A Novel Approach to Hospital Palliative Care: An Expanded Role for Counselors

Abstract

Background:

A large tertiary hospital in central Georgia has found a novel approach to hospital palliative care.

Approach:

It is unique in that the approach has a strong counseling base in providing the palliative service, rather than major reliance on advance practice nurses or palliative physicians. The Medical Center of Central Georgia employs master's prepared counselors who spend the hours needed to assist families in making difficult end-of-life decisions.

Model:

Using a family systems therapy approach, these counselors have developed the Transitions and Palliative Care Therapy Model, which has proved to be a successful means of providing the services. The model includes the “7 Core Components of Communication and Decision Making,” which gives the counselors actual interventions to use in working through these complex cases.

Outcomes:

The growth of the program over 7 years is staggering with the outcomes far exceeding even the predicted volume from the Center to Advance Palliative Care.

Conclusions:

The model has the counselor at the heart of the team, keeping the communication open and flowing. The Transitions and Palliative Care Therapy Model has become an accepted standard of practice at Medical Center of Central Georgia and continues to be a successful means of managing the most complex cases in the hospital.

Introduction

There is an increasing focus to provide quality patient-centered care through emphasis on guiding patients and families through the illness continuum. “Palliative care helps patients understand the nature of the illness and make timely, informed decisions about their care, together with their families. Seriously ill patients benefit from palliative care at any stage of the illness. Therefore, palliative care should be considered a key component of medical care along with all other appropriate treatments.”¹

Most hospital-based palliative care programs have adopted models where the key members are either advance practice nurses or physicians.^2–8 A multidisciplinary approach has been recommended with “a medical staff leader, a nursing leader, a medical social worker, a pain management specialist, a pastoral care representative and an administrator being the minimum team members.”⁹ Early psychosocial interventions can be offered by palliative care counselors or pastoral care that can facilitate communication with nurses and physicians.¹⁰ “The ultimate goal of palliative care is improving the overall quality of care for patients with serious illness and their families.”¹¹ How each hospital accomplishes this goal varies from one organization to another.

We report a 7-year experience of delivering competent palliative care to hospitalized patients through a patient-centered, interdisciplinary approach, relying on family systems therapy integration into standard medical practice.¹² This mode of delivering palliative services, called the Transitions and Palliative Care Therapy (TPCT) Model, has been field-tested with over 10,000 hospitalized patients since its inception in 2004. The TPCT Model was built on the foundation set forth in the National Consensus Project (NCP) 2004 Clinical Practice Guidelines for Quality Palliative Care and revised in 2009.^13,14 It is unique in that the model has a strong counseling¹⁰ base in providing the palliative service, rather than major reliance on advanced practice nurses or palliative physicians.^2–8 The model consistently diminishes potential for conflict, communication deficits, time constraints, and knowledge gaps.

Approach

The Center for Palliative Care (CPC) is part of the Medical Center of Central Georgia (MCCG), a 603-bed nonprofit teaching hospital located in central Georgia. The CPC has three distinct components: the Palliative Consult Service; a 5-bed inpatient palliative care unit; and transitions counselors.

The Palliative Consult Service responds to a consult order written by an attending physician, with 90% of initial palliative consults being completed by midlevel providers. Full-time members of the Palliative Consult Service include a nurse practitioner and a clinical nurse specialist, both of whom are certified as advance practice hospice and palliative nurses. Part-time members include two physician assistants with specialization in geriatrics. The midlevels collaborate with two part-time hospice and palliative medicine certified physicians and consultative services such as chaplains, speech therapists, hospice nurses, and case managers. Palliative Consultants always work in tandem with the Transitions Counselors' evaluation of the family dynamics.

The second component is a 5-bed closed unit available if a palliative consult has been completed and the clinician determines a need for admission to the palliative unit.¹⁵ The goal of care in the unit is acute pain management or symptom control, a more suitable environment for end-of-life care/inpatient hospice or a transition from curative to comfort based care. Palliative care standing orders are available for the nursing staff on this unit. Patients are referred by physicians from all over the hospital such as the intensive care units, emergency department, general medical floors, and various specialty areas.¹⁶ Nurses and administrators on this unit are trained in palliative care and critical care. The unit specializes in quality end-of-life care.

