Table Of ContentPalliative Care
Core Skills and
Clinical Competencies
LINDA L. EMANUEL, MD, PhD
Buehler Professor of Medicine
Director, Buehler Center on Aging, Health & Society Principal,
The Education in Palliative and End-of-Life Care (EPEC) Project
Northwestern University Feinberg School of Medicine
Chicago, Illinois
S. LAWRENCE LIBRACH, MD, CCFP, FCFP
W. Gifford-Jones Professor
Professor and Head, Division of Palliative Care
Department of Family and Community Medicine
University of Toronto
Director, Temmy Latner Centre for Palliative Care
Mount Sinai Hospital
Toronto, Ontario, Canada
Palliative Care
Core Skills and
Clinical Competencies
SECOND EDITION
3251 Riverport Lane
St. Louis, Missouri 63043
PALLIATIVE CARE: CORE SKILLS AND CLINICAL COMPETENCIES ISBN: 978-1-4377-1619-1
EXPERT CONSULT ONLINE AND PRINT, SECOND EDITION
Copyright © 2011, 2007 by Saunders, an imprint of Elsevier Inc.
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any
means, electronic or mechanical, including photocopying, recording, or any information storage and
retrieval system, without permission in writing from the publisher. Details on how to seek permission,
further information about the Publisher’s permissions policies and our arrangements with organizations
such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website:
www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical
treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described herein. In
using such information or methods they should be mindful of their own safety and the safety of
others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the
most current information provided (i) on procedures featured or (ii) by the manufacturer of each
product to be administered, to verify the recommended dose or formula, the method and duration
of administration, and contraindications. It is the responsibility of practitioners, relying on their
own experience and knowledge of their patients, to make diagnoses, to determine dosages and the
best treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors
assume any liability for any injury and/or damage to persons or property as a matter of products
liability, negligence or otherwise, or from any use or operation of any methods, products,
instructions, or ideas contained in the material herein.
Library of Congress Cataloging-in-Publication Data
Palliative care : core skills and clinical competencies / [edited by] Linda L. Emanuel, S. Lawrence
Librach. — 2nd ed.
p. ; cm.
“Expert consult online and print.”
Includes bibliographical references and index.
ISBN 978-1-4377-1619-1 (pbk.)
1. Palliative treatment. I. Emanuel, Linda L. II. Librach, S. Lawrence.
[DNLM: 1. Palliative Care. 2. Clinical Competence. WB 310]
R726.8.P3427 2011
616′.029—dc22
2011006018
Acquisitions Editor: Pamela Hetherington Project Manager: Jessica Becher
Developmental Editor: Jessica Pritchard Design Manager: Ellen Zanolle
Publishing Services Manager: Anne Altepeter
Printed in the United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1
Courtesy St. Christopher’s Hospice, London, UK
“The last stages of life should not be seen as defeat, but rather as life’s fulfillment.
It is not merely a time of negation but rather an opportunity for positive achievement.
One of the ways we can help our patients most is to learn to believe and to
expect this.”
Cicely Saunders, 1965
—First published in American Journal of Nursing;
republished in Cicely Saunders: selected writings by David Clark
Oxford University Press, 2006
We dedicate this book to the memory of Dame Cicely Saunders. In its pages, we
have sought to provide for the core skills that a clinician needs to make it possible
for every man, woman, and child that, when dying is necessary, it becomes life’s
fulfillment.
Linda L. Emanuel, S. Lawrence Librach
This page intentionally left blank
CONTRIBUTORS
Carla S. Alexander, MD
Assistant Professor of Medicine, Department of Medicine, University of Maryland
School of Medicine, Institute of Human Virology, Baltimore, Maryland
HIV/AIDS
Wendy G. Anderson, MD, MS
Assistant Professor, Division of Hospital Medicine and Palliative Care Program,
University of California, San Francisco, San Francisco, California
Withholding and Withdrawing Life-Sustaining Therapies
Peter Angelos, MD, PhD
Professor and Chief of Endocrine Surgery, Associate Director of the MacLean
Center for Clinical Medical Ethics, Department of Surgery, University of
Chicago, Chicago, Illinois
Principles of Palliative Surgery
Robert M. Arnold, MD
Professor of Medicine, Division of General Internal Medicine, Chief, Section of
Palliative Care and Medical Ethics, Director, Institute for Doctor-Patient
Communication, University of Pittsburgh School of Medicine, Pittsburgh,
Pennsylvania
Leo H. Criep Chair in Patient Care, School of Medicine, University of Pittsburgh,
