice care. When hospice
and palliative care referrals finally are made, it often
is late in the illness or when a person is close to dying.
A better understanding of each healthcare option is
needed for appropriate and timely referral.
Historically, medical care has focused on cure.
As people live longer, the possibility of experiencing
chronic and life-limiting disease increases and raises
the ethical question, “Is length of life or quality of life
most important?” For people facing incurable or life-
limiting diseases, palliative care can be instituted as
early as at the time of diagnosis. This type of care is
coordinated by an interdisciplinary team of profes-
sionals focused on providing symptom management
with the goal of enhancing quality of life.
Palliative care is “an approach that improves the quali-
ty of life of patients and their families facing the prob-
lem associated with life-threatening illness, through
the prevention and relief of suffering by means of
early identification and impeccable assessment and
treatment of pain and other problems, physical, psy-
chosocial and spiritual” (WHO, 2002b, p. 3).
Palliative care evolved from the hospice movement
and has become a care-management strategy to care
for patients who have chronic illnesses but are not yet
eligible for hospice support. Palliative care is a resource
for anyone who has a chronic disease that eventually
will cause his or her death, or for elderly people who
experience general disability and discomfort. Palliative
interventions can be implemented in conjunction with
curative interventions during all phases of an illness.
Any chronic disease can be managed using palliative
care principles, and treatment can be customized to
meet the needs of each person. Not only are physical
symptoms addressed, but support is also provided for
the psychosocial and spiritual challenges that arise for
both the patient and the family. The goal is to provide
the best-possible quality of life for each person dur-
ing the course of an illness and to improve quality of
dying for people and families facing a life-threatening
The WHO (2002a) identifies key characteristics
of palliative care (Table 1). During the last 5 years,
NHPCO further expanded the WHO definition
of palliative care, explaining that “Palliative care
extends the principles of hospice care to a broader
population that could benefit from receiving this type
of care earlier in their illness or disease process. No
specific therapy is excluded from consideration. An
individual’s needs must be continually assessed and
treatment options should be explored and evaluated in
the context of the individual’s values and symptoms.
Palliative care, ideally, would segue into hospice
care as the illness progresses” (NHPCO, 2003, p. 1).
Moreover, palliative care can be provided in a variety
of settings, including the home, assisted living facility,
long-term care facility, or hospital. Care is provided
Table 1. World Health Organization Key Characteristics of
Palliative Care (WHO, 2002a)
Provides relief from pain and other distressing symptoms
Affirms life and regards dying as a normal process
Intends neither to hasten nor postpone death
Integrates the psychological and spiritual aspects of patient care
Offers a support system to help patients live as actively as possible until death
Offers a support system to help the family cope during the patients’ illness and during their own bereavement
Uses a team approach to address the needs of patients and their families, including bereavement counseling if
Will enhance quality of life, and also may positively influence the course of illness
Is applicable early in the course of illness in conjunction with other therapies that are intended to prolong life,
such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and
manage distressing clinical complications
62 Rehabilitation Nursing • Vol. 35, No. 2 • March/April 2010
Palliative or Hospice Care? Understanding the Similarities and
by an interdisciplinary team including physicians,
nurses, social workers, dieticians, pharmacists, and
complementary therapists. Primary care physicians
also work in conjunction with palliative care physicians
to provide seamless care.
Palliative care is not reserved for adults. Pediatric
palliative care can be initiated for children experienc-
ing serious illness that may become fatal. Children
may be symptom-free and live “normal” lives between
periods of exacerbation. Families frequently sacrifice
their life savings and employment to seek treatment,
focusing their energies on the ill child while siblings
are cared for by others during their absence, and leave
support systems behind if treatment centers are located
outside their geographic area.
For people experiencing progressive heart failure,
pharmacological modalities enhance comfort while
nonpharmacological interventions focus on adapta-
tion and increased functioning. Energy-conservation
strategies and education about early identification of
symptoms signaling exacerbation are interventions
that are considered palliative measures in the treat-
ment of advanced cardiac disease. As the disease pro-
gresses and the heart’s pumping capacity diminishes,
patients experience unrelieved physical symptoms
such as breathlessness, fatigue, and difficulty walking
and sleeping. These symptoms accentuate psychologi-
cal, social, and spiritual symptoms. By taking a pal-
liative approach, patients with heart failure who are
at the end of life receive treatment that is intended to
relieve or eliminate symptoms and provide individual-
ized comfort care.
Open communication and respect for family roles
are other crucial elements in optimal end-of-life care.
Positive outcomes for patients and families can be
achieved through honest discussions that may cover
available services, conflict resolution on withholding
or withdrawing therapy, medical futility, and expecta-
tions about the final hours of life. With effective symp-
tom management and use of palliative principles,
quality of life can be enhanced for people experiencing
Hospice is a philosophy of care dating back to the
early Middle Ages (Paradis, 1985; Stoddard, 1991)
that became incorporated into modern-day health
care in 1967 through the work of Dame Cicely
Saunders in London, who specialized in humane
and compassionate care of dying people during the
last phases of incurable diseases (Kuebler, Davis,
& Moore, 2005). Hospice is an interdisciplinary
approach to providing comprehensive care for those
approaching the end of life. To qualify for hospice
services (Table 2), a patient must be in the terminal
phase of an illness with a life expectancy of 6 or
fewer months as certified by two physicians (U.S.
Department of Health and Human Services, 2001).
Hospice care focuses on symptom management,
which enables patients to maintain dignity and
quality of life. Hospice treats the person and fam-
ily rather than the disease and affirms life, neither
hastening nor prolonging death (NHPCO, 2008a).