The third key component of the CPC is Transitions, which consists of eight full-time master's prepared Transitions Counselors (from schools of Family Therapy and Counseling) who make initial contact with patients suffering from severe chronic disease or terminal illness. Referrals to the Transitions service can be initiated by anyone in the hospital. Most often referrals come from a nurse or physicians, but even a family member may ask for the service. Transitions counselors meet the psychosocial needs of patients and families within the hospital setting through medical family therapy. Throughout this article whenever “family” is mentioned, it includes the patient and family members, unless specifically indicated otherwise.

Transitions counselors are trained to provide critical services in a medical facility helping families navigate complex systems. Counselors attend weekly Interdisciplinary Palliative Rounds to increase their knowledge of medical issues related to the palliative patients. The counselors are integrated into the intensive care units (ICUs) and medical–surgical units through rounds where they receive pertinent information on specific disease processes and treatment options. The palliative medical director provides oversight to the Transitions counselors.

The palliative care team is thus composed of 8.0 FTE counselors, 2.5 FTE midlevel practitioners, and 0.5 FTE palliative physicians. The large majority of patient and family contacts, including family meetings, are initiated by counselors, allowing the midlevels and physicians to concentrate on biomedical issues and provide overall medical supervision.

MCCG supports the 2009 NCP recommendation for timing of palliative care to “begin at the time of diagnosis of a life-threatening or debilitating condition and continue through cure or until death and the family's bereavement period.”¹³ This referral system provides interdisciplinary access sooner to more patients with life-limiting or severe chronic illnesses.¹⁷ The focus of earlier intervention is on educating families about disease trajectory, coordinating multiple physician views, and collaborating with outpatient services. Collectively, this promotes continuity of care.

The 2009 NCP Clinical Practice Guidelines for Quality Palliative Care emphasize that all evaluations and interventions should be patient-centered, incorporating at all levels of the illness the central role of the family unit in decision making.¹³ The Transitions counselors achieve this through a systems therapeutic approach in addressing the uniqueness of each case. Part of the master's training of these individuals focuses on the reality that when patients enter the hospital for care, they do not come alone. Most patients bring with them functional or dysfunctional family systems. Families are likely to be symptomatic when going through a transition, such as complex medical decision-making and facing the impending death of a loved one.

Model

Transitions counselors have developed the Transitions and Palliative Care Therapy Model (TPCT; Fig. 1), which focuses on “7 Core Components of Communication & Decision Making.” These components consist of Getting Ready, Assessing Situation, Managing Conflict, Providing Information, Identifying Roles, Processing Essentials and Follow Through.

FIG. 1.

Transitions and palliative care therapy model.

Transitions counselors address each one of the complex cases, working through all of the interrelated subsystems.¹⁸ These subsystems include the hospital system with its rules and regulations, the many different consulting physicians focusing on their specific areas of expertise and the family unit. Physicians also respond personally with their own emotions, values, beliefs and cultures. Families tend to respond best to a system that has clear boundaries, rules and messages, but in the complex health care system, this is difficult to control. Physicians and nurses often have neither the time nor training to navigate this complex emotional, cultural, and spiritual system. The TPCT model of patient-centered care enhances interactions among providers, departments, and health care settings.

Getting ready

Before meeting with a family, there is preparation needed in order to “Get Ready” for whatever the family may have on their agenda. The Transitions counselor reviews the medical records and speaks with the health care team members to determine whether there is a consensus by the medical professionals on the patient's overall condition. If there are discrepancies, the counselor will make verbal contact with physicians both consulting and especially the attending, to get clarification. Goals are set for the discussion before meeting with the family, but keeping in mind that the family may have their own goals. It is central to keep in mind that TPCT is a “communication” model. Keeping in touch with the attending and other members of the clinical team, is key to fostering transparency among the team and with the family. It is important for the clinical team to be on the same page when talking with family members. The counselor will invite key members of the health care team, family members, and family support systems to the meeting. The counselor's role is to coordinate, act as mediator, and keep the meeting running smoothly. By considering what information and decisions need to be made, the counselor can keep on track despite the families' attempts to deviate. This provides the clinical team the time to focus on providing critical information about the patient's medical condition. Once this information has been shared, the clinical team is able to exit the meeting and leave the counselor to assist the family in processing this information. Often times there are follow-up conferences with the attending physician. This insures communication of any family concerns with the attending. It also assures the counselor is in sync with the attending.