Pittsburgh, Pennsylvania
Withholding and Withdrawing Life-Sustaining Therapies
F. Amos Bailey, MD
Associate Professor Division of Geriatrics, Gerontology and Palliative Care,
Internal Medicine, University of Alabama, Birmingham, Alabama
Director, Safe Harbor Palliative Care Program, Internal Medicine, Birmingham VA
Medical Center, Birmingham, Alabama
Veterans, Veterans Administration Health Care, and Palliative Care
Al B. Benson III, MD, FACP
Professor of Medicine Division of Hematology/Oncology, Northwestern University
Feinberg School of Medicine, Chicago, Illinois
Gastrointestinal Malignancies
Ann M. Berger, MD, MSN
Bethesda, Maryland
Nausea and Vomiting
vii
viii
Contributors
Richard H. Bernstein, MD, FACP
Adjunct Associate Professor, Baruch/Mount Sinai MBA Program in Health Care
Administration, Zicklin School of Business of the City University of New York,
New York, New York
Associate Professor of Clinical Medicine, Department of Medicine, Associate
Professor of Clinical Preventive Medicine, Department of Preventive Medicine,
The Mount Sinai School of Medicine, New York, New York
Chief Medical Officer, VNSNY CHOICE Health Plan, Visiting Nurse Service of New
York, New York, New York
Integrating Palliative Care Guidelines into Clinical Practice
Susan Blacker, MSW
Adjunct Lecturer, Division of Palliative Care, Department of Family and
Community Medicine, University of Toronto
Director, Cancer Services Planning & Performance, St. Michael’s Hospital, Toronto,
Ontario, Canada
Supporting the Family in Palliative Care
Alexander A. Boni-Saenz, JD, MSc
Skadden Fellow/Staff Attorney, Chicago Medical-Legal Partnership for Seniors, Legal
Assistance Foundation of Metropolitan Chicago, Chicago, Illinois
The Economic Burden of End-of-Life Illness
Robert O. Bonow, MD
Max and Lily Goldberg Distinguished Professor of Cardiology, Chicago, Illinois
Vice Chairman, Department of Medicine, Chicago, Illinois
Director, Center for Cardiovascular Innovation, Chicago, Illinois
Northwestern University Feinberg School of Medicine, Chicago, Illinois
Heart Failure and Palliative Care
Kerry W. Bowman, MSW, PhD
Assistant Professor, Department of Family and Community Medicine, University
of Toronto, Toronto, Ontario, Canada
Clinical Bioethicist, Department of Bioethics, Mount Sinai Hospital, Toronto,
Ontario, Canada
Understanding and Respecting Cultural Differences
Eduardo Bruera, MD
Professor, Department of Palliative Care and Rehabilitation Medicine, Chair,
Department of Palliative Care and Rehabilitation Medicine, The University of
Texas MD Anderson Cancer Center, Houston, Texas
Palliative Care in Developing Countries
Robert Buckman, MB, PhD
Professor, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
Adjunct Professor, The University of Texas MD Anderson Cancer Center, Houston,
Texas
Medical Oncologist, Department of Medical Oncology, Princess Margaret Hospital,
Toronto, Ontario, Canada
Communication Skills
ix
Contributors
Toby C. Campbell, MD, MSCI
Assistant Professor, Department of Medicine, University of Wisconsin, Madison,
Wisconsin
Hematology/Oncology
Elizabeth K. Chaitin, MSW, DHCE
Assistant Professor of Medicine, Department of Medicine, University of Pittsburgh,
Pittsburgh, Pennsylvania
Director, Department of Medical Ethics and Palliative Care Services, University of
Pittsburgh Medical Center Shadyside, Pittsburgh, Pennsylvania
Withholding and Withdrawing Life-Sustaining Therapies
Anita Chakraborty, MD, CCFP
Lecturer, Department of Family and Community Medicine, Division of Palliative
Care, University of Toronto, Toronto, Ontario, Canada
Consultant, Department of Palliative Care, Sunnybrook Health Science Centre,
Toronto, Ontario, Canada
Neurodegenerative Diseases
Harvey Max Chochinov, MD, PhD
Professor of Psychiatry, Community Health Sciences, and Family Medicine,
Division of Palliative Care, University of Manitoba
Director of the Manitoba Palliative Care Research Unit, CancerCare Manitoba,
University of Manitoba, Manitoba, Canada
The Therapeutic Implications of Dignity in Palliative Care
Alexie Cintron, MD, MPH
Director, Pain and Palliative Care Fellowship, Memorial-Sloan Kettering Cancer
Center, New York, New York
Palliative Care Services and Programs
Kenneth E. Covinsky, MD, MPH
Professor of Medicine, Department of Medicine, University of California, San
Francisco, San Francisco, California
The Economic Burden of End-of-Life Illness
Maria Danilychev, MD
Geriatrician, San Diego, California
Last Hours of Living
Liliana De Lima, MS, MHA
Executive Director, International Association for Hospice and Palliative Care,
Houston, Texas
Palliative Care in Developing Countries
Christopher Della Santina, MD
Mid-Atlantic Permanente Medical Group, Rockville, Maryland
Integrating Palliative Care Guidelines into Clinical Practice
