The Four C’s of Palliative Care
Neil A. Solomon, MD Co-Founder, CMO & Chief Compliance Officer
How do we help patients and their families have a “good” death?
As caregivers we usually know when someone had a “good” death, that is, a person was at peace during their last stage of life. We may talk of this in rounds or think about the patient’s passing in retrospect with that feeling. Some of this has to do with the patient and their personal situation, but caregivers can also play an important role. How do we help patients when they are still living, as well as their families, to ultimately have that outcome? This is a very important question in palliative and hospice care, but it is relevant for many more patients, and in fact for all of us. After all, we are all going to die someday even if it does not feel imminent.
In providing care I try to keep four things in mind, which can be remembered easily as the four C’s.
The most immediate and obvious is comfort. This is at the heart of most palliative care. In our practice we use the Edmonton Symptom Assessment Scale (ESAS) to track pain, shortness of breath, nausea, anxiety, fatigue, and other symptoms. The ESAS is almost like vital signs for this population. We need to address these vital issues before we can move onto other concerns. Fortunately, we have strategies – often medications – to address these symptoms.
Next, I think about control. We all want to have a sense of control, but this is even more important for patients who are in the late stages of life as they often feel out of control, which can be scary. Caregivers should work to understand where control matters to the patient—and where it’s possible—and help them exert that where they can. It may take the form of which side they lie on, who can visit, the dimness of the lighting, whether they would be returned to the hospital for acute symptoms. Even if it’s only limited, a sense of control may help reduce anxiety and pain, i.e., enhancing comfort.
The third is closure. In my experience people want the chance to say goodbye or to finish conversations that are lingering in their minds. Often it is as simple as to say, “I forgive you,” or “I want you to know how much I love you.” The need for closure is really a two-way street between the patient and their loved ones. After all it is the loved ones who will carry the memories after the patient passes away. It is so important that they feel nothing was left unsaid. For this reason, I counsel family to do their talking and visiting early, even if it is uncertain how close the patient is to the end. What’s the harm in saying those things too early and then having additional time together? But if they miss in the other direction, there is no going back.
Finally, there is completeness. By this I mean the patient feels their life had purpose. Whether it was raising children who will continue to do great things, having a meaningful career, contributing to a community or in other ways, the patient is proud of their accomplishments and the legacy they will leave. The sense of completeness comes from a lifetime, not just the late stage of life, so it can feel like this is outside of a clinician’s ability to assist. It is truly never too late in life to have meaning. My mother-in-law was very brave and loving in her last months, and that has stuck with me and my family. She was teaching through example to the day she died. I have had patients who decide at the end to donate their organs as a last act of generosity.
When my own mom died, I told friends that she passed away peacefully, she had a chance to say goodbye to all her children and grandchildren, she chose where and when the end would happen, and she left a legacy about which she was proud. I was thankful for all of that, both for her sake and mine. I miss my mom almost every day. And when I think of her, I smile and know she died a good death. It is my goal to help patients and their families have the best late-life experience possible by keeping these four objectives in mind.