Assessing situation

The Transitions counselor begins additional interventions with his/her goals in mind but remains flexible to what the family may need. The counselor allows the family to tell the story of the illness⁴ and their understanding of the previous discussions with physicians. Focus is on joining the family¹⁸ and earning their trust by naming the emotions that they seem to be feeling (i.e., overwhelmed, angry, and frustrated). The counselor, keeping patient autonomy in mind, advocates for good communication about choices for medical care. If there seems to be any misunderstandings, the counselor will arrange additional meetings with the appropriate clinician. This leads to more informed decisions. It is important to recognize and address any barriers to communication (Table 1).

Table 1.

Assessing Situation

Barriers	Questions	Interventions
Preferences
Pt/family not ready for bad news Family asks to withhold information from the patient	What have you been told about your medical condition? Have you been told any prognosis or what to expect?	Ask direct questions for clarification Utilize empathetic listening Encourage patient involvement as they will know something is being held from them
Availability
Key members may live out of town or have transportation issues Family may have to work May not have next of kin (NOK)/family	Is there anyone that you would like to be here to discuss your medical situation? When is the best time for your family to come for a family meeting? If they are unable to be present, do I have your permission to call them?	Appeal to the importance of receiving accurate information that allows for informed decisions. Encourage all who will be assisting with decisions to attend meeting or be available by phone to avoid confusion Each organization has its own process for dealing with no legal NOK
Differing Viewpoints
Different views and past experiences with end of life care Family may not agree with patient or each other If patient unable to participate, patient's wishes may be unknown to family	Can you tell me who is in your family and how close they are to you? Does everyone understand about patient's medical condition?	Allow everyone to have equal chance to express their concerns. Remain caring and compassionate. Restate to clarify your understanding
Health Literacy
Everyone understands medical information at different levels	Can you tell me how you ended up in the hospital? What was your condition before this episode? What effect did it have on your ability to do things for yourself? Is there anything causing your health concerns?	Provide information about the patient's current medical condition. Speak to patients/family at a level they can understand, avoiding complex medical terms Use both written and verbal explanations
Language
Non-English speaking Broken English Hearing and vision impairments	Would you like for me to discuss your medical condition with you or someone else?	Assess the patient/family's communication skills by asking them to restate Assess the patient/family's knowledge base. Utilize a translator based on organizational policy
Age Appropriate
If patient is a child, age and maturity determine if child should be part of discussion Maturity level of grown children should be assessed if they are young adults Are there young children that need to leave the room during discussion	Are you the patient's parent? Is there a legal guardian? Are there other family members I need to speak with?	Assess the appropriate person to legally be making decisions (refer to state laws) Never assume that you know the relationship of who is in the room, always assess

Identifying roles

Families are organized with hierarchies and subsystems^18,19 that make each unique. When faced with complex decisions, families work around or through unresolved stressors that existed before the patient entered the hospital. These unresolved stressors, coupled with an unfamiliar environment and anticipatory grief, often result in chaos. Many times health care members find themselves caught in the middle of these unresolved issues, resulting in distress and burnout. Transitions counselors assess the family dynamics, hierarchies and subsystems, and how the patient's hospitalization affects this structure. New roles may have to be clarified and agreed upon in order to move forward with any decision making. Transitions counselors arrange family meetings to avoid coalitions and triangulations,²⁰ giving every family member a chance to speak up.

Through regular family meetings and ongoing documentation of family dynamics, Counselors facilitate effective decision making among family members (Table 2). Families are guided through the often confusing health care system and are proactively encouraged to request physician meetings or to list their questions in order to promote communication. Physicians specifically benefit because Transitions counselors are able to spend the minutes to hours required to identify the key decision makers, assess cultural or spiritual issues, establish rapport, and address baseline questions. Counselors identify family dysfunction and how it directly affects their ability to make decisions about patient goals-of-care. When the physician or nurse begins to discuss medical details, much of the conversation builds on the framework already developed by the Counselors.

Table 2.

