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Missouri State Board of Registration for the Healing Arts
by Carl Myers, M.D., Member
Adopted: January, 2001
Palliative Care Guidelines
During recent meetings, the Missouri Board of Healing Arts has held several discussions
regarding the treatment of terminally ill patients and their concern that physicians who are
treating these patients are not knowledgeable about palliative care. It is the Board's position that
physicians who care for terminally ill patients should be knowledgeable about palliative care.
The Board's definition of palliative care includes, fully assessing and evaluating the patient's
needs; understanding the patient's goals and values; helping with advance care planning and
honestly discussing treatment options; aggressively managing pain and other symptoms; using
the team approach; and documenting the case. If you are treating terminally ill patients, you are
encouraged to follow the following guidelines:
A. Evaluating the Patient:
A patient with life limiting chronic illness should be given the option of palliative care.
Physicians should use prognostic guidelines to identify patients who are entering the terminal
period of their lives. Assessment should include the patient's disease state, prognosis, physical
symptoms, and psyhosocial and spiritual concerns. Coexisting disease and the impact of
symptoms on functioning should be documented. The needs of the family, or other care-givers,
for information and support should be assessed.
B. Understanding the Patient's Goals and Values:
Discussions between the patient and physician about advanced directives and goals and values of
the patient are central to palliative care and should be conducted as early as possible in the
clinical course to maximize patient input to decision-making. It is advisable to have the patient
name which person, or persons should serve as substitute decision-maker if the patient is no
longer able to participate in decision-making. The patient's preferences should be documented in
an advance directive. The substitute decision-maker should follow the patient's expressed wishes.
C. Discussing Treatment Options:
The burdens and benefits of shifting from curative treatment to palliative care need to be
carefully explained by the physician to the decisional patient or substitute decision-maker to
obtain informed consent for the care plan. This plan should be based on the goals of the
decisional patient or those expressed in the patient's advanced directive. The consensus of the
family should also be sought. Decisions about resuscitation and withholding and withdrawing
treatment should be consistent with these goals.
D. Aggressive Management of Pain and Symptoms:
It is the ethical responsibility of the physician to provide pain and symptom management that
promotes the best quality of life for the patient. Physical symptoms may not be controlled by
standard treatment when the patient has unrelieved emotional or spiritual suffering.
Multidisciplinary assessment and treatment should be used to define and address the many
dimensions of suffering. Refer to the Missouri Intractable Pain Treatment Act for guidelines in
pain management. (Missouri Statutes 334.105, 334.106, 334.107)
E. Team Approach:
The multiple types of suffering experienced by patients and families may best be managed by a
team approach: an effective multidisciplinary team of professionals as indicated by the patient's
needs with interest and expertise in palliative care. Examples of such teams are a hospice
program, and informal group of skilled professionals, or a palliative care consultation team.
F. Documentation:
Good documentation protects patient preferences. All discussions and treatment decisions should be documented by the physician in the medical record. Such documentation should be accessible for guiding subsequent decisions. To evaluate effectiveness of treatment, documentation of pain assessment and treatment response should use a standard pain scale when possible.
These guidelines were adopted by the Missouri Board of Healing Arts during their January 2001 Board meeting.