NHPCO states “hospice recognizes that the dying
process is a part of the normal process of living and
focuses on enhancing the quality of remaining life”
(NHPCO, 2008a. p. 2). Support and comfort-care
measures are employed so patients can live as fully
and comfortably as possible.
The hospice team includes an interdisciplinary
team of professionals including physicians, nurses,
home health aides, social workers, chaplains, coun-
selors, and trained volunteers working together to pro-
vide physical, emotional, and spiritual care to patients
and families. Table 3 lists major responsibilities of the
team as identified by NHPCO (2008d).
Hospice care can be provided across settings. More
than 90% of hospice services are provided in the home
setting (American Cancer Society, 2008). Other setting
options include hospital-based hospices, long-term-
care facility-based hospices, and independent or free-
standing hospice units. Admission to an inpatient
acute-care unit is granted only for patients experienc-
ing a crisis situation necessitating symptom manage-
ment. Patients requiring inpatient admission must
have uncontrolled pain or other uncontrolled physi-
cal symptoms, a caregiver or spiritual crisis, or safety
issues. Regardless of the setting, comprehensive care
is coordinated by the hospice team in conjunction with
the facility healthcare team.
Key Practice Points
1. As the number of people suffering from life-limiting diseases
continues to increase, there is a lack of information
available to help patients make healthcare choices when
health status declines.
2. People with serious chronic illness often live long lives and
require effective supportive medical care throughout the
3. Early referral to palliative or hospice care can provide
symptom management and increased quality of life for
patients suffering progressive chronic disease.
4. Nurses can provide support and guidance for patients and
families as they experience chronic illness, declining health,
and face end-of-life issues.
Rehabilitation Nursing • Vol. 35, No. 2 • March/April 2010 63
A special supplement to the Hastings Center Report
“Access to Hospice Care: Expanding the Boundaries,
Overcoming Barriers,” identified problems related
to hospice care access: Some dying patients never
are referred to hospice, some are referred only in the
final days of life, and some aspects of hospice care
are needed before the last 6 months of life (Jennings,
Ryndes, D’Onodrio, & Baily, 2003). Jennings and col-
leagues also identified cultural differences and barri-
ers as contributors to inequitable distribution and use
of hospice services. Hospice services are not reserved
only for people with cancer. Fewer than 25% of deaths
in the United States are due to cancer, and only 41%
of hospice patients have a cancer diagnosis (Heron,
Hoyert, Xu, Scott, & Tejada-Vera, 2008). The majority
of deaths are attributed to chronic conditions such as
heart disease, unspecified debility, dementia, and lung
disease (NHPCO, 2008b).
Unlike palliative care, for which eligibility is not
restricted by federal guidelines, patients must meet
hospice-admission criteria as defined by Medicare
hospice benefit guidelines (Forman, Kitzes, Ander-
son, & Sheehan, 2003). Hospice services also can be
reimbursed through Medicaid or private insurance
plans. According to NHPCO (2008), more than 90%
of hospices in the United States are certified by
Medicare because the majority of patients using hos-
pice services are older than age 65. Hospice services
are available to anyone who meets eligibility criteria
regardless of age.
Medicare Part B and Medicaid cover some
treatments and medications used in palliative care.
Private insurers also provide some coverage for
palliative care through chronic care and long-term care
benefits, but these benefits vary based on individual
plans. Patients and families can contact their insurance
providers for specific information about policies and
Nurses are positioned to integrate palliative and
end-of-life care into their practice through educa-
tion, support, and guidance for patients and families
as they cope with the stresses of chronic illness
and declining health. Nurses must have a sound
knowledge base about death and dying and be able
to provide competent and compassionate care for
seriously ill or dying patients. End-of-life content
included in undergraduate and graduate nursing
curricula can strengthen a nurse’s knowledge and
skills. Consultation and collaboration between nurs-
ing and medical schools and residency programs
can provide needed educational and training experi-
ences. Continuing education programs provide the
theoretical component on pathophysiology, death,
and dying, while consultation with palliative care
nurse specialists and hospice-referral services can
provide clinical support for nurses caring for seri-
ously or chronically ill patients.
Compassionate and comprehensive conversations
early in the disease process about patient care options,
patient wishes, and care management can promote
Table 2. Hospice Admission Criteria
The patient is certified as being terminal, with a life expectancy of 6 or fewer months if the illness runs its
The patient wants hospice care.
The patient has a physician who is willing to provide medical care and consultation.
Table 3. Major Responsibilities of the Hospice Team
Managing pain and symptoms
Providing needed medications, medical supplies, and equipment
Coaching and educating family caregivers
Delivering special services when needed
Making short-term inpatient care available for symptom management or respite
Providing grief/bereavement support for loved ones and friends
Table 4. Community and Support Resources
National Hospice and Palliative Care Organization
Center to Advance Palliative Care
64 Rehabilitation Nursing • Vol. 35, No. 2 • March/April 2010
increased understanding of the illness and care
choices and improve quality of life. Physical, social,
and spiritual patient assessments provide nurses
and the team with the necessary information to form
individualized care options. Education about disease
progression, symptom management, and available
community resources (Table 4) is paramount in
decision making for those who are considering a
palliative care or hospice program. Discussing care
options with patients and families is essential to
developing an appropriate plan to promote quality
health care and to initiate support for those coping
with life-limiting diseases as they near the end of life.
About the Author
Nancy Henne Batchelor, MSN RN CNS, is an assistant profes-
sor of clinical nursing at the University of Cincinnati in Cincin-
nati, OH. Address correspondence to her at nancy.batchelor@
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