Identifying Roles

Decision makers	Questions	Interventions
Next of Kin
Every state has a medical consent law that determines who makes decisions in the absence of a patient with decision-making ability	Is the patient married? Are there adult children? Does the child/adolescent have parents/guardian available?	Explain to family that the law determines who has decision making authority Encourage all family members to be part of the decision making process
Quality of Life
Patient may have expressed his/her wishes for end-of-life care Everyone has their own opinion about what constitutes quality of life	Has patient ever discussed what he/she would want if at the end of life? Can you tell me what patient was like (active, independent, just enjoyed TV)? Can you tell me about your previous and current health?	Assist family in discussing end of life care from patient's perspective Try to determine if patient ever expressed his/her wishes directly to anyone Document patient's own stated words and level of understanding
Advance Directives
Every state has different advance directive laws If a patient lacks decision-making ability, the advance directive takes precedence over the next of kin	Does the patient have advance directives? Who is the health care agent (durable Power of attorney for health care)?	Copy of advance directives should be seen (copy on chart), do not assume Reinforce that health care agent has the authority to make patient's decisions
Family Hierarchies
All families have their own rules and values Someone usually holds the power in the family (matriarchal, paternal) who may not be legal next of kin	Is there anyone that usually makes the decisions for your family? How have you worked together during previous family crises?	Acknowledge the family hierarchy and try to join with the one who holds the power Determine a designated spokesperson for large families
Culture/Spirituality
Culture and spirituality may play a lead role in decision making	Do you have any beliefs about end of life that are important to you? Is there anything forbidden or discouraged with medical care in your culture/religion?	Respect patient/family's beliefsListen for signs of cultural/spiritual beliefs that could hinder decision making Join with family on this level Offer for spiritual/cultural leaders to be included Include patient/family cultural needs in goals of care

Providing Information

One of the most important aspects of palliative care is assisting the family in making informed decisions, including pros and cons of treatment options and likely progression of the illness. Physicians explain complex medical conditions using terms that many families may not understand. The counselor spends the time with the family in order to identify the best ways to communicate with them, knowing there are many different ways that individuals retain information. Transitions counselors use appropriate resources to ensure the families have what is needed to make these informed decisions (Table 3).

Table 3.

Providing Information

Resources	Questions	Interventions
Educational Tools
People learn in different ways (visual, auditory)	Would you like written information? Can you tell me what you understand at this point? Does it help you to make notes or write down your questions?	Use simple education sheets that the patient/family can understand Explain the information sheets verbally Ask for them to verbalize understanding
Support Systems
Families have their own support systems such as church and friends Hospitals have support systems such as social workers, counselors and chaplains	Do you have anyone who supports you in your community? Who has helped you with difficulties in the past?	Educate family support systems as they may have much influence on decisions Refer to appropriate disciplines for supportive services (i.e., ST, PT, OT, chaplain, etc)
Active Listening
It is important to listen and understand what the issues may be for the patient/family There issues may not be the same as the issues you feel most crucial	Is there anything else that I can answer for you? What do you think would most help you through this situation?	Repeat back to avoid misunderstandings Use nonverbal communication that is reassuring and shows that you are attentively listening Involve related health care members
Establish Rapport/Trust
Patients/families will first determine if you are competent and trustworthy before they will share with you Explain your role Some families need to hear from the physician	Can you tell me what you understand at this time? How are you doing?	Take your time in explaining the patient's medical condition, personalizing experience to what it means for them Answer their questions even if they seem small Follow through with meeting their needs Add patient/family goals to be addressed
Boundary Setting
Although you are joining with the patient/family it is important to keep a professional boundary	Is there anything else bothering you?	Don't promise things you cannot fulfill Do not offer false hopeOffer to “hope for best but prepare for worst” Share work times, contact numbers and who is covering
Provide Information
Most patients fear the unknown more than dealing with bad news They desire open, honest communication	I have information to share that may be hard to hear, is everyone here that needs to be?	Do not be afraid to use the words “dying or death” Allow silence Give prognosis while using eye contact, touch as appropriate Discuss how this information is difficult to hear and explain that pain and symptoms will be managed Refer back to patient/family goals to stay focused
Make Suggestions	For Patient:
Guide the patient/family using your expertise and training It is important to establish clear and realistic goals of care based on what is important to the patient/family	What are your thoughts or feelings about what has been said?For Family:If your loved one could hear this information, or see themselves in the bed, what do you thing he/she would say?	Make statements such as, “It is the recommendation of the health care team that we make you comfortable and not add any more aggressive treatments.”Discuss do-not-resuscitate (DNR) ordersDiscuss benefits and burdens of treatmentsDo not offer multiple options at one timeEducate on what to expectRefer back to patient/family goals

Processing essentials

When the patient shows signs of terminal decline, symptoms of grief may inhibit the families' comprehension and decision-making abilities. The Transitions counselors have recognized several responses to grief that are common in these situations (Table 4). They gain the trust of the families by joining in their family system and assisting them in mentally and emotionally processing the information given by the medical team. Through this rapport-building, they often become a trusted precursor to the Palliative Consult Service. The hospital medical staff comes to rely on the counselors to know when it is the best time to share bad news or make decisions.

Table 4.

Processing Essentials

Responses	Interventions
Detach
Some individuals will withdraw and become very quiet	Use silence to allow time to process and ask questionsAsk open ended questions to foster conversationUse eye contact and touch
Panic
This is evident when an individual becomes irrational and can't seem to make even simple decisions	Repeat what you have told patient/family on different visitsCommunicate to other healthcare team members that prognosis needs to be reiterated (use IDT meeting as a means to discuss)
Disbelief
Individuals seem to be non-trusting, it seems safer to keep believing they will get better	Join with patient/family by making statements such as “this just doesn't seem fair,” or “seems like a bad dream”Continue to talk of future empathetically without offering false hopeGive idea for the next step
Fight-or-Flight
These individuals will curse, raise their voice and/or become very demanding, or will become unavailable May avoid future contact or decisions	Do not take their actions toward you personally, they are upset at the situation, not youAcknowledge their anger, but ask for appropriate behaviorGive them time to process their feelings and set a specific time for future discussions once emotions have calmed
Manipulate
Asking repeat questions of different team members may indicate an individual that is looking for ways to catch clinicians in differing answers They may ask for inappropriate therapies to be tried They may request to only speak to individuals that offer hope or say things they want to hear	Hold to your statements about poor prognosisDo not offer false hope with giving in to inappropriate therapiesMay need to have expert clinical consults performed so that they can hear the same information from the specialist physicianHave discussion with physician about patient's prognosis and need for verification
Resilient
Thankfully, there are many individuals who seem to cope appropriately and are accepting of their situation	Provide reassurance that they have made the right decisionDiscuss how the family is showing that they care by making these decisionsBegin to discuss next steps

IDT, interdisciplinary team.

Managing conflict

The situations that are faced in palliative care can be very stressful on patients, families, healthcare staff, and clinicians. There can be conflict between the clinician and family, within the family, between healthcare staff and the clinician, and between clinicians themselves. The TPCT Model addresses these conflicts as one of the “7 Core Components of Communication and Decision Making” (Table 5). The Counselors have all received extensive training in managing conflict through their master's programs. Systems Theory is used on a daily basis to maneuver through all of the various conflicts that arise from such complex cases. It is important to remember that there are also legal and ethical factors (Table 6) when dealing with conflict. There is no one right answer to every case, but the counselor will assist the health care team in finding the middle ground to work toward a compromise. “Law provides guidance through various sources, but does not provide the answer.”²¹

Table 5.

Managing Conflict

Scenarios	Interventions
Family vs. Family—family members may have interpersonal conflict between themselves due to their own personal myths, values, beliefs and personal experiences.	Arrange a family meeting to inform/educate where all family members hear the same informationCounselor acts as mediator for family meeting.Allow each family member to express their viewpoints.Redirect family to consider what the patient would want if he/she could speak, not what their heart is telling them.If spirituality is basis for the family decisions, consider involving the chaplain.Multiple family meetings may be needed.Respect individual rights.
Family vs. Physician—The Physician may not agree with the family's decisions for patient. Physician may have their own internal conflict about one of their patients dying.	Arrange a family meetingUse TPCT Model to work with family and the emotional responses.Counselor acts as mediator in family meeting.Respectfully allow family to express their concerns and answer their questions.Consider who is speaking for the patient, advocating for patient's wishes.Make referral for an Ethics Consult and/or Legal Consult.
Staff/Consulting Physician vs. Physician—sometimes the healthcare team members may not agree with the physician. This may also be due to differing cultures, values, beliefs and/or levels of involvement. Professionals may have their own emotional responses with end-of-life issues.	Facilitate open communicationAssist in clarifying values and beliefsConsider organizing a Care Conference to discuss differing viewpointsRespect each team members roles and expertiseMake referral to Ethics Committee if necessary

TPCT, Transitions and Palliative Care Therapy Model.

Table 6.

Managing Conflict: Legal vs. Ethical

Legal vs. Ethical —While working through the interpersonal conflicts, you must keep in mind each individual's rights and the laws that govern society:	Legal	Ethical
Patient/family	Constitution—laws that are made by the people based on ethical issues that have arisen in the past. These serve as a guide, but are not “the answer”Patient/family have the right to request another physicianThe legal age to make healthcare decisions is 18State laws differ in emancipated minors. Depending on the state, minors may be emancipated by pregnancy, marriage, high school graduation, living financially independent, and military service	Principle of Autonomy—every individual has the right to decide what they want for themselves, self determinationInformed consent - this cannot be achieved without open communication and disclosure of both the good and bad information about the medical condition
Physician	Constitution—laws that are made by the people based on ethical issues that have arisen in the past. These serve as a guide, but are not “the answer”Patient/family have the right to request another physician“Baby Doe Laws”—life-sustaining treatment is not required “when the provision of such treatment would merely prolong dying, not be effective in ameliorating or correcting all of the infant's life-threatening conditions, or otherwise be futile in terms of the survival of the infant” [45 Code of Federal Regulations 1340, April 15, 1985]	Nonmaleficence—do no harm to patients Beneficence—promoting good, do what's right for patientsUltimately, the physicians have to decide what is best for their patient, weighing what information they have received from the family members and others
Hospital	Policies and Procedures—every hospital has policies and procedures that are based on federal and state laws, such as HIPPA and DHR, which serve as a guide to dealing with conflicts in the hospital	Ethics Committee is a multidisciplinary group made up of physicians, health care staff, administration and community members that review consults on ethical dilemmas
Societal	Common Laws—local laws for case by case adjudication through the local Courts are available	What is good for the community as a whole

Follow through

After bad news is shared by clinicians, Transitions counselors assess whether the family has accepted the information and able to make decisions on appropriate goals-of-care. If the family is not able to accept the impending death, counselors move toward discussing long-term goals-of-care, which include discussions on quality of life. If the family does accept end-of-life care, counselors assess the family's feelings of guilt and reassure them by providing education on the signs and symptoms of nearing death. The goal of therapy at this stage is to normalize these feelings.²²

The Transitions counselors keep all other health care team members notified of any changes and introduce new team members in order to keep trust between family and staff. The plan of care is clearly documented to minimize confusion between care team members. Once the patient dies, the counselor will make a follow-up call to the family to initiate the CPC Bereavement Program.

Outcomes

Since the initiation of the program, it was evident that actual data tracking was important to consistently report to hospital administration the success of the palliative team and the TPCT Model.²³ CAPC has provided the means to estimate program volume that takes into account the hospital's average length of stay, frequency of deaths and patient mix.²⁴ The CPC has proven its success and sustainability with exceeding the CAPC estimated volume of 338 potential referrals by actually receiving 751 referrals in the first year of operation. The team uses a database that keeps actual outcomes of the program at their fingertips making it easy to report to administration on a regular basis (Fig. 2). Growth has continued due to the obvious needs of the patients at MCCG and the physicians' realization of the team's skills.²⁴ MCCG has many specialized physicians, being the second largest hospital in Georgia, that bring many complex cases needing the services of the palliative team.

FIG. 2.

Palliative care growth, 2004–2009.

The TPCT model with the use of counselors has allowed early access to patients in need of services. The CPC department has 8.0 FTEs Transitions counselors, 2.5 FTEs midlevel providers, and 0.5 FTE palliative physicians. This staffing distribution is strikingly different from most published inpatient palliative models,^2–8 which have a stronger focus on the physician/NP/PA team members. Despite the U.S. economic hardships in the last few years, the palliative team has continued to prove its value to the hospital organization.

Conclusion

The TPCT model has the counselor at the heart of the team, keeping the communication open and flowing. The specialized training that the counselors receive is based on a systemic approach where all parts of the interdisciplinary team and the patients' families and support systems are collaborating to make the difficult decisions involved at the end of life. This TPCT model appears to be a cost-effective way to provide palliative services, using counselors who are hired at a much lower cost than clinical staff. This model has attracted interest from other hospitals and is now being replicated at various sites. The Transitions and Palliative Care Model has become an accepted standard of practice at MCCG and continues to be a successful means of managing the most complex cases in the hospital.

We have presented a novel approach to having counselors in a strategic role in a hospital palliative care team. The purpose of this article has been to present our unique model. Our intention is to have an additional article to present the data that has resulted from this approach.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Additional Resources

Rolland JS: Families, Illness, & Disability. New York: Basic Books, 1994.

Morgaine C: Family Systems Theory. (Last accessed August 12, 2010).

Nichols MP, Schwartz RC: Family Therapy: Concepts and Methods, 2nd ed. Boston: Allyn & Bacon, 1991.

McDaniel S, Hepworth J, and Doherty WJ: Medical Family Therapy: A Biopsychosocial Approach to Families with Health Problems. New York:

Basic Books, 1992, pp. 61–93.

Kübler-Ross E: On Death and Dying. New York: Scribner, 1969